Injury, Int. J.

Care Injured 50S3 (2019) 17–22

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Optimal use of transmedullary support screws and fibular

management in distal tibial fracture nailing based on a
new biomechanical classification$
Mario Goldzaka,1,2 , Roland Biberb,c,1,* , Mirosław Falisd
a
Clinique de l'Union, 31240 Saint Jean, France
b
Dr. Erler Kliniken, Kontumazgarten 4-18, 90429 Nürnberg, Germany
c
Paracelsus Medical University, Prof.-Ernst-Nathan-Str. 1, 90419 Nürnberg, Germany
d
Department of Orthopaedics and Traumatology, Limanowskiego 20/22 Str, 63-400 Ostrow Wlkp, Poland

A R T I C L E I N F O A B S T R A C T

Introduction: Based on a novel simple frontal view classification, a comprehensive concept for systematic
Keywords: management of intramedullary fixation of distal tibial fractures is introduced. Even the usage of thin
Distal tibial fractures
(unreamed) nails allows for anatomic reduction and stable fixation if applied in combination with
Transmedullary support screws
Poller screws
transmedullary support (TMS) screws. Our classification system guides the placement of the TMS screw
Unreamed nailing (medial or lateral) and suggests whether to fix the fibula or not.
Fibular fixation Patients and methods: The fixation concept of the classification was applied to 67 distal tibial fracture
Classification system cases. Patients were followed up until nail removal after at least 12 months.
Results: All fractures united. Besides 5 cases of slight external malrotation (<5 degrees) no axial malunion
was found. Two infections were encountered, but both were treated effectively by exchange nailing,
antibiotic therapy until wound healing and C-reactive protein normalization.
Final functional assessment according to Olerud/Molander Score was 85 pts (100 pts. possible, range
50–100 pts).
Discussion: The stability we achieved even with single screw interlocking was high due to anatomic
reduction with interfragmental compression in the lowest fracture line. In cases of fracture extension into
the ankle joint, interfragmental compression screws were applied before nail insertion. In more
comminuted fracture types additional screws are advisable.
Conclusions: The frontal view classification has proven to be a reliable guideline for effective
intramedullary fracture fixation by minimally invasive means, allowing for optimized soft tissue
protection.
© 2019 Elsevier Ltd. All rights reserved.

Introduction predominant aspect, which is perfectly addressed by intramedul-

lary (IM) nailing.
Heim regards distal tibial fractures and tibial pilon fractures Fixation of distal tibial fractures by nailing however is
predominantly as soft tissue injuries with accessory bone injury associated with increased rates of malalignment in fractures
located in a square defined by the maximum width of the distal located within 10 cm above the ankle joint. A small nail diameter
tibia [1]. There are two major issues in distal tibial fracture within the large intramedullary canal of the distal tibia provides a
management: soft tissues preservation and fracture reduction. very limited support, which is the basic reason for the difficulty of
Limitation of surgical soft tissue compromise remains the reducing the fracture only by nail. According to Krettek, the
difficult task is to properly guide the nail through the wide bone
cavity [2,3]. However, Stedtfeld demonstrated that an additional
$
This paper is part of a Supplement supported by The Küntscher Society. transmedullary support (TMS) screw provides the necessary
* Corresponding author at: Vogtsbergstr. 50, 90453 Nürnberg, Germany. support to the short fragment in order to reduce it and keep it
E-mail addresses: mario.goldzak@clinique-union.fr (M. Goldzak), anatomically aligned [4].
unfallchirurgie@erler-klinik.de, webmaster@biberweb.de (R. Biber), falis@osw.pl
(M. Falis).
Plates and external fixators are good alternatives to fix tibial
1
The authors contributed equally to this work. distal fractures, but the rate of soft-tissue problems such as wound
2
First author is deceased. breakdowns, skin necrosis and wound infection are frequently

https://doi.org/10.1016/j.injury.2019.08.007
0020-1383/© 2019 Elsevier Ltd. All rights reserved.
18 M. Goldzak, R. Biber and M. Falis / Injury, Int. J. Care Injured 50S3 (2019) 17–22

associated with those techniques. This has largely been reduced by Patients and methods
the use of minimal invasive techniques. However mini-invasive
plating techniques still provide an infection rate higher than that of We prospectively studied all patients with distal tibial fractures
nailing. Finally, in specific cases, all usual surgical techniques need treated by nailing between October 2007 and October 2010. We
additional secondary surgical procedures like dynamization, bone decided to include all tibial shaft fractures type 42A, 42B1, and
grafting and fibulotomy. The need for such secondary procedure 42B2 with the fracture line ending within 10 cm above the ankle
even increases, as thin unreamed nails are used more and more [5]. joint and all metaphyseal fractures type 43A, 43C1, and 43C2. We
Consequently, the issue of fibular fixation remains controversial in excluded young patients with open growth plates as well as
nailing techniques; many surgeons perform additional fibular patients with previous ipsilateral tibial fractures.
plating hoping to decrease the rate of secondary procedures due to All patients were operated by a single senior surgeon
malalignment. according to a pre-defined plan based on frontal and sagittal
There are two main classifications: Rüedi-Allgöwer [6] and AO X-ray views. We classified all fractures by using two different
classification [7,8]; the latter ones being the usual reference classification systems: the AO classification [7] for group 42 and
around the world. However, the border line between pilon tibial group 43 fractures and our personal classification system based
fractures and diaphyseal fractures with distal extension is not clear upon the frontal X-ray view. The cases were classified into three
yet and the AO classification is not adapted to these cross border main types (see Fig. 1):
types. Its limited impact on surgical planning is another reason
why other classification principles are proposed [9]. We propose a  Type 1: single fracture line
new distal tibial fracture classification, which is based upon a  Type 2: more than one fracture line the distal end-point of the
frontal X-ray view. It offers a guideline for the use of unreamed thin complex fracture line is located on the medial side
nails in combination with transmedullary support screws (TMS  Type 3: more than one fracture line; the distal end-point of the
screws) and for evaluation of the need for additional fibular complex fracture line is located on the lateral side
fixation. Our goal was to reduce skin related problems, to avoid
malalignment rate and finally to ensure good bony healing with We also distinguish two subtypes:
optimal management.
Location and number of TMS screws (Poller screws, blocking  Subtype A: Fibula is intact or fibula is fractured at the level or
screws) have been previously described by several authors [2,4]. above the level of the tibial fracture (45 cases)
Their proposed algorithms were simple and required neither  Subtype B: Fibula is fractured below the level of the tibial
preoperative planning nor meticulous differentiation of fracture fracture (22 cases)
pattern. Others are more complex, however not specific for distal
tibia [10]. Yet the basic principles of fracture reduction by All along the operative technique, we treated with thin
interaction of nail and TMS screw have almost achieved perfection. unreamed nails (8 mm diameter), TMS screws (blocking or Poller
It has minimized malalignment and increased the rate of screws) and, if needed, fibular fixation by wiring or plating on a
undisturbed fracture healing. standard table under fluoroscopic control. The implants used for
We propose a pragmatic and simple-to-use classification fracture fixation were Targon T, Targon TX (BBraun Aesculap) and
helping to decide about TMS screw placement and fibular fixation. Expert (Synthes) nails in combination with TMS screws. TMS

Fig. 1. Classification based upon the frontal X-ray view: single line fracture (type 1), fracture with secondary lines and medial distal extension (type 2), and fracture with
secondary lines and lateral distal extension (type 3). Types 1 and 2 are associated with a distal fracture extension on the medial side, the TMS screw should be placed medially
to the central tibial axis. Type 3, which is associated with a distal fracture extension on the lateral side, requires the TMS screw laterally.
All three types may present as subtype A or B, depending on the location of the fibular fracture in relation to the proximal border of the tibial fracture (horizontal dotted line).
Subtype B fractures are below this level and should additionally be treated with internal fibular fixation.
 M. Goldzak, R. Biber and M. Falis / Injury, Int. J. Care Injured 50S3 (2019) 17–22 19

Table 1
Fracture type distribution according to the new classification proposal.

frontal x-ray classification type n % subtype n %

type 1 (single line) 31 46 % A 25 37 %
B 6 9%
type 2 (1 fracture lines; 28 42 % A 17 25 %
distal fracture end is medial) B 11 16 %
type 3 (1 fracture lines; 8 12 % A 3 4%
distal fracture end is lateral) B 5 7%

screws were either standard 4.5 mm Targon interlocking screws or

Standard 4.5 mm AO Synthes screws.
Only for fractures classified as subtype B, fibular fixation was
performed with 3.5 mm AO LCP locking plates or K-wires.
Undisplaced articular involvements were fixed by percutaneous
screwing.
All patients were followed up until nail removal between the
12th and the 16th month after the accident. Check-ups were made
by x-ray and clinical examinations at 3, 6, 12, 24, 36 and 55 weeks.
Radiological healing criteria were based upon callus and cortical
continuity on four cortices in frontal and sagittal x-ray projections.
Clinical evaluation included Olerud Molander score (Table 1),
Fig. 2. Optimal management of a type 2B fracture: fibular fixation and
rotational comparative control, and goniometric knee and ankle
transmedullary support screw (a) finally make the nail reducing the fracture via
joint mobility control one month after removing the nail during the this artificial point of support (b).
last 55 week review examination. We further controlled x-rays in a
frontal and sagittal view.
nailing was still possible until two weeks later. The proximal
Results interlocking screw was dynamic in 30 patients and static in the
others; however, we performed proximal dynamization in 22
The whole study population (n = 67) included 45 males and 22 cases after 12 weeks. Most of the dynamizations were made in
females, the mean age being 45 years (18–84). 48 fractures resulted the Targon T group. Expert and Targon TX allowed dynamic
from high-energy trauma and 19 from low-energy trauma. This interlocking.
included 18 home accidents, 17 road accidents, 22 sport accidents We observed one compartment syndrome proven by compart-
and 10 occupational injuries. There were 13 Gustilo 1 and 2 Gustilo ment pressure measurement. It was treated by fasciotomy within
3A open fractures. The fibula was fractured in 45 cases but only 22 48 h. Finally, only a partial deficit in dorsiflexion of the great toe
were located below the start of tibial fracture line (subtype B). 17 was observed. In addition, two patients suffered from algoneur-
articular extensions of the fracture were noted. odystrophia. These patients recovered to their former activity level
Using the AO classification, there were 11 variant patient but kept residual deficits of sensitivity.
groups: 10 patients 42A1; 7 patients 42 A2; 10 patients 42B1; 1 We encountered two infections treated by a new surgical
patient 42B2; 9 patients 42C1; 1 patient 42C2; 14 patients 43A1; 5 procedure (exchange nailing) and double antibiotic therapy until
patients 43A2; 3 patients 42A3; 6 patient 43C1 and 2 patients the wound healing and the CRP normalization. All fractures had
43C2. Patient distribution according to frontal x-ray classification healed after 12 months. There were two TMS screws with slight
is given in Table1. backing out without any skin laceration.
In subtype B fractures, fibular fixation by a locking plate in mini- We followed up all 67 patients until nail removal. The mean
invasive approach in 14 cases or intramedullary K-wiring in 8 cases follow-up was 14 months (12–24). In radiological controls we did
was performed before the nailing procedure. In the other 45 cases not notice any evidence of secondary displacement and the
subtype A cases the fibula was not stabilized; this subtype A position of the TMS screw remained identical.
collective consisted of 23 patients with intact fibula and 22 Clinical evaluation was made by using the Olerud and Molander
patients with fibula fracture at the level or proximal to the level Score [11]. The mean score corresponded to 85 points (range
of the tibia fracture. A typical fixation for subtype B is shown in 50–100). There was no pain at walking but seven patients felt
Fig. 2. infrapatellar knee pain related to the nail entry point. Only five
Tibia fracture fixation was started by placing the TMS screw patients had slight malrotation with less than 5 of external
(blocking or Poller screw) at the place designated by our rotation compared to the contralateral side.
classification. So in type 1 and 2 fractures, the TMS screw was The most reliable rotational measurement in the operative
placed on the medial side (Fig. 3), whereas in type 3 fractures the theatre seemed the 3-point-control in a supine patient by a long
lateral side was chosen for TMS placement (Figs. 4–6). wire, which this is easier to perform with new generation nails
Subsequently the nail was inserted under fluoroscopic control, allowing to put the knee in extension. To evaluate rotation, the
making sure that the TMS screw worked as artificial point of anterior superior iliac spine, the patella midpoint, and medial
support for the nail, thus reducing the fracture with good border of the hallux were aligned in 62 cases. This control could
interfragmental contact. An interlocking screw was placed distally also be made during the follow-up examinations. The ankle joint
in a frontal plane in 56 cases without fibular plating or in a sagittal mobility was similar to the other side in 58 cases. All patients can
plane in 11 cases with fibular plating. In cases of articular fracture now walk without aids. No shortening was detected in our group;
extension, we fixed it first by one or two percutaneous screws 62 patients returned back to their normal activity level.
before inserting the nail. In Gustilo 3 open fractures we performed We did not find any malunions. Mean fracture healing time
a two-stage surgery with temporary fixation using an external mean was 16 weeks (range 10–26). When there was no cortical
fixator and bone coverage by fascio-cutaneous or muscular flaps; callus after 12 weeks on x-ray, we performed dynamization. After
20 M. Goldzak, R. Biber and M. Falis / Injury, Int. J. Care Injured 50S3 (2019) 17–22

Fig. 3. Type 2B fracture: 3D scan (a), operative procedure (b), intra- (c) and postoperative (d, e) x-rays.

Fig. 4. Type 3A fracture before and after intramedullary fixation.

 M. Goldzak, R. Biber and M. Falis / Injury, Int. J. Care Injured 50S3 (2019) 17–22 21

TMS screws reducing the metaphyseal fragment by counteracting

the soft tissue imbalance and fibular fixation guided by an X-ray
frontal view classification however facilitates fracture manage-
ment and reduces the risk of malalignment and malunion.
The recent literature about intramedullary nailing for the
treatment of distal tibial fractures consists of more than 10 studies,
but none of them includes the use of transmedullary support
screws in a prospective and systematic way. We propose a new tool
for nailing management of distal tibia fractures based upon our
own experience. The procedure we propose leads to a systematic
application of TMS screws in combination with thin (unreamed)
nails. The fibular fracture only needs to be fixed only if the fracture
level is located below the upper part of the tibial fracture line. The
classification results in a clear decision about when to fix the fibula
and where to place a transmedullary support screw. The latter
allows improved reduction of the tibial fracture and reduces
healing time.
The technique of introducing blocking screws goes back to
Krettek [2,3] who has given a new dimension of fracture fixation
with intramedullary nailing by providing a solution for correcting
axial deformities of dia-metaphyseal fractures even with a small
Fig. 5. Frontal X-ray view and planning sketch for a type 3B fracture. diameter nail. Stedtfeld [4] has presented a logical explanation of
the optimal use of transmedullary support screws under the
condition of soft tissue induced axial displacement. Reduction of
four more weeks we performed additional x-ray in order to the short fragment, even with interfragmental compression,
evaluate bone union. Hardware failures were found with the becomes possible with the nail after establishing an artificial
expert nail group in two cases (broken interlocking screws). point of support in the short fragment. The fixation construct is an
The mean rate of distance between the TMS screw and the ankle intramedullary three-point tension band construct. Finite Element
joint was measured 40 mm (range 10–80 mm). The nail tip position Analysis (FEA) calculations seem to indicate that the steeper the
was centered in the distal fragment in 55 cases, less than 10 mm to fracture line, the higher the compression forces between frag-
the medial side in 11 cases, and less than 10 mm to the lateral side ments obtainable by a TMS screw.
in 1 case. An eccentric nail tip position was not correlated with The literature on intramedullary nailing for treatment of distal
malalignment. Such radiological findings were common for type tibial fractures includes several studies [1,2,4,5,11–17], of which
2A and 3A. only one is multicenter [13]. In these papers the number of patient
population ranged between 15 [16] and 73 patients [1]. None of
Discussion these studies includes the use of TMS screws (Poller screws or
blocking screws) in a prospective and systematic way.
The use of thin intramedullary nails and TMS screws in distal We generally used unreamed thin nails. The majority of
tibial fracture management minimizes soft tissue compromise and publications report on the usage of reamed nails [2,3,12,15,17,18].
fragment devascularization. Common classifications hardly help in The 100%-rate of fracture union found in our study is however
decision making for distal tibial fracture management. They comparable to major parts of the literature, which reports on rates
address neither the aspect of additional fibular plating nor the ranging 97–100% [1–4,12,13,15–17]. There have even been some
indication for nailing versus plating versus fixator. Optimal use of authors describing a 4–13% nonunion rate [5,11,14].

Fig. 6. Same type 3B fracture: preoperative X-rays (a), postoperative AP view (b), AP view after nail removal (c).
22 M. Goldzak, R. Biber and M. Falis / Injury, Int. J. Care Injured 50S3 (2019) 17–22

Malalignment in our experience was found in two cases (3%), as Declaration of Competing Interest
opposed to 10 out of 38 patients (26%) by Bonnevialle [19]. We
performed a reoperation in 22 cases (33%), these were cases of The authors declare that they have no conflict of interest in
secondary dynamization after 3 months with Targon T nails. In connection with this paper. In addition, no benefits in any form
literature re-operation rate ranges from 0 cases [12] up to 22 cases have been received or will be received from a commercial party
out of the 56 (39%) [14]. Since the new generation nails Targon TX related directly or indirectly to the subject of this paper.
and Expert nails allowing for primary dynamic proximal inter-
locking, the rate of secondary dynamization is likely to decrease.
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