Intramedullary Nailing of Tibial Shaft Fractures

Overview

Tibial fractures are the most common long-bone fractures, with an overall incidence of about 20 per 100,000 person-years; up to 24% are open (AO). The anterior third of the tibia lies subcutaneous, so even closed fractures often injure the skin, and compartment syndrome is more frequent than with other fractures (up to 9%) (AO).

Locked intramedullary nailing is the standard treatment for displaced tibial shaft fractures (Campbell; AO; Rockwood). Randomized trials favor operative fixation over closed treatment for nonunion, malunion, complications and time to return to work (Rockwood). Most fractures are statically locked, usually with two screws proximally and two distally (Campbell; AO).

Evaluation

• Soft tissues are the most important factor in the treatment decision: document wounds, contamination, bruising, swelling and blisters (AO).

• Vascular examination: Check dorsalis pedis and posterior tibial pulses; capillary refill can be misleading because collateral flow may preserve foot color despite major arterial injury. Abnormal pulses that persist after correcting deformity mean vascular injury until proven otherwise (AO).

• Compartment syndrome: Severe pain unrelieved by opioids is the key symptom; tense, shiny skin, pain on passive stretch of the toes and first web space paresthesia are important signs. Pulses are usually present. Suspicion requires pressure measurement or fasciotomy (AO). It can also occur in open fractures (AO).

• Imaging: AP and lateral radiographs including the knee and ankle (AO). CT of distal-quarter fractures is advisable, because 43–69% have intraarticular extension (most often a coronal posterior malleolar fracture), and 14% of articular involvement is missed on plain films (Rockwood).

Classification

Indications

• AO: Open fractures; polytrauma; floating knee or ankle; failure to achieve or maintain acceptable closed reduction; neurovascular compromise; compartment syndrome.

• Rockwood: Inadequate closed reduction, open fracture, vascular injury, soft tissue envelope preventing casting, an unreliable patient, or patient preference; nailing allows immediate knee and ankle motion and usually immediate weight bearing.

• Nonoperative treatment (well-molded cast then functional brace) is reserved for undisplaced or minimally displaced low-energy fractures, stress fractures and incomplete fractures (AO).

• Plating of shaft fractures is used when nailing is not possible: periprosthetic fractures around a TKA, a canal too small or deformed, or an ipsilateral plateau fracture that complicates nailing (Rockwood). Displaced unstable fractures of the proximal and distal thirds are the best indications for plates (AO).

Timing

• Open fractures and polytrauma: early debridement and damage control; reduction and external fixation can be a reasonable first step (AO). Best practice is early debridement with repeat debridement and soft tissue cover within 5–7 days (AO).

• Conversion from external fixation to a nail should be done within 2 weeks to avoid increasing infection risk (AO).

• Open fractures: Immediate nailing after irrigation and debridement is supported for low-grade open fractures (overall infection 3%, union 89%); the SPRINT trial showed low infection with primary nailing and that reaming is safe (Rockwood). In the LEAP study of high-grade open fractures, infection was 16% and complications 33–57% (Rockwood). Suprapatellar nailing of open fractures does not appear to increase knee septic arthritis (Rockwood).

Preoperative Planning

• Is the fracture suitable for a nail? Confirm it is not too proximal or distal; recognize intraarticular extension so it can be clamped or screwed before nailing (Rockwood).

• Contralateral tibia radiographs help determine nail diameter, the expected amount of reaming, and length in comminuted fractures (Campbell).

• Nail length:

  • The proximal end should be countersunk, and the distal end centered to slightly lateral in the distal epiphysis (Campbell).

  • The tibial tubercle–medial malleolus distance is reported to be the most accurate and least expensive estimate (Campbell).

  • Allow for further impaction if a comminuted fracture is later dynamized (Campbell).

  • Very tall or short patients may need nail lengths that are not normally stocked (Campbell; Rockwood).

• Nail diameter: Measure the canal at its narrowest point, best seen on the lateral radiograph (Campbell; AO). Typical smallest nails are 8.5–9 mm; locking holes are no larger than half the nail diameter, so small nails often take smaller locking screws, which may limit construct life (Rockwood).

• Reamed vs unreamed: These terms describe the technique, not the implant (Campbell).

  • Several randomized trials showed higher union and fewer complications with reamed nails; open fractures can also be safely reamed (AO; Rockwood). Endosteal blood supply disrupted by reaming recovers within 8–12 weeks, and reaming debris may act as a biological stimulus (AO).

  • Unreamed nails are usually 8–10 mm and cannot be used if the canal is narrower than 8 mm (Campbell).

  • Campbell recommends reamed nailing for open or closed fractures with minor soft tissue injury and reserves unreamed nailing for more extensive soft tissue injury.

• Approach selection (Rockwood): A narrow arthritic patellofemoral joint or limited patellar mobility makes suprapatellar nailing difficult; limited knee flexion makes hyperflexed infrapatellar nailing difficult; wounds, previous incisions and an ipsilateral femoral fracture (one incision for a retrograde femoral nail) also influence the choice.

• Make sure the canal is clear (TKA, other implants, previous fracture) (Rockwood).

Table Selection

Campbell's preference is a standard radiolucent table with the limb over a bolster. The table must allow imaging from knee to ankle (Rockwood).

Patient Positioning

Infrapatellar (Hyperflexed)

1. Supine with a bump under the ipsilateral hip to prevent external rotation; a radiolucent triangle under the knee whose position can be changed to vary knee flexion (Rockwood). Alternatively, thigh flexed over a padded bolster (Campbell).

2. A skilled assistant is needed for reduction and limb support (Campbell).

3. A femoral distractor or two-pin external fixator can hold reduction: one Schanz pin 1 cm distal to the knee and one 1 cm proximal to the ankle, parallel to the joints. The proximal pin must lie in the posterior tibial condyle, out of the nail's path; for distal fractures the distal pin can go into the talus or calcaneus (Campbell; AO; Rockwood).

Fracture Table (Campbell)

1. Calcaneal traction pin before positioning; hip flexed 45°, knee 90°; thigh on a well-padded crossbar proximal to the popliteal fossa.

2. Reduce under fluoroscopy, then release traction until the portal is made to reduce neurologic traction injury.

Semiextended / Suprapatellar

• The leg rests on a radiolucent foam ramp with a bump behind the knee (Rockwood). A common difficulty is too little knee flexion to obtain the correct sagittal wire trajectory (Rockwood).

C-Arm and Tourniquet

• C-arm contralateral or ipsilateral according to preference (Rockwood); perpendicular to the tibia (AO).

• Ream with the tourniquet deflated (Campbell). Most North American surgeons do not use one during reaming; if needed for debridement of an open fracture, place it sterile on the lower thigh so it is not forgotten during reaming (Rockwood).

Measuring Rotation

Clementz method (Campbell):

1. Before nailing, measure tibial torsion in the uninjured leg with the knee extended: rotate the leg until the femoral condyles superimpose on a true lateral view.

2. Keeping the knee and foot still, swing the C-arm to AP and image the ankle; turn it until a tangential view of the inner surface of the medial malleolus is obtained (the ankle reference line); tilt 5° cranially to improve the image.

3. Tibial torsion equals the angle between this line and the perpendicular.

4. Alternative: Alignment of the iliac crest, patella and second ray of the foot.

Other methods: Compare the rotational angle between a perfect lateral of the knee and a mortise view of the ankle with the contralateral side; a simple fibular fracture that is malreduced can signal tibial malrotation (Rockwood). In transverse 42A3 fractures, matching proximal and distal cortical thickness helps; also check skin tension lines (AO). Note that normal side-to-side tibial torsion differs by more than 10° in about 12% of people (Rockwood). External malrotation is twice as common as internal (AO).

Nail Insertion Technique

Approaches

Transtendinous and paratendinous approaches have not been shown to differ in knee pain (Campbell; AO).

Entry Portal

1. Make a 3 cm incision along the medial border of the patellar tendon, extending proximally from the tibial tubercle; extend if needed to protect the soft tissues during reaming. Campbell's current preference is semiextended instrumentation.

2. Insert a threaded-tip guidewire through the anterior metaphysis with a soft tissue sleeve (Campbell).

   • Ideal entry (safe zone): On the AP view, just medial to the lateral tibial spine (medial slope of the lateral tibial eminence); on the lateral view, immediately anterior to the articular margin (Campbell; AO; Rockwood). Use a true AP of the knee (the fibula bisected by the lateral tibial border), because tibial rotation can shift the apparent wire position by up to 15 mm (Rockwood).

   • Modern nails have a proximal (Herzog) bend; the ideal start lies between the joint line and the tibial tubercle — not so proximal as to injure the menisci or so distal as to ream out the tubercle (Rockwood; AO).

3. Confirm on true AP and lateral views (Campbell).

   • Pitfall – external rotation of the limb: The portal ends up too medial, which can damage the plateau and intermeniscal ligament (Campbell).

   • Pitfall – portal too distal: Damage to the patellar tendon insertion, or too steep an entry that splits the tibia or penetrates the posterior cortex (Campbell).

4. Trajectory: In the coronal plane in line with the tibial axis; in the sagittal plane parallel to the anterior tibial cortex (Rockwood; Campbell). For infrapatellar nailing, find the start with moderate flexion, then hyperflex over the triangle and advance the wire parallel to the anterior cortex; for suprapatellar nailing a parallel wire guide ("Gatling gun") helps (Rockwood).

5. If the wire angles too far posteriorly: Pass the entry reamer only 1–2 cm, remove the wire, and correct the path with a curved hand reamer or awl (Rockwood).

6. Open the portal with a cannulated entry reamer and protective sleeve, or a cannulated curved awl, protecting the patellar tendon or patellofemoral joint (Campbell; Rockwood).

Reduction

1. The goal is a functional reduction: length, alignment and rotation, restoring the mechanical axis (AO).

2. Aids: manual traction, femoral distractor or external fixator, percutaneous clamps through small incisions (especially for simple oblique patterns; avoid skin pressure), joysticks, blocking screws, temporary unicortical plates (AO; Rockwood). Plating the fibula sometimes improves tibial reduction in distal fractures (AO; Rockwood).

3. Away from the diaphysis, the wide canal does not allow the nail to reduce the fracture; reduction must be achieved before reaming (AO; Rockwood).

Guidewire and Reaming

1. Pass a ball-tipped guidewire across the fracture. In the distal fragment it should be centered to slightly lateral on the AP view and central on the lateral view (Campbell; Rockwood), stopping 0.5–1 cm from the ankle joint at the level of the physeal scar (Campbell; Rockwood).

2. Reaming:

   • Start with a reamer smaller than the measured canal and increase in 0.5 mm steps (Campbell); ream until cortical contact ("chatter") to increase the working length at the isthmus (AO).

   • Ream to about 1–1.5 mm larger than the nail (Campbell; AO; Rockwood). Campbell's preference: "minimal" reaming, no more than 2 mm beyond first chatter. Sharp reamers reduce heat (AO).

   • Ream with the knee flexed to avoid over-reaming the anterior cortex (Campbell).

   • Keep the fracture reduced during reaming; the nail follows the reamed path, and eccentric reaming causes malalignment (Campbell; Rockwood).

   • Do not let the guidewire pull back (Campbell).

Nail Selection and Insertion

1. Choose a nail 1–1.5 mm smaller than the last reamer; ream the entry wide enough for the proximal nail diameter (Campbell).

2. Do not undersize. A loose nail is less stable and small nails are weaker; use the largest nail suitable (Campbell).

3. Measure length with the system depth gauge or overlapping guidewire, keeping the fracture out to length (Campbell).

4. Attach the insertion handle and proximal targeting guide with the apex of the proximal bend facing posteriorly. Insert with the knee flexed (except in some proximal-third fractures) to avoid impingement on the patella (Campbell); the knee must be flexed with the Herzog bend to avoid posterior cortex perforation (AO).

5. Excessive force should not be needed; if the nail does not advance with each mallet blow, withdraw it and ream further or use a smaller nail (Campbell). Keep the fracture aligned during insertion (Campbell; Rockwood).

6. Once the nail is well into the distal fragment, remove the guidewire so it does not become incarcerated; release traction during final seating; do not over-shorten segmentally comminuted fractures (Campbell).

   • Proximal end: 0.5–1 cm below the cortical opening, judged on the lateral view; a proud nail causes knee pain and difficulty kneeling, while excessive countersinking makes removal difficult (Campbell).

   • Distal tip: 0.5–2 cm from the subchondral bone of the ankle; distal fractures need the nail toward the distal end of this range (Campbell).

Locking

1. Remove the guidewire before attempting locking screws (Rockwood).

2. Proximal locking through the jig: transverse medial-to-lateral or oblique (anteromedial/anterolateral) screws (Rockwood; Campbell). Use multiple screws in proximal fractures — ideally at least three for the most proximal patterns (Rockwood). Oblique proximal screws at 90° to each other resist varus–valgus better than single-plane screws (Campbell). Take care with anteromedial-to-posterolateral screws near the common peroneal nerve at the fibular neck (Rockwood). Avoid overly long screws on the medial side, which are often symptomatic (Rockwood).

3. Distal locking (freehand, perfect circles): Adjust the lateral beam until the holes are perfectly round; center the drill in the hole, bring it in line with the beam, drill the near cortex, confirm passage through the hole, then drill the far cortex; measure and insert (Campbell; Rockwood). Two or more distal screws in distal fractures (Rockwood; Campbell).

4. AP distal screws: Percutaneous insertion endangers the tibialis anterior, EHL, anterior tibial artery and deep peroneal nerve; use a mini-open approach large enough to protect them (Rockwood; Campbell). Newer nails offer oblique distal options (Campbell).

5. Distraction: Avoid it, because it increases nonunion risk. In axially stable patterns, lock distally first and back-slap the nail to compress before proximal locking; some nails have internal compression devices (Campbell; AO; Rockwood).

6. Static vs dynamic: Static locking is the default (Campbell). AO recommends two proximal and two distal screws; proximal dynamic locking is acceptable only for a simple transverse 42A3 fracture with a gap of up to 2 mm (AO). Comminuted and metaphyseal fractures need static locking (Campbell).

7. Check rotation before and after locking (Rockwood). Obtain full-length tibial radiographs before closure to confirm alignment (Rockwood).

Proximal-Third Fractures: Preventing Malalignment

• Typical deformity: Valgus and apex-anterior angulation (procurvatum) (Rockwood; AO).

  • Valgus results from a start point that is too medial, or "reamer skid" creating a medial-to-lateral path (Rockwood). A suprapatellar start that is too lateral can produce varus by the same mechanism (Rockwood).

  • Apex-anterior deformity comes from extensor mechanism pull and a reaming path angled too far posteriorly (Rockwood).

• Nailing off the fracture table allows freer manipulation (Campbell).

• To prevent valgus: Place the portal in line with the lateral intercondylar eminence and centered on the canal on the AP view; an incision lateral to the patellar tendon can be used (Campbell).

• To prevent apex-anterior angulation: Move the portal more proximal and posterior, with a more vertical trajectory parallel to the anterior cortex; proximal locking with the knee extended relaxes the patellar tendon pull (Campbell).

• Semiextended technique (Tornetta): About 15° of flexion with a partial medial parapatellar arthrotomy and lateral retraction of the patella (Campbell).

• Suprapatellar nailing was developed largely to avoid proximal malalignment: the start point and reaming path are not blocked by the patella, and the extensor mechanism exerts less deforming pull in extension (Rockwood; AO). A nail with a more proximal bend reduces anterior displacement of the proximal fragment (Campbell).

• Reduce before nailing: AO distractor applied medially, or limited open reduction with a unicortical plate (Benirschke), useful in open fractures (Campbell; AO). Do not compromise bone blood supply when placing temporary plates (Rockwood).

• Blocking (Poller) screws (Krettek): Place them where you do not want the nail to go, usually on the concave side of the deformity in the short fragment (Campbell; AO; Rockwood). In the proximal tibia, a screw in the distal–lateral part of the proximal fragment prevents valgus, and a screw in the distal–posterior part prevents apex-anterior deformity (Rockwood; AO). They can be left in place to add stability, especially in wide geriatric canals (Rockwood).

• If malalignment occurs after nailing, remove the nail, place blocking screws and ream a new path (Rockwood).

Distal-Third Fractures

• Prone to malalignment because the metaphysis is much wider than the nail (Rockwood).

• Place the guidewire tip at the physeal scar, slightly lateral to the center of the plafond on the AP view and central on the lateral view (Rockwood; Campbell).

• Plating the fibula before nailing can help restore alignment and length, particularly with simple fibular and very distal tibial patterns; make sure the tibia is not left in varus (Rockwood). Whether to fix the fibula remains controversial (Rockwood).

Postoperative Care

• Elevate the leg for the first few days; encourage active mobilization to prevent knee flexion and ankle equinus deformities (AO). A splint with the ankle in neutral may help prevent equinus and lower compartment pressure (Rockwood). Start with a removable splint or orthosis and early range of motion (Campbell).

• Severe postoperative pain requires immediate assessment for compartment syndrome (AO).

• Weight bearing:

  • Axially stable fractures (e.g., transverse diaphyseal): unrestricted weight bearing (Campbell; Rockwood); with a statically locked nail, progressive weight bearing with crutches immediately (AO).

  • Axially unstable or proximal/distal metadiaphyseal fractures: restrict weight bearing until early callus (4–6 weeks), then progress (Campbell); Rockwood notes partial or non–weight bearing for 6 weeks is common, although immediate weight bearing after nailing of extraarticular distal fractures did not cause secondary displacement.

• Follow-up: Typically at 2, 6, 12, 26 and 52 weeks, with radiographs at each visit after the first; very proximal or distal fractures may need closer early follow-up (Rockwood). Closed fractures usually show healing at 3–6 months (Rockwood).

• Implant removal: Not routinely needed; for pain from a prominent nail, usually no earlier than 12–18 months after remodeling (Campbell). Symptomatic locking screws can be removed once healing is adequate (Campbell; Rockwood). About 30% of patients request implant removal (AO).

Complications

• Anterior knee pain: The most frequently reported complication, in 31–73% of patients; nail removal rates of 26–50% in some series (Rockwood). Up to 30% (AO); historically 56% chronic pain and difficulty kneeling (Campbell).

  • Possible causes: young active patients, nail prominence, meniscal injury from an intraarticular start point, missed articular injury, increased patellofemoral pressure, infrapatellar nerve injury and scarring (Campbell; Rockwood). A correct start point and countersinking may reduce but not eliminate it (Rockwood).

  • It improves with time but in the long term correlates with quadriceps weakness and lower knee scores (Campbell).

• Compartment syndrome: More than one-third of leg compartment syndromes are associated with tibial shaft fractures; highest risk in men about 30 years old with closed fractures (AO).

• Infection: Closely related to soft tissue injury: about 1% in closed and grade I–II open fractures, but 10–40% when soft tissue reconstruction is needed (AO).

• Delayed union and nonunion: Up to 14%, more common in distal-third, open and high-energy fractures (AO).

  • Exchange to a larger reamed nail is the standard treatment for aseptic nonunion (AO); it is indicated for small (8 mm) or loose nails, axially unstable and perimetaphyseal fractures, and fails when more than one-third to one-half of the cortical circumference is lost (Campbell).

  • Percutaneous bone grafting (mainly for IIIB fractures and bone loss), external stimulation, and dynamization (if the fibula has not healed) are other options (Campbell).

• Malalignment: Most common in proximal- and distal-third fractures (Campbell; Rockwood).

• Symptomatic locking screws are common (Rockwood).

References

1. Rudloff MI. Fractures of the lower extremity. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 59, Technique 59.9.

2. Lourenço PRBT. Tibia, shaft. In: Buckley RE, Moran CG, Apivatthakakul T, eds. AO Principles of Fracture Management. 3rd ed. Stuttgart: Thieme; 2017. Chapter 6.8.2. (Turkish edition: AO Kırık Tedavisinin Prensipleri.)

3. Butler B, Boulton CL, O'Toole RV. Tibia and fibula shaft fractures. In: Tornetta P III, Ricci WM, Ostrum RF, McKee MD, Ollivere BJ, de Ridder VA, eds. Rockwood and Green's Fractures in Adults. 10th ed. Philadelphia: Wolters Kluwer; 2024. Chapter 63. (Turkish edition: Erişkin Kırıkları.)