A Prospective study of Functional Outcome of Tibial Metaphyseal Fractures treated with Intramedullary Nailing with Blocking Screws (Poller Screws)

A dissertation on

A PROSPECTIVE STUDY OF FUNCTIONAL OUTCOME OF

TIBIAL METAPHYSEAL FRACTURES TREATED WITH

INTRAMEDULLARY NAILING WITH BLOCKING SCREWS

(POLLER SCREWS)

Dissertation submitted in

partial fulfillment of the regulations required for the award of

M.S. DEGREE IN

ORTHOPAEDIC SURGERY

CERTIFICATE

This is to certify that this dissertation titled "A PROSPECTIVE STUDY

OF FUNCTIONAL OUTCOME OF TIBIAL METAPHYSEAL

FRACTURES TREATED WITH INTRAMEDULLARY NAILING WITH

BLOCKING SCREWS (POLLER SCREWS)" is a bonafide record of work

done by Dr.A.Jaya Micheal Esthak during the period of his post graduate

study from May 2016 to September 2018 under the guidance and supervision in

the INSTITUTE OF ORTHOPAEDICS AND TRAUMATOLOGY,

Coimbatore Medical College and Hospital, Coimbtore-641018, in partial

fulfilment of the requirement for M.S.ORTHOPAEDIC SURGERY degree

examination of The Tamilnadu Dr. M.G.R. Medical University to be held in

May 2019.

Prof.Dr.D.R.RAMPRASATH M.S.Orth., D.Orth.

Associate Professor & Guide

Institute of Orthopaedics and traumatology Coimbatore Medical College &Hospital Coimbatore- 641018

Prof. Dr.B.ASOKAN,M.S,Mch

CERTIFICATE - II

This is to certify that this dissertation work titled "A PROSPECTIVE STUDY OF FUNCTIONAL OUTCOME OF TIBIAL METAPHYSEAL FRACTURES TREATED WITH INTRAMEDULLARY NAILING WITH BLOCKING SCREWS (POLLER SCREWS)" of the candidate Dr. A.JAYA MICHEAL ESTHAK with registration Number 221612251 for the award of MASTER OF SURGERY in the branch of ORTHOPAEDIC SURGERY. I personally verified the urkund.com website for the purpose of plagiarism check. I found that the uploaded thesis file contains from introduction to conclusion pages and result shows 6% plagiarism in the dissertation.

Signature of the Thesis Guide Prof.Dr.D.R.RAMPRASATH

M.S.Orth., D.Orth.

Associate Professor & Guide

DECLARATION

I declare that the dissertation entitled "A PROSPECTIVE STUDY OF

FUNCTIONAL OUTCOME OF TIBIAL METAPHYSEAL FRACTURES

TREATED WITH INTRAMEDULLARY NAILING WITH BLOCKING

SCREWS (POLLER SCREWS)" submitted by me for the degree of M.S

Orthopaedics is the record work carried out by me during the period of May

2016 to September 2018under the guidance of Prof.Dr.D.R.RAM PRASATH

M.S.Orth., D.Orth., Associate Professor, Institute of Orthopaedics and

traumatology, Coimbatore Medical College & Hospital, Coimbatore. This

dissertation is submitted to the Tamilnadu Dr.M.G.R. Medical University,

Chennai, in partial fulfillment of the University regulations for the award of

degree of M.S.ORTHOPAEDIC SURGERY examination to be held in May

2019.

Place: Coimbatore Signature of the Candidate

Date:

(Dr.A.JAYA MICHEAL ESTHAK)

Signature of the Thesis Guide Prof.Dr.D.R.RAMPRASATH

M.S.Orth., D.Orth.

ACKNOWLEDGEMENT

I express my thanks and gratitude to our respected Dean Prof.Dr. B.Asokan, M.S, Mch, Coimbatore Medical College & Hospital, for having given permission for conducting this study and utilize the clinical materials of this hospital.

I have great pleasure in thanking my beloved Professor & Head of the Department

Prof.Dr. S.Vetrivel Chezian, M.S.Ortho., D.Ortho, FRCS., PhD, Director, Institute of Orthopaedics and Traumatology, for his guidance and constant advice provided throughout this study.

I sincerely thank my thesis guide Prof.D.R.Ramprasath, M.S.Ortho., for his advice, guidance and unrelenting support during the study.

My sincere thanks and gratitude to Prof.T.Karikalan, M.S.Ortho, for his constant advice and guidance.

My sincere thanks to Prof.P.Kosalaraman, former Associate Professor, Department Of Orthopaedicsfor their constant inspiration, guidance and advice.

I sincerely thank Dr.K.S.Maheswaran, Dr.Marimuthu, Dr.M.S.Mugundhan, Dr.Balamurugan, Dr.Vivekanandhan, Dr.Ravi Kumar, Dr.ArunKumar, Assistant Professors of this department for their valuable suggestions and help during this study.

I thank all anesthesiologists and staff members of the theatre and wards for their endurance during this study.

CONTENTS

Sl.No CONTENTS PAGE NO.

1. INTRODUCTION 1

2 AIM OF THE STUDY 4

3 TIBIAL METAPHYSEAL FRACTURES 5

4

BIOMECHANICS OF DEFORMITIES AND

NECESSITY OF POLLER SCREW APPLICATION – LITERATURE REVIEW

34

5 MAIN OUTCOME MEASUREMENTS 53

6 MATERIALS & METHODS 54

7 POST OPERATIVE PROTOCOL 62

8 ANALYSIS OF RESULTS 64

9 DISCUSSION 84

10 CONCLUSION 92

11 BIBILOGRAPHY 93

CASE ILLUSTRATIONS 100

PROFORMA 110

CONSENT IN TAMIL 112

INTRODUCTION

Nowadays with the advancement of automobile technology human life is set at a faster mode. The increase in the number motor vehicles and the urbanization has directly led to an increase in the number of road traffic accidents and deaths. Globally the number of deaths due to major road traffic accidents is estimated to be 1.2million deaths /year while the number injured is as high as 50 million injuries /yr. In India, more than 1, 00,000 lives are lost due to road traffic accidents every year (WHO global safety report 2011). A 4.4 fold increase has been detected in the number of road traffic accidents between the years 1970- 2011.This increase in the road traffic accidents has significantly led to an increase in the incidence of long bone fractures.

Tibia because of its subcutaneous location is one of the most commonly fractured long bones. Proper treatment of these fractures is of paramount importance. There are various methods of treating tibial fractures such as conservative treatment by maintaining traction or application of plaster casts and surgical treatment by open or closed reduction and internal fixation by intramedullary nailing or plateosteosynthesis and external fixation.

Management of metaphyseal fractures of the tibia is a big challenge to the operating surgeon.The treatment aims onreduction of sagittal and coronal mal-alignment, establishment of length and rotational alignment and maintaining the same until fracture union. Intramedullary Interlocking nailing is still the gold standard treatment for closed fractures of the tibial diaphysis. However it is also been used to treat proximal and distal diaphyseo-metaphyseal junctional fractures. Intramedullary nails are currently becoming the effective method in treating extra-articular tibial metaphyseal fractures due to its advantages such as reduced hospital stay,early full weight bearing and time for bony union.Also it spares the extra-osseous blood supply, acts as a load sharing device and more importantly avoids extensive soft tissue dissection.

The term “Poller” refers to small metal devices placed in the roads of European countries to block or guide traffic. The concept of a poller screw is based on the principle that the mal-alignment induced by oblique, proximal and distal fractures can be counteracted by the nail-directing effect of the screw. These blocking screws reduces the diameter of medullary cavity when placed properly and thereby guides both the guide-wire and the intramedullary nail into a desired central position. Thus it aids in proper reduction of the fracture, maintaining the reduction and improving the stability of the bone-implant complex. The Poller screw can be a small fracture screw or a locking screw, depending on the local anatomy. It can be inserted in any plane but is usually inserted in sagittal or coronal planes. Poller screws act via a 3- point fixation principle to nullify the displacing muscular forces and ligament pull and narrow the metaphysis play. They can also nullify tissue tension when placed in concave side, close to the center of rotation of angulation(CORA), adjacent to the nail track and perpendicular to the deformity plane. They are used by Orthopaedic surgeons for the following four purposes:

a) To correct fracture alignment after insertion of nail,by using screw as a

reduction tool.

b) To improve of the mechanical stability of the BIC(bone – implant construct) by

reducing the medullary canal diameter, especially to control shearing forces. c) To maintain the fracture alignment till union.

AIM OF THE STUDY

TIBIAL METAPHYSEALFRACTURES

Anatomy of Tibia

The tibia is also known as the shinbone, and is the second largest bone in the body. The tibia is found on the medial side of the leg next to the fibula and closer to the median plane or centre-line. The tibia is connected to the fibula by the interosseous membrane of the leg, known as syndesmosis.It has a shaft and two extremities.

The length of an adult tibia varies between 30cm to 47cm in length on average and a diameter of 8mm to 15mm. There is also an anterior angulation of proximal tibia of about 15 degrees. The backward slope of the tibial plateau, of about 6 degrees provides an obvious entry point for passage of IMIL nail, where the cancellous bone can be perforated easily.

Metaphysis of Tibia:

Tibial Metaphysis refers to an area within a square, in which the sides are of

the same length as the widest part of the articular surface. On cross section the

shaft of tibia appears to be triangular. Both the proximal and distal metaphyseal region are widened in order to articulate the proximal part with femur and the distal part with the talus and fibula thus supporting the entire body’s weight at the knee and ankle joint.

by medial and lateral tibialcondyles. The distal end has a medial projection known as Medial Malleoli.

Diaphysis of tibia: (body/shaft)

The body has three borders and three surfaces.

Borders:

The anterior crest is the most prominent of the three. It extends from the tibial tuberosity to the anterior border of Medial malleolus. It is sinuous and prominent in the upper two-thirds of its extent, but smooth and rounded below. The deep fascia of leg is attached to the anterior border of Tibia.

Medial border of Tibia is smooth and rounded above and below, but more prominent in the center. It extends from the medial epicondyle to the posterior border of medial malleolus ; The upper part provides attachment of about 5cm of the tibial collateral ligament of the knee., and some fibers of the Popliteus are inserted in this region; Few fibers of the Soleus and Flexor digitorum longus originates from the middle one third of medial border of Tibia.

Lateral border also known as the interosseous border is thin and prominent, in its central part. It provides attachment to the interosseous membrane which connects tibia and fibula. It extends from the articular facet of fibula, and distally it bifurcates, to form the boundaries of a triangular notch, for the attachment of the interosseous inferior tibiofibular ligament.

COMPARTMENTS OF THE LEG: The three compartments of the leg are:

3. Posterior/ flexor – subdivided into superficial and deep.

ANTERIOR COMPARTMENT OF THE LEG:

Four muscles in the anterior compartment of the leg : Tibialis Anterior, Extensor Digitorum longus, Extensor Hallucis longus and Peroneus tertius. Collectively, they act to dorsiflex and invert the foot at the ankle joint. The extensor digitorum longus and extensor hallucis longus also extend the toes. These muscles are innervated by the deep fibular nerve (L4-L5), and blood is supplied via the anterior tibial artery.

LATERAL COMPARTMENT

There are two muscles in the lateral compartment of the leg; the fibularis longus and brevis (also known as peroneal longus and brevis).

POSTERIOR COMPARTMENT

The posterior compartment of the leg contains seven muscles, organised into two layers – superficial and deep. The two layers are separated by a band of fascia. The posterior leg is the largest of the three compartments. Collectively, the muscles in this area plantarflex and invert the foot. They are innervated by the tibial nerve, a terminal branch of the sciatic nerve.

The superficial muscles form the characteristic ‘calf’ shape of the posterior leg. They all insert into the calcaneus of the foot (the heel bone), via the calcaneal tendon.

There are four muscles in the deep compartment of the posterior leg. One muscle, the popliteus, acts only on the knee joint. The remaining three muscles (tibialis posterior, flexor hallucis longus and flexor digitorum longus) act on the ankle and foot.

Ossification:

Ossification of Tibia occurs from one primary and two secondary

ossification centers. Primary ossification center for body and Secondary centers

for either extremities. Primary center appears in the middle of shaft at about the

seventh week of fetal life, and gradually extends toward the extremities. The

upper epiphysis appears just before birth(at the end of 9th month) which fuses with the shaft at about 16-18 years; It is flattened in form, and extends as a thin

tongue-shaped process in front, to form the upper part of tibial tuberosity. The

present, the upper epiphysis center whichis tongue shaped process forms the

tibial tuberosity, and another center for the formation of medial malleolus.

Anterior aspect of Proximal Metaphysis

Distal Metaphysis :Anterior aspect With soft tissue attachments

Vascular Anatomy

The vascular system of tibia consists of 3 parts each having an arterial and venous part – 1.Nutrient vessels, 2.Epimetaphyseal vessels, 3.Periosteal vessels.

METAPHYSEAL FRACTURES: Epidemiology:

rates of metaphyseal ankle fractures by age and gender1. The incidence of fractures ranges from 3 per 10,000 per year among the age of 30 to 34-years in women to28 per 10,000 per year among the age of 15 to 19-years in boys.

Mechanism of injury:

In most cases injuries to tibia occurs due to the road traffic accidents, direct trauma, gun shot injuries, fall from the height and sports injuries. The trauma to tibia is directly proportional to the occurence of major soft tissue

damages. Henceforth, assessment of injuries are based regarding the violence

of the injury. Therefore,the prognosis depends on the injury to the soft tissues.

Clinical evaluation:

in distribution of involved nerves, muscle weakness and stretch pain. Acute compartment syndrome is usually a medical emergency. Compartment syndrome can be confirmed by measuring compartment pressure, hence it should be monitored periodically. Compartment pressure ranging from more or within 30 mmHg of the diastolic pressure is indicative of emergency fasciotomy. Evaluation of the distal neurological status is always performed .. In cases of fracture of neck of fibula the common peroneal nerve is most commonly injured .These injuries occurs more common on its association with proximal tibial metaphyseal fractures. Thereafter the pattern of fracture and its displacements are to be assessed clearly. There is always a possibility of developing valgus and antecurvatum mal-alignment of the proximal fragment which is due to the gastrocnemius muscle acting posteriorly, tibialis anterior which acts anterolaterally and patellar tendon which acts anteriorly. Most often the tibial fractures are associated with the ligament injuries in the knee. Hence clinical assessment of the ligaments of knees is mandatory and also important. In cases of proximal or distal metaphyseal fractures, the stability of the knee or ankle joint are evaluated respectively.

Radiological evaluation

fractures usually leads to the extension of the fracture into the joint, the radiographs must include the knee and the ankle joints. Sometimes Intra articular extension of the fracture is evaluated using the CT scan. Ligament injuries occurring in proximal tibial metaphyseal fractures can be ruled out using MRI scan.

CLASSIFICATIONS:

There are 2 Classification systems for Classifying Fractures of Tibial: I. AO/OTA Classification

II. Taylor and Martin SUD classification

AO/OTA Classification:

In the AO/OTA classification, the tibia is given the number 4 and the metaphyseal regions are designed as follows:

Proximal metaphysis is designated as 41.

Distal metaphysis is designated as 43.

AO/OTA Classification of proximal tibial Fractures( AO 41): Type A – Extra - articular, Type B - Partialy articular

Type C - Completely articular.

A - Extra articularfracture

A2 - Extra articular fracture, Metaphyseal simple A2 .1. Oblique in frontal plane

A2 .2. Oblique in sagittal plane A 2 .3. Transverse

A3 - Extra articular fracture, Metaphyseal multifragmentary A3.1. Intactwedge

A3 .2. Fragmented wedge A3.3. Complex

B – Partial articular fracture

B1 – Partial articular fracture, Pure split B1.1 Of the lateral surface

B1 .2 Of the medial surface

B1.3 Oblique, involving the tibial spines and one of the surfaces B2 - Partial articular fracture, Pure depression

B2.1 Lateral total

B2.2 Lateral limited B2. .3 Medial

B3 - Partial articular fracture, Split depression B3 .1 Lateral

B3.2 Medial

C – Complete articular fracture

C1 – Complete articular fracture, articular simple, metaphyseal simple C1.1 Slight displacement

C1.2 One condyle displaced C1.3 Both condyles displaced

C2 - Complete articular, articular simple, metaphyseal multifragmentary C2.1 Intact wedge

C2.2 Fragmented wedge C2.3 Complex

C3 – Complete articular fracture, multifragmentary C3.1 Lateral

C3.2 Medial

C3.3 Lateral and medial

2.AO/OTA Classification of Distal tibia (AO 43):

A – Extra articular fracture

A1 – Extra articular, Metaphyseal simple A1.1 Spiral

A2 - Extra articular fracture, Metaphyseal wedge A2.1 Posterolateral impaction

A2.2 Anteromedial wedge

A2.3 Extending into the diaphysis

A3 - Extra articular fracture, Metaphyseal complex A3.1 Three intermediate fragments

A3.2 > 3 intermediatefragments A3.3 Extending into the diaphysis

B – Partial articular fracture

B1 – Partial articular fracture, Pure split B1.1 Frontal

B1.2 Sagittal

B1.3 Metaphyseal multifragmentary

B2 - Partial articular fracture, split depression B2.1 Frontal

B2.2 Sagittal

B2.3 Of the central fragment

B3 - Partial articular fracture, multifragmentary depression B3.1 Frontal

B3.2 Sagittal

C – Complete articular fracture

C1 – Complete articular fracture, articular simple, metaphyseal simple C .1 Without depression

C1.2 With depression

C1.3 Extending into diaphysis

C2 - Complete articular, articular simple, metaphyseal multifragmentary C2.1 With asymmetric impaction

C2.2 Without asymmetric impaction C2.3 Extending into diaphysis

C3 – Complete articular fracture, multifragmentary C3 .1 Epiphyseal

C3 .2 Epiphyseo - metaphysis

C3 .3 Epiphyseo - metaphyseo – diaphyseal

II. Taylor and Martin SUD classification of metaphyseal fractures

Taylor and Martin devised a classification system for metaphyseal fractures (SUD) in which the main fracture is classified as stable (S), unstable

S-Stable

- extra articular - <2mm displacement - >2mm displacement

U-Unstable

- extra articular - <2mm displacement - >2mm displacement.

D-Diaphyseal Extension

- extra articular - <2mm displacement - >2mm displacement

According to Taylor and Martin classification the treatment shifts toward external fixator and away from open reduction with progression from type’ S’ to type’ D’.

Treatment of Metaphyseal tibial fractures: The aimsof treatment are:

- To achieve good alignment of fracture.

- To achieve pain-free weight bearing in the injured limb.

- To provide functional range of motion in the knee and ankle joints at

These goals are to be achieved in order to obtain an optimal treatment , while the complications, likely infection should be minimised. The hinge joints present at the knee and the ankle, does not allow adjustment for rotatory deformity after fracture. Henceforth, proper care should be taken during reduction to correct such deformities.

Factors influencing the treatment and prognosis of metaphyseal fractures: 1.Condition of the soft tissues:

The extent and type of soft tissue damage plays a major role in the progression of fracture healing and occurrence of infection . Tscherne’s method is useful in describing closed fractures, while Gustilo’s grading is useful in describing open fractures. According to Gustilo-Anderson grading, the incidence of injury to the soft tissue ranges from 1 percent in type I to 30 percent in type IIIC.

2. Extent of the Bone injury:

3.Stability of the fracture:

Fracture is considered to be stable when the bone attains the weight bearing ability. Conservative treatment is given to stable fractures with less displacement. Stable fractures are easily fixed by internal fixation and hence unnecessary soft tissue dissection is avoided. Severely comminuted fractures being the least stable fracture, requires mechanical fixation and soft tissue dissection.

4.Degree of wound contamination:

The degree of contamination plays an important role in cases of open fractures. On clinical examination, the limb is thoroughly assessed for signs of soft-tissue damage, bruising, excessive swelling, crushing or tenting of the skin, and gas gangrene in open wound.

Treatment options

a. Conservative method b. External fixator.

c. Open reduction with plateosteosynthesis

d. Open reduction or Closed reduction and internal fixation with intramedullary interlocking nailing.

Conservative method of treatment:

Conservative method of treatment is indicated in debilitated patients,

any medical illness contraindicating the surgical treatment and in cases of

Demerits of conservative management:

1.Mal union/Delayed union 2.Nonunion

3. Post traumatic joint stiffness

4.Secondary Osteoarthritis of knee /Ankle joints

Methods of surgical management

1. Open reduction, internal fixation with plateosteosynthesis.

2. Closed reduction/open reduction with intra medullary and inter locking nailing

3. External fixation

1.Open reduction with plateosteosynthesis:

This method is indicated in

1. Metaphyseal fractures with very short proximal/distal fragment.

Advantages:

 Feasiblity of bonegrafting

 Anatomic reduction with stable fixation  Fixed angle fixation,

 Bicolumnar fixation

 Maintenance the length & alignment.

There is a high incidence of 10 to 15% of soft tissue complications in many cases. In recent advances, plating like indirect reduction and percutaneous plating (LISS- Less Invasive stabilisation System) is indicated in tibial metaphyseal fractures with periarticular metaphyseal comminution. The use of standard incisions according to Collinge and Sanders also improves the wound healing.

Locking compression plates:

Complications and disadvantages of plate osteosynthesis: 1. Soft tissue complications like delayed wound healing

2. Risk of superficial infection is high due to poor soft tissue cover

3. Superficial wound problems increases the risk of deep infection upto

six fold.

4. Malalignment is a most common complication occuring in percutaneous

plating than with other methods of fixation.

5. Fracture alignment cannot be achieved by the locked plate . Fracture has

to be reduced before applying the plate12.

6. Pain may occur over the distal tibial and fibular plate orscrews1

7. Locked compression plating needs careful preoperative planning.

8. Failures are common if applied without following the principles of

plating and the order of putting the screws17.

External fixation:

External fixation is indicated in conditions like:

 Compound fractures with severe contamination

 Associated vascular injuries

 Fractures with acute compartment syndrome

 Fractures with large bone defects

 Severely comminuted / unstable fractures with articular extension with severe soft tissue damage.

Methods of external fixation:

 Knee spanning or ankle spanning external fixators  Ilizarov ring fixator

 Hybrid fixator

Hybrid external fixator:

Usually in metaphyseal fractures, the proximal and distal fragments are short and hence it becomes difficult to insert two pins in the longitudinal axis. Therefore ,in order to stabilise the short fragment the pins are inserted in the tranverse axis and a special ¾ or ½ ring is used. The diaphyseal fragment is fixed with longitudinal pins with AO rods and thus stabilised. Later the two fragments are interfixed with two or more AO rods.

Disadvantages of external fixators:

 This method is not an option for definitive treatment.

BIOMECHANICS OF DEFORMITIES AND NECESSITY OF POLLER SCREW APPLICATION – LITERATURE REVIEW

development of the Kuntschner’s ‘Detensor’ nail and described by Kempf and Klemmet al, was a major breakthrough. The comparative studies between conservative treatment and IMIL nailing shows superior results with intramedullary interlocking nailing than the conservative management17. In a prospective randomized study done by Bone et al, he found that nonunion and malunion occurred only in 2% patients of nailing group when compared with the incidence of 26% malunion and 10% nonunion that occurred in their conservatively managedgroup18.

Principles of IMIL nailing:

Effect of Nailing on circulation:

The inner two thirds of the cortex is supplied by the medullary arteries, and the outer one third is supplied by the periosteal vessels via its soft-tissue attachments. These medullary vessels are damaged when a fracture occurs. This leads to necrosis of around 50-70% of the bony cortexnear the fracture site. In addition to this, IMIL nailing also damages the medullary blood supply, resulting in partial cortical necrosis. The endosteal vasculature regenerates around the nail, and the greater the space between the nail and the cortex, more rapidly this revascularization progresses. The regeneration of the nutrient artery may be delayed upto6 months. It is delayed further in the presence of a more close-fitting nail.

Reaming of Medullary canal:

The medullary canal is more like an hourglass than a perfect cylinder. Reaming the medullary canal is an attempt to make the medullary canal of a uniform size to adapt the bone to the nail and thus provide a large contact area between it and the nail. Reaming is beneficial as it improves the nail-bone contact area; when the nail is the same size as the reamer, 1mm of reaming can increase the contact area by 38%.Reaming widens the medullary cavity, lets insertion of a larger diameter nail, improves the length of contact, reduces working length and increases the stability of the “tube within a tube”.

Side effects of Reaming:

direct damage to the endosteal vasculature or by invasion of bone marrow elements and fat into the intracortical blood vessels leading to thrombosis. Revascularisation occurs from the periosteal side. After reaming, periosteal vascular proliferation and hyperemia occur together with the periosteal new bone formation. The time for regeneration of cortical vascularity is shorter in tibias treated with non-reamed nailing than those treated with reamed nailing. The rate of the revascularization depends on the extent of the reaming performed. Wenda et al intra operatively measured intramedullary pressure while reaming and found that values with reaming was between 420 - 1510 mm Hg , as compared with 40-70 mm Hg in cases where unreamed solid nails were used.

Bone Healing after Nailing:

Fixation with a nail of adequate stiffness leads to satisfactory bone healing. If thin and loosely fitting nails are used, delayed union and non-union results. Nail fixed fractures heal by periosteal callus whereas plate fixed fractures heal mainly by endosteal callus formation; the mechanical strength of both is similar at 120 days.

Indications for Nailing:

also. At present IMIL nailing is the treatment indicated for most of the Gustilo Anderson’s type I, type II, and type IIIA compound and closed tibial diaphyseal and metaphyseal fractures.

Advantages of nailing:

In closed IMIL nailing the fracture hematoma and periosteal blood supply is not disturbed. This helps in early fracture healing. The endosteal vasculature is disturbed in the reamed nailing but it improves the periosteal blood supply. Intramedullary nails are load sharing devices when compared to plates which are designed as load bearing devices. So the chance for periprosthetic osteopenia and periprothetic fractures is very low.

Reamed versus Unreamed nailing:

of open tibial fractures treated with reamed nailing and with unreamed nailing. The problems of delayed union and hardware failure with unreamed nailing have led to usage of the reamed nailing for tibial fractures.

In a randomized, prospective study by Blachutet al. ,73 fractures treated with reamed nailing was compared with 64 fractures treated with unreamed-nailing. The results were similar in terms of infection (0% for reamed, 1.6% for unreamed), malunion (4.1% reamed, 3.2% unreamed), and fracture union (95% reamed, 89% unreamed).

In another study by Finkemeier et al., comprising 94 tibial shaft fractures, he found that for open fractures the results were similar between reamed and unreamed nailing in terms of time to union. A higher number of closed fractures treated with reamed nailing healed at 4 months time, than those treated with unreamed nailing. But the union was similar at 6 and 12 months.

Bhandari et al in a study suggested that the risk of implant failure in non reamed nailing is higher while compared to the unreamed nailing. Overall the authors suggested that reamed nailing of closed tibial diaphyseal fractures

led to earlier union. All these studies indicate that fracture pattern and

soft-tissue injury levels are more important in determining outcome of fracture than

the choice of treatment.

reamed intramedullary interlocking nailing is the treatment of choice due to its economically less financial burden when compared to the conservative methods which cause a higher financial burden due to the long duration of the treatment and lower functional outcome.

Intramedullary interlocking for tibial shaft fractures:

The IMIL nailing is the gold standard treatment method for diaphyseal fractures of tibia. Closed intramedullary nailing preserves the soft- tissues around the fracture site, hence aids in early fracture union and early mobilisation of joints. The provision of locking the nails proximally and distally gives control of length, alignment, and rotation in case of unstable fractures and enhances stability of fractures.

Intramedullary nailing in tibial metaphyseal fractures:

At present IMIL nailing is widely used as the treatment of choice for extra articular tibial metaphyseal fractures. Prevention of malalignment and maintenance of the reduction until union are the concerns here12. Different authors used various supplementary procedures to effectively manage the tibial metaphyseal fractures with IM nailing.

Various techniques to prevent the malalignment of fragments:  ‘Poller’ blocking screws

 Lateral entry point of nail.

 Unicortical plating of tibia

Proximal metaphyseal fracture of tibia:

In case of a Proximal tibial metaphyseal fracture the short proximal fragment will go for mal-alignment owing to the pull of patellar tendon anteriorly, pull of gastrocnemius tendon posteriorly and the mismatch between nail size and medullary canal width. Ante-curvatum and valgus are the most common deformities occurring in the coronal and sagittal planes respectively. Other deformities are recurvatum and varus.

Biomechanism of deformities:

The mismatch between the nail insertion axis and the anatomic axis of the distal segment which contains the isthmus results in valgus deformity. It is mainly caused by use of a far medial entry point and to some extent due to the shape of the proximal tibia. The AP diameter of the tibia is much narrower on its medial half than in its lateral half, so the medial cortex forces the nail laterally. A medial parapatellar incision with the patellar tendon retracted laterally to expose the entry site causes the valgus deformity. Additionally in proximal metaphysis, the fracture starts in the lateral aspect and extends medially and distally. There is no lateral cortex to guide the nail distally. Once the nail enters the distal segment, valgus deformity occurs.The musculature of the anterior compartment acting on the lateral tibial surface, contributes to valgus deformity during the nailing.

the Herzog’s bend, results in an anterior angulation and posterior translational deformities. When the entry point is eccentrically placed, it causes the antecurvatum deformity. Displacement of upto 1cm is seen when fracture is proximal to the Herzog’s bend, with the distal fragment translating posteriorly. The patellar tendon anteriorly pulls the proximal fragment and the gastrocnemius posteriorly pulls and contributes to the deformity.

What literature says?

In 1996,Tornetta et al in their study concluded that semi extended position can prevent the anterior translation and antecurvatum deformities. In 1997 Buchler et al & Tembcke et al advocated a laterally placed entry point to prevent valgus angulation.

In 2003, Laflamme et al suggested that more oblique screws can be used to maintain the alignment33.In 2006 Sean E Nork suggested the use of the additional temporary unicortical plating of tibia to achieve alignment. Laflamme et al and Nork demonstrated the wedging effect, when the Herzog’s bend is distal to the fracture site resulting in malalignment of the fragments. So they suggested use of nails with more proximal bend33,1.

Proximal locking of nail with the knee in flexion causes proximal fragment extension due to the pull of patellar tendon. Lang et al. studied 32 proximal tibial fractures treated with statically locked nailing and found >5 degrees angulation in 84% and displacement of > 1 cm in 59%. Recent techniques like more precise nail entry point and the use of supplemental fixation procedures such as blocking screws( poller), unicortical plates have reduced the frequency of this complication.

In a study Oh CW, Kim SJ et al confirmed that the use of ‘poller’ blocking screws in proximal metaphyseal tibial fracture can prevent malalignment16.

In another study Peter Schandelmaier, MD et al advocated that poller screws are useful to prevent malalignment in fractures of proximal tibial metaphysis.

Ricci et al. in a study of 12 proximal 1/3rd tibial fractures treated with locked intramedullary nailing supplemented with ‘poller’ blocking screws reported occurrence of malunion in one patient only. He concluded that the

poller screws are effective, simple method to prevent malalignment.

In 1998, Andrew H Schmidt and MD, Christopher G Et al reported that use of ‘poller screws’ is the simplest technique to prevent malalignment in metaphyseal fractures of proximal tibia17.

IMIL nailing in distal metaphyseal fractures:

In fractures of distal metaphysis of tibia the short distal fragment goes for valgus or varus malalignment due to various soft tissue deforming forces acting on it.

What literature says?

In a study Tarr et al. and Puno et al. stated that distal tibial malalignment leads to more morbidity than proximal fracture malalignment. Robinson et al in 1995 resected the distal few millimetres of the standard AO nail and used a large reduction forceps percutaneously to achieve and maintain alignment throughout the procedure. He used the distal locking bolts as a lag screw through the fracture site41.

Valgus angulation Varus angulation

five had satisfactory clinical outcomes34. Intramedullary nailing of more distal fractures is possible, but farther the fracture extends distally lesser is the ability to maintain a mechanically stable reduction.

Gorczyca et al. reported that the results achieved in fractures at 4 cm distance from the tibiotalar joint fixed with a shortened nail was similar to that of the stability achieved in standard IM nailing of fractures.

In 2003 James Kellam noticed that intramedullary nailing of distal tibial metaphyseal fractures supplemented with fibular plating or ‘poller screw’ showed excellent results35. In 2004 the techniques of using ‘Poller screws’ in distal tibial fractures was described by Hans Warner Stedfield et al1.

In 2007 Dodd et al in his study advocated that when comparing with other methods ‘Poller screws’ are the most effective method to prevent malalignment in open reduction and fixation of the distal tibial fractures.

Poller screw

Purposes of poller screws:

1. To achieve fracture alignment, by using screw as a reduction tool.

2. Avoids fracture displacement and maintains the fracture alignment till union with poller blocking screw

3. To reduce the medullary canal diameter and thereby increasing the bone

– implant construct stability.

Biomechanism of poller blocking screw function:

Poller or blocking screw works on three-point fixation principle as in elastic intramedullary nail or plaster cast for Colles’ fracture. Use of a single blocking screw can achieve three point fixation as long as adequate support exists at two other points of fixation. The supplementary points of fixation maybe the entry point of the nail or the cortical wall through isthmus in a long segment or a hold at the nail tip in a short segment. A second blocking screw may be needed on the opposite side when fixation provided by supplementary points is insufficient. A transmedullary blocking screw prevents axial displacement caused by imbalanced soft tissues.

In varus deformity, the nail is centralized in the medullary cavity with the help of the poller screw acting as substitute for the medial cortex.

In valgus deformity the poller screw i s applied anterior to posterior on the concave side of deformity. It reduces medullary canal diameter and act as substitute in guiding the nail. It guides the nail properly when the nail is displaced laterally in case of a more medial entry of the nail.

In antecurvatum deformity, poller screw is placed in medial to lateral direction as a substitute for posterior cortex. It directs the nail centrally in the medullary canal as in a middle third fracture. The poller screw is placed in the posterior aspect of the proximal tibia in the sagittal plane. This screw blocks the nail from passing posteriorly and neutralises the extension forces in antecurvatum deformity. In case of recurvatum deformity vice versa is done.

Similarly, in case of distal 1/3rd tibial fractures the nail passes into the short distal fragment eccentrically due to the medullary canal diameter disparity between the short distal and the long proximal fragment which results in malalignment. An AP blocking screw placed laterally or medially decreases medullary canal diameter keeping the nail centrally, by acting as substitute for the lateral/medial cortex. Thus it prevents valgus/varus deformity.

The rule of poller screw insertion

Demonstration of function of poller screw:

In the above figure, Malalignment occurs due to

1. Disparity in medullary canal diameter and off center nail entry point

Finally the deformity is corrected with the poller screw applied in the short fragment on the concave side of the deformity.

Demonstration of cases :

a)Proximal metaphyseal fractures:

The recurvatum deformity is corrected by the “poller” screw placed posterior to the nail mediolaterally.

Distal metaphyseal fractures : In valgus deformity :

The “poller” screw is put on the lateral side of the nail in an antero-posterior direction on the concave side of the deformity. Another additional screw is

inserted on the medial side of the deformity.

In varus deformity:

Literature :

The clinical applications of screws was first described by Krettek et al in 1994 who named it as “poller” screws. The poller screw prevents the coronal and sagittal plane deformities of proximal and distal 1/3rd tibial metaphyseal fractures during intra medullary nailing.

In 2010, 135 patients were studied by C.petrou, Baikousis. He noticed that the distal1/3rd tibial fractures treated with IMIL nailing supplemented with ‘poller’ blocking screw showed acceptable radiographic alignment, defined as angulation of <5° in any plane.

In a study, Ricci et al. operated twelve consecutive fractures of the proximal 1/3rd tibia found that all patients had <5° of malalignment except one patient who had a 6° valgus deformity.

In a prospective study , seventy-three proximal fractures were reported by Tornetta et al an algorithm devised for the application of the poller screws in metaphyseal fractures was used.

MAIN OUTCOME MEASUREMENTS

MATERIALS AND METHODS

This is a prospective case study of 20 patients admitted with tibial metaphyseal fractures in the emergency department of Coimbatore Medical College Hospital between October 2016 and September 2018.

All of them were treated with open reduction/closed reduction with statically locked IM nailing supplemented with ‘poller screws’.

Inclusion criteria:

 Skeletally mature patients

 Either proximal or distal metaphyseal tibial fractures.

 Closed fractures and Gustilo Anderson Grade I Open fractures

 Segmental fractures with involvement ofmetaphysis.

Exclusion criteria:

 Skeletally immature patients

 Very minimally (or) undisplaced fractures.

 Compound fractures Gustilo-Anderson Grade II & III with bone loss

 Tibial metaphyseal fractures extending into the articular surface

 Pathological fractures

Implants used:

1. Intramedullary Nails (In varying sizes9x320,340,360,380 mm):

2. “Poller” screws:

Interlocking bolts in size of 4.9 mm,were used as “poller” screw

Pre operative assessment:

•

•

recurvatum deformity was noted preoperatively.

•

•

•

•

1. Pre-operatively, in the contralateral normal limb, measured fromthe tibial tuberosity to the medial malleolus.

2. Intra operatively by clinical method

Methods:-

• All the cases were operated under spinal anaesthesia • on traction table with knee in semiextended position

• allowing the movement of C-Arm to take AP and lateral views intraoperatively.

Operative Technique:

- Under spinal anaesthesia patient in supine position

- The affected limb is connected to a fracture table with a padded knee support with the knee flexed to < 30 degrees. For distal metaphyseal fractures the flexion was maintained at 90degrees.

- Through patellar tendon splitting approach 4-5cm incision is made starting from the inferior border of the patella upto the tibial tuberosity. - The patellar tendon is incised and split in line of the skin incision. Extra

articular surface of the tibia exposed and precise entry point was marked.

- Entry point made with bone awl at a point proximally and laterally in

- The bone awl is initially pointed posteriorly and later directed in line with the medullary canal.

- Then under the C-Arm guidance fracture was reduced. The tendency of the fragment for which deformity is noted.

- The poller screw is inserted under the C-Armguidance according to the deformity ,on the concave side of the deformity, in the short fragment.

- Then the guide wire is passed and reaming was done. In proximal metaphyseal fractures the reaming was done close to the anterior cortex. - Serial reaming was done upto 1mm higher than the proposed nail size.

The measured size nail was inserted and locked statically.

- Additional poller screws were applied according to the correction deformities.

Algorithm for placement of poller screws: Proximal metaphyseal fractures:

Deformity Site of insertion in short fragment

Antecurvatum Near posterior cortex mediolaterally

Recurvatum Near anterior cortex mediolaterally Valgus Lateral to the nail, anteroposteriorly

Intraoperative case demonstration: In Proximal 1/3rd fractures:

Valgus deformity:

Valgus angulation in proximal metaphyseal fracture.

Poller screw is applied anteroposteriorly on the concave side

In Distal Metaphyseal fractures

Deformity Site of screw insertion in short fragment

Valgus Deformity Lateral to the nail, anteroposteriorly

Varus Deformity Medial to the nail, anteroposteriorly

In varus deformity

The varus deformity is corrected with poller screw.

According to the deformities present at the time of surgery, the poller screws were inserted in all the 20 patients according to the above criteria.

Additional poller screws were inserted under C-Arm guidance according the need for correction of the other deformities.

In all the 20 cases reamed nailing technique was used.

The medullary canal was reamed incrementally upto 1mm higher than the measured nail size.

All the nails were locked statically.

POST OPERATIVE PROTOCOL Time Table for related events

S.No EVENTS TIMING

1. Passive knee and ankle

mobilisation- 2

nd

POD

2. Quadriceps strengthening exercises

2nd POD or as soon as pain subsides

3. Radiographs taken on

- Immediate postop - 6weeks

- 12weeks - 24weeks

4. Partial weight bearing started When callus formation is seen on X ray

5. Full weight bearing After full union

EOT- Examination of the wound On Table. POD - Post Operative Day.

On Follow-up

Karlstrom-Olerud Scoring System:

1. Residual angulation : ( 0 to 3points)

• 0 degrees -- 0 point

• 1 - 3 degrees -- 1 points • 4 - 5 degrees -- 2 points • More than 5 degrees -- 3 points

2. Time to Fracture healing: (0 to 3points)

• Fracture Union occurs in < 12weeks -- 0 point

• >12 weeks -- 1 point

• > 12 weeks requiring -- 2 points secondary procedures

• > 6months -- 3 points

3. Cast support: (0 to 1 point)

•

•

Outcome measured:

 0 & 1 Points - Excellent

 2 & 3 Points - Good

 4 Points - Satisfactory

 5 Points - Fair

 6 & 7 Points - Poor

ANALYSIS OF RESULTS Sex-wise Distribution:

Table-1

Sex No.of patients Percent

Male 16 80%

Female 4 20%

20 100%

There were sixteen male and four female patients with the average age of 49.45years,with 95% lower confidence limit(LCL) of 46.98years,and 95% upper confidential limit( UCL)of51.92years.

80% 20%

SEX DISTRIBUTION

Males

Age-wise Distribution:

Table-2

Age group No. of patients Percent

<30 2 10%

31-40 2 10%

41-50 8 40%

51-60 4 20%

>60 4 20%

0 1 2 3 4 5 6 7 8 9

<30 31-40 41-50 51-60 >60

AGE DISTRIBUTION

Side of Injury:

Table-3

Side affected No. of patients Percent

Left 9 45%

Right 11 55%

Total 20 100%

The injury is right side in 11 cases and left side in 9 cases

45% 55%

Side of injury

Gustilo-Anderson Classification of fractures:

Table-4

Grade No. of patients Percent

Closed 14 70%

Grade I Open 6 30%

Total 20 100%

There were 14 simple fractures and 6 Compound Grade - I fractures.

70%

30%

Gustilo-Anderson Fracture pattern

Simple

AO Classification type:

Table-5

AO Type No.of patients Percent

41-A 4 20%

42-A 5 25%

43-A 11 55%

Total 20 100%

There were predominantly 11 distal metaphyseal fracture.

0 2 4 6 8 10 12

41A 42A 43A

No. of Cases

Distance of fracture from the nearby Joint: Table-6

Distance from nearby joint No.of patients Percent

<4 cms 5 25%

4-6 cms 7 35%

>6 cms 8 40%

Total 20 100%

25%

35%

40%

Distance from joint line

Reduction technique used:

Table-7

Reduction technique No.of patients Percent

Closed reduction 18 90%

Open reduction 2 10%

Total 20 100%

Among the 20 cases 2 cases were undergone open reduction

90%

10%

Reduction technique

Closed reduction

Diameter of the Medullary canal:

Table-8

Medullary Mean SD 95% LCL 95% UCL

Isthmus 9.85 0.65 9.20 10.5

Fracture level 12.3 2.92 9.38 15.22

Purpose of the Poller Screw:

Table- 9

Purpose of Poller screw* No.of patients Percent

1 10 50%

2 17 85%

3 20 100%

Total 20 100%

*Purpose of the poller screw used:

1. To achieve fracture alignment( In 10cases)

2. To improve stability of the bone – implant construct (17cases)

3. To maintain fracture alignment till union (20cases)

Purpose of Poller Screw 0

20 40 60 80 100

1 2 3

Purpose of Poller Screw

Number of Poller Screws used:

Table-10

No.of poller screws used No.of patients Percent

1 16 80%

2 4 20%

Total 20 100

Among the 20 cases, 4 Cases needed one additional poller screw to correct the existing deformity

1 poller screw 80%

2 poller screws 20%

No. of POLLER SCREWS USED

Karlstrom-Olerud Scoring: I.Mean angulation

 Varus and Valgus deformities:

Table – 11

DEFORMITY TIME N Mean SD 95% LCL 95% UCL

Varus deformity

Pre operative _{5 5.2 2.38 3.10 7.29} Post operative 5 1.8 1.48 0.49 3.10

At Union _{5 1.8 1.48 0.49 3.10}

Valgus deformity

Pre operative _{15 9.67 7.49 5.87 13.45} Post operative _{15 2.6 1.8 1.68 3.5}

At Union _{15 2.6 1.8 1.68 3.5}

Post operative residual mean varus alignment is 1.8 degree ( 95 % LCL is 0.49 degrees,95% UCL is 3.10 degrees) when compare to the preoperative mean value of 5.2 degree(95% LCL is 3.10 degrees,95% UCL is 7.29 degrees). The P value is = 0.006 (<0.05) which is statistically significant.

0 1 2 3 4 5 6

Pre-operative Post-operative At union

VARUS ANGULATION

VARUS ANGULATION

0 2 4 6 8 10 12

PRE-OP POST-OP AT UNION

VALGUS DEFORMITY

 Antecurvatum and Recurvatum deformities:

Table – 12

DEFORMITY TIME N Mean SD 95% LCL 95% UCL

Antecurvatum deformity

Pre operative 10 8.2 6.39 4.23 12.16

Post operative 10 3.0 3 0.9 5

At Union 10 3.0 3 0.9 5

Recurvatum deformity

Pre operative 10 7.7 5.18 4.48 10.91 Post operative 10 4.8 4.36 2.09 7.5

At Union 10 4.8 4.36 2.09 7.5

Post operative mean antecurvatum angulation is 3.0 degree ( 95 % LCL is 0.9 degrees,95% UCL is 5 degrees) when compared to the preoperative mean value of 8.2 degrees(95% LCL 4.23 degrees,95% UCL is 12.16 degrees). The P value was 0.0004 which was (<0.05)statistically significant.

0 1 2 3 4 5 6 7 8 9

PRE-OP POST-OP AT UNION

ANTECURVATUM DEFORMITY ANTECURVATUM DEFORMITY 0 1 2 3 4 5 6 7 8 9

PRE-OP POST-OP AT UNION

RECURVATUM DEFORMITY

II. Time to fracture union:

Table - 13

Time to fracture union No.of patients Percent

< 15 weeks 13 65%

15 – 20 weeks 6 30%

> 20 weeks 2 10%

Total 20 100

The mean time to fracture union is 14.9 weeks. (95% lower confidential limit is 13.3 weeks,95% upper confidential limit is 16.4 weeks).

Time for union 0

2 4 6 8 10 12 14

<15 weeks 15-20 weeks >20 weeks

Time for union

III. Cast support:

Table-14

Cast support given No.of patients Percent

Yes 2 10%

No 18 90%

Total 20 100%

Cast support

Karlstorm-Olerud Scoring System:

Table - 15

Score No.of patients Percent

0 , 1 3 15%

2, 3 12 60%

4 4 20%

5 1 5%

6 0 0%

Final Outcome measured :

Table - 16

Outcomes No.of Patients Percent

Excellent 3 15%

Good 12 60%

Satisfactory 4 20%

Fair 1 5%

Total 20 100%

15

60

20

5 0

10 20 30 40 50 60 70

Excellent Good Fair Satisfactory

OUTCOME

Complications:

In our study Poller screw related complication occurred in none of the patients. Post operatively one case was complicated with delayed surgical wound healing. In this wound gap was at the subcutaneous level only. We have done daily saline dressing supplemented with appropriate antibiotic treatment. The wound healed well in 3 weeks. No complication like compartment syndrome, nail breakage or screw breakage occurred in ourstudy.

Table-17

Complications No. of cases Percentage

Delayed Union 1 5%

Delayed wound Healing 1 5%

Nil 18 90%

In our study only one case reported with delayed union. The cause of the delayed union was due to increased comminution of the fracture.

5% 5% 90%

COMPLICATIONS

Delayed union

Delayed wound healing

DISCUSSION

The metaphyseal fractures of tibia have coronal and sagittal malalignment owing to the mismatch in the medullary canal diameter of the proximal and distal fracture fragments and to the medullary canal anatomy particularly in the proximal tibial metaphyseal fractures.

Various authors had advocated various methods. Some of them are discussed here. The treatment options for fractures of tibia include

1.Conservative or non-operative treatment. 2.Intramedullary nailing

3.ORIF with plateosteosynthesis 4.External fixation

non operative treatment was compared to surgical fixation. A systematic review of the literature analyzing 13 RCTs demonstrated that closed treatment had higher rates of nonunion, malunion and infection than operative treatment with plates or nails. Bone et al in their level III retrospective cohort study of 99 patients compared outcomes of non operative treatment to IM nailing and found better outcomes in the nail group with lower nonunion rates(2%Vs 10%), faster time to union (18 Vs 26 weeks), and better SF-36,knee and ankle outcomes at a 4 year follow up.

The most important fact is that no randomized study has favored nonoperative management over IM nailing.

The acceptable malalignment in Tibial Diaphyseal fractures according to

Trafton’scriteria:

Alignment parameter Acceptable Malalignment

Varus <5 degrees

Valgus <5 degrees

Apex anterior/posterior < 10 degrees

Rotation < 10 degrees

Shortening < 15 mm

obtained when used in fixation of open fractures of tibia. A systematic review of the literature showed that the pooled deep infection rate was 11%, but some series have higher rates.

Outer et al in their comparative study between functional bracing and plating conducted on 170 patients, reported that plating was associated with a higher complication rate but conservative treatment resulted in higher rates of malunion and a longer time to healing.

Jensen et al published the results of 207 tibial fractures treated conservatively or with various plating techniques and reported lower malunion rates with plating(0-8% and 21%) but a high risk of complications including refracture after hardware removal(11%) and infection(11%).

External fixation is an appealing treatment method for open fractures as no metal is placed at the fracture site, therefore theoretically reducing risk of infection. A meta-analysis comparing external fixation and unreamed nailing in Gustilo Anderson type II fractures showed few differences. Malunion rates of 39% to 48% have been reported with progressive collapse of the fracture demonstrated over time. Albers et al showed that time to union and delayed union rates were higher with external fixation compared with nailed fractures. Shannon et al demonstrated a delay to full weight bearing and more clinic visits with external fixation. A recent review of literature comparing IM nailing and ring external fixation consisting of 61 patients showed that the only difference was a 2 week faster healing time in the fixator group.

It is notoriously difficult to obtain adequate alignment using tibial nail in proximal tibial fractures. The typical deformity present is apex anterior(procurvatum) and valgus deformity. The valgus is typically created by using too medial a starting point that creates an initial reaming pathway which runs from too medial to lateral. The use of an ideal starting point and starting wire direction is particularly important for proximal fractures as is reducing the fracture before reaming.

Dunbar RP et al. made modifications in nail designs such as different proximal bends and more oblique screws.

Sean E Nork et al described the use of temporary unicortical plating of tibia with a medially placed femoral distractor that was used efficiently to achieve reduction in proximal 1/3rd tibia fractures.

In distal 1/3rd tibia fractures, use of poller screws, the fibular plating and cutting the distal few millimetres of nail distal to the distal screw hole can help to achieve alignment. A cross locking bolt across the fracture site acts as lag screw. Supplementary procedures like use of a large point reduction forceps percutaneously, temporary unicortical plating, manipulation with schanz pins percutaneously,and femoral distractor can be used to achieve the alignment.

In our study we have used the method of poller screw insertion in fractures of proximal and distal tibial metaphysis to achieve alignment. It is a simple and less invasive procedure to correct malalignment of both the proximal and distal metaphyseal fractures. Failure to correct the deformities results in malunion of these fractures, which is leads to functional impairment of the nearby joints. Hence it is necessary to avoid these complications.