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Yeah. So the deforming forces are important to understand uh because one, it helps you uh envisage how you're going to reduce this fracture. And it can come up as part of the M C Q questions, it just helps you manage these injuries. So, um for the proximal fractures, you have deforming force from the extensive mechanism acting on the tibial tuberosity. And that gives you that apex anterior um uh deformity. Uh The Pez Anserinus uh kicks the fragment into valgus and your gas trucks flex the distal fragment. Um So, avoiding full flexion and full extension will help take the tension off both the gas strokes and the extensive mechanism and balance. The force is allowing you to reduce things easily. And that's why things like semi extended nailing are helpful and part as part of your reduction tools um which we'll talk about later. So blood supply to the tibia proximity, it's from the metaphysical vessels arising from the genicular anastomosis. And again, you get a nutrient vessel feeding into the endosteal blood supply uh which predominately comes from the posterior tibial artery. Uh the periosteal vessels provide the periosteal supply and again, a bit like the femur flow is centrifugal from inside to out from high pressure, too low pressure. Okay. So your initial management again, same as femoral fractures. So get that line in this is a high energy injury because it normally is in a young patient. Um and I would manage this according to A T L S guidelines, to rule out any life threatening injuries. I will assume that this is a closed and neurovascular intact injury, they'll correct you if it's not and then reduce the fracture, place them in a back slab. Get a piano lateral X ray. I would consider a CT or a CT angio. Uh if there was any vascular compromise to assess for any uh articular extension, if the fracture pattern indicated that okay. So then we talk about how we're going to actually fix it, which is what the majority of the exam is going to be about. And then you can talk about in, in tibial sharp fractures. There is a role for conservative management, okay. Whether that how valid that role is and whether it's a bit like humeral shaft fractures, um it takes a long time to heal, okay. So the best series we have is from Sarmento um in the States who also did the humeral bracing. Um He did what's known as a same inter car. So functional bracing, which you can see here and you might have seen in clinic uh when we occasionally manage these injuries conservatively and what same enter showed that in? He got the fractures to heal within 18 weeks. Okay. And the overall nonunion rate was approximately 1%. And so you look at that and you think, wow, that's amazing. Like why are we fixing these? I'm sure you can manage them non optimally. What, what the story doesn't tell you is that same into is always very involved in the conservative management and it is very intensive. So he would see them regularly. He would wedge the cast in order to correct alignment. Um He would regularly check that um, patient's were compliant, the cast wasn't loose. Um And that's not really what we do when we conservatively manage these fractures, we just wrap them in a plaster and send them away and see them whenever, um, which isn't the same. Uh And so different series written by Bone, it'll uh found the average time to union in a conservatively manufacturer around 26 weeks and about 10% of them went on to non union, which sounds more, more generalized, able. Okay. So the problem with Conservative management is, um, it's, it's malunion, okay. Uh You get, you can get problems with length, rotation, angulations. Uh the knee will be stiff because for the first six weeks, they're in a above knee plaster. Um, they can get ankle stiffness as well. Uh dvts and it takes longer to get them back up on their feet and back to work and compared to a introductory now. So it's also miserable because I think basic things like sitting on a toilet, um, in an above knee plaster is miserable. Um, and it's very difficult to cope with. Um, so it has a role but most patient's will probably opt for surgery. Um, given the time it takes. So if we're gonna do an operation, question is how are we going to position the patient? So this picture shows semi extended nailing, which there are a few approach, a few different types of nailing you can do through a semi extended position. And then this shows a figure of four position which you can do for uh infrapatellar nailing. So, nailing with your entry point through the patella tendon or just medial or lateral to the patella tendon um and that works uh by keeping the X ray up and down and then reaming sideways rather than over the top like you would normally with the infrapatellar nailing. Okay. Um That is a reasonable thing to do in difficile fractures. But the vast majority of people at the moment are leaning towards super patellar nailing and semi extended nailing. So the advantage of semi extended nailing is that you detention the muscles and it helps you with your reduction. Okay. And uh the I I takes X rays at 90 degrees to the table essentially. Okay. So it's much easier to do with a, with a very junior radiographer um than it is to get your adequate x rays for your infrapatellar nailing, okay. Um Most people are now doing it through what's called a super patella portal. And so we'll have got used to doing super patella nailing okay. The advantage is not from being super patella, but it is from the positioning of being semi extended. Okay. Super patella just makes doing some extended nailing a little bit easier and uh and Tidier, but there are alternate ways to do it and we'll talk about that now. So these are all the approaches you can do, right. So you can do on the, on the at the bottom. That's your standard infrapatellar approach. So you put the patient um with their knee slightly flexed uh under on a triangle and then you need to get them flexed up even more to get the nail down. So you need to go into deep flexion to get the nail down, which you can imagine if you're doing that for a proximal fracture would really put strain on that extensive mechanism. So it really flexes up that proximal fragment fragment which often leaves you with a deformity and you nail, it's very difficult to control the proximal fragment. Um Then the other two approaches you can do in the semi extended position, right? So the two approaches are super patella, which people are quite familiar with and the one that people are less familiar with. And I find that when I show registrars and they've not seen it before. Is para patella nailing and this is super patella nailing before super patella nailing was invented. Okay. So it's what was it was the technique originally described by Paul Torretta? Okay. So he's the guy who invented the super patella jigs and the semi extended approach. He initially did a medial para Patel approach. You can also do a lateral parag Patel approach. And what most people advocate is you test which way the patella goes on which way they're more flexible and you can do a para Patel approach and usually about five or six centimeter incision, um either side of the patella and you make an incision in the retinaculum and you subluxed the patella out of the way so that you can get your, your shot and you can either be within the joint, okay, like you would for a super patella nailing or you can be what's called extra synovial. So you can see there's a gap, you can sign O V um lies over the joint and you can stay outside of that and avoid going into the joint but still do everything semi extended, okay. Um So that's a nice technique. The advantage of that as well is if you want to do semi extended nailing, but the patient has P F J arthritis, then uh instead of struggling with your jig trying to get a super patella approach, um if you can get the advantages of super patellae by doing it semi extended, but do it through a para patella approach and just subluxed the uh patellar out of the way. Okay. Then we talk about entry point, okay. And the key to any nailing is getting the entry point. Perfect. Okay. Um I find it is actually a lot easier to get the entry point when you're doing semi extended nailing um because you're, you're fighting things a lot less. Um So I would uh first of all make sure you've got a good A P X ray and buy a good A P X ray means you want the fibula head overlapping by around 40 to 50% of the tibia. And then, you know, that's a true AP and the entry point on the AP is just medial to the lateral tibial spine. Okay. And that's what that's the landmark you want to see and that's what you want to do where you want to go on the lateral, you want to get a perfect lateral. This X ray is not a perfect lateral, but um it's one that I lifted from a paper um And what you want to do is just be on the edge of that extra articular sloping, proximal surface of the tibia on that lateral view just where I'm showing you there. And then just as important as the entry point is the endpoint. And so lots of people have described this, but when I was training, it wasn't really well described or described in the books. Um It's really important that your nail, your guidewire ends up uh in the center of the ankle. Now, the center of the ankle doesn't mean the center of the PLO font. So if you can see here with a nail down, it's more lateral, it's abutting the lateral cortex almost um uh than uh than the tibia profound and probably two thirds of the way across laterally, which would correspond to the center of the Taylors, which is the center of the ankle and that's what you want to aim for. So, always try and get as lateral uh an endpoint as possible. Um And that will help with your reduction and it will help prevent you getting um al reduction. And then the nail, the tibial nails are designed in certain ways. So you've got much more locking options. So we're pushing the boundaries of nailing both in the femur and the tibia and uh to help us get good purchase the nails now come with multiple locking options. Okay. So this particular brand of nail has five proximal locking options and four distal locking options. Um The distal, the three most distal locking bolts, I think within like two centimeters of each other. So all you need in terms of um being able to nail, a fracture is two centimeters. Also of distal bone depending on what type of nail you have. Okay. So you can nail very distal fractures now that comes with its own challenges and difficulties. And we'll talk about that later. As you've noticed, tip, your nails have a bend. That bend is called a Herzog bend. And that bend is designed to get your nail down and around the corner and into the tibia. Um Sometimes if the nail is uh too proximal and you can't get distal enough, acts as a wedge and deforms a proximal tibial fracture. So you've just got to be wary of your implant design and how it can affect your reduction. Uh Then the question is to re more not to ream. Um And there was a lot of back and forth around a decade ago about whether we should be doing reamed nails or undreamed nails, whether we're disrupting the endosteal blood supply and causing non unions or whether we should re memory thing and be as rigid as possible. And the short version is that we should remove most tibial nails. What they, the, the trial that showed us that was a sprint trial um which randomized uh reaming to non reaming in uh fractures with closed and open. And what they found is it is safe. It lead to quicker union in closed fractures um and reduce the need for further surgery. Um There's no difference in the risk of malunion compartment syndrome, fat embolism, inter operative blood loss or infection between reme Doran reme nails. Okay. So rates of union and closed fractures were higher um what it did tell us as well from that cohort, was that high energy open fractures take longer to heal. Okay. Um And they can take up to a year. Okay. The practice previously was that if they're not beginning to show healing in some centers at three or four months, they would consider intervening and re operating. And that's way too early for a uh for a tibial fracture. Uh They were advocating that, you know, it should be at least uh not until after six months, but there were fractures uniting without intervention up to a year in high energy fractures. So, the learning point from that paper was that the main learning point was that tibial sharp fractures can take a long time to heal in high energy cases. Okay. Um So the question about soup pro versus infrapatellar nailing. Um The jury is still out, there are a few papers, essentially, one is as good as the other. Uh There are some papers to suggest that you get improved pain, postoperative pain, uh shorter fluoroscopy time, uh less anterior knee pain uh in super patella nailing. And there's no increased incidence of postoperative complications between the two groups. Okay. People that prefer infrapatellar will generally be saying I don't, why do I want to damage the patella femoral joint? The jigs have got a lot better. They have protective sleeves and as long as you use them, generally, the telephone, your joint is preserved and intact and there's no damage. But if you lose your concentration, uh you can make a mistake and remount patella femoral joint and that would be bad. Um So what's the outcome when we nail a fracture? So close fractures take around 18 weeks to heal. And that's from various trials. At 12 months, the prompts significantly reduced uh were significantly reduced in about 40% of patient's would still have some persistent pain. Um at the midterm follow point of four years, uh the uh patient's had excellent knee and ankle schools. Um and at longer term, follow up their pain had got much better. So I think the majority of people were talking about anterior knee pain, which was, which is a, a, a significant problem for some people. It's usually active men who sustain tibial shaft fractures and they usually have active jobs that are quite manual. So for example, plumbers, mechanics and they might end up being on their knees for quite some time. So you can imagine how disruptive it is if they've had a tibial nail and they can't kneel, um, they would want something done about it and you might see some patient's come to you in the clinic and say I've healed, I want my tibial nail out okay. And if you were to do that, um, a lot of some of the patient's would get better okay. Or I think it's around 60 70% would get better. Um But if you left them alone. Generally, after a few years, that pain settles on its own without removing the metal work. So it's a conversation to have with the patient that the evidence shows that things should improve. Unless there's an obvious reason, like half the nail is sticking out into the knee, then that should probably the nail need to come out. But if the nail is well buried and there's no obvious prominent metal work to explain the anterior knee pain, then you should just reassure them that things usually settle on their own rather than um form another operation. And that's what this bit. So 71% of patient's following to be or nailing uh found an improvement, uh sorry, uh 71% patient had anterior knee pain following to bill nailing and 92% will have pain on kneeling. Uh There's more, there's a, there's a multifactorial cause for anterior knee pain and uh in the patient's that had it removed. Uh 40% had complete relief. 31 had partial relief and about a third of them, 29% also had uh persisting pain in the 16 months following removal. Um A further study showed that 71% percent of patient's um had relief after eight years without removing the now. So whether we, if we fast forward, you're probably better off leaving the nail in um and having more chance of your symptoms settling. Um following a reamed, I am nail rate of non unions around 2 to 4%. Okay. Alternatives, of course, external fixation. Uh Yeah, I'll go through para patella approaches uh in a sec. Um So uh you can do um ex fixes, okay. Um There's not much difference between I am nail and frames. Uh and I am nail has more anterior knee pain compared to frame. But the tradeoff for a frame is that you get pinsight infections and actually the rate of non unions higher um alternative is or if of course for distal tibial fractures or proximal tibial fractures. And uh plate fixation is usually reserved for these metaphyseal injuries. If you meet PPO them, you can preserve the biology, um plates and load share ing devices. And so as any low chairing device, it can fatigue fail and fracture and you may want to partial weight, bear to begin with. Um up to 55% of patients will experience pain from the plate. And so may necessitate removal of plates that they to date. Proximal fractures usually quite difficult to manage. Um They tend to be kicked into a valgus deformity. Um And you get flexion, shortening, uh post your translation of the distal fragment uh with an apex anterior deformity. As you can see there, it says various techniques to overcome them as we've discussed and then just as difficult as distal fractures. And that includes um uh intra-articular fractures. But this study looked at only extra articular fractures okay. So they fixed D T trial you probably need to know about is from 2017 and it's a bit like proper and draft. It's one of the things that's a big randomized control trial that you probably need to know a bit about. So, um the randomized nails versus plates for distal fractures and they had a little diagram with a box was two cortical wits that required that were included in the inclusion criteria. And if it met that inclusion criteria, you could randomize to nail this plate. Um What it showed is that at six months, there was no difference. Okay. So everyone had the same outcome at six months and beyond in the first three months. However, the nails had better functional outcome and we're more favorable in terms of their prom scores, but this didn't last long term. Okay. Which kind of makes sense because you're probably more confident in weight bearing a nail rather than weight bearing a plate fixation. Okay. Um And then for proximal fractures, you just and distal fractures, you just need to have a strategy for your reductions. So this is so you can do blocking screws or wires, you can do a super patellar approach or a uh para patella approach and you can, you can do adjunct plating for a proximal fracture. So you do like a mini mini anterolateral if you're really struggling and just put a little mini frag plate on to reduce that fracture and hold it there and then just nail it um and that just holds it reduced. So, in summary, uh that is not the saved version, okay. So in summary, you need to uh be able to manage tibial uh shaft fractures uh and how and predict what problems are going to have. They're going to cause you especially proximal and distal fractures. You need to be aware of all the approaches and be able to manage them. You need to know the cross sectional anatomy uh for the exam and you need to rule out any life threatening injuries according to A T L s and um uh then focus on fixation options. Okay. So that is it for tibial shaft fractures, you stop the