Journal of Musculoskeletal Trauma

How to obtain the desired results from distal tibial nailing based on anatomy, biomechanics, and reduction techniques: Jungtae Ahn, Se-Lin Jeong, Gu-Hee Jung; J Musculoskelet Trauma 2025;38(2):74-85. Published online March 31, 2025; DOI: https://doi.org/10.12671/jmt.2025.00024

Abstract PDF: Distal tibial metaphyseal fractures are commonly caused by high-energy injuries in young men and osteoporosis in older women. These fractures should be clearly distinguished from high-energy pilon fractures. Although the optimal surgical intervention methods for distal tibial metaphyseal fractures remain uncertain and challenging, surgical treatments for nonarticular distal tibia fractures can be broadly divided into two types: plate fixation and intramedullary nail (IMN) fixation. Once functional reduction is achieved using an appropriate technique, distal tibial nailing might be slightly superior to plate fixation in reducing postoperative complications. Thus, the surgical strategy should focus on functional realignment and proceed in the following sequence: (1) restoring the original tibial length, regardless of whether fibular fixation is to be done; (2) making the optimal entry point through an anteroposterior (AP) projection based on the overlapping point between the fibular tip and lateral plateau margin; (3) placing Kirschner wires (Ø2.4 mm) as blocking pins (in the AP orientation for coronal control and in the mediolateral [ML] orientation for sagittal control) as close to the upper locking hole as possible without causing further comminution on the concave aspect of the short fragment; and (4) making the the distal fixation construct with at least two ML and one AP interlocking screw or two ML interlocking screws and blocking screws. After the IMN is adequately locked, blocking pins (Ø2.4 mm) need to be replaced by a 3.5 mm screw.

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Subtrochanteric Fracture Reduction during Intramedullary Nailing: Technical Note: Gyu Min Kong; J Korean Fract Soc 2019;32(2):107-111. Published online April 30, 2019; DOI: https://doi.org/10.12671/jkfs.2019.32.2.107

Abstract PDF: The subtrochanteric area is the place where mechanical stress is most concentrated in the femur. When a fracture happens, bone union is delayed and nonunion often occurs. The recommended treatment for atypical fractures is an anatomical reduction of the fracture site as the frequency of nonunion is higher than that of ordinary fractures. Various reduction methods have been suggested, and good results have been obtained. On the other hand, the occurrence of posterior displacement of the distal fragment during the insertion of an intramedullary nail is often overlooked. This is probably because the bone marrow of the femur tends to form an elliptical shape in the anteroposterior direction. The author attempted to insert a blocking screw into the distal part of the fracture to prevent posterior displacement of the distal fragment while performing intramedullary nailing of the femur fracture and achieved a good reduction state easily.

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Failure of Removal of Stripped Locking Screw after Locking Compression Plating: Sung Jin Kim, Kyung Jae Lee; J Korean Fract Soc 2011;24(2):169-173. Published online April 30, 2011; DOI: https://doi.org/10.12671/jkfs.2011.24.2.169

Abstract PDF

PURPOSE
The purpose of this study was to evaluate the incidence and possible causes of stripped locking screws that make difficult to remove the locking compression plate. We also tried to find the useful methods to remove the stripped locking screws.
MATERIALS AND METHODS
Between May 2005 and January 2009, 84 patients who underwent operations for removal of locking compression plate were included in this study. We removed 298 3.5-mm locking screws and 289 5.0-mm locking screws in these patients. We retrospectively investigated the incidence and possible causes of stripped locking screws and evaluated the pros and cons of the methods that we have used to remove the stripped locking screws.
RESULTS
17 out of 298 3.5-mm locking screws (5.7%) and 2 out of 289 5.0-mm locking screws (0.7%) were encountered with difficulties by hexagonal driver during removal because of the stripping of the hexagonal recess. First we used the conical extraction screw for all the stripped locking screws and only 3 screws were removed successfully. We removed 3 screws by cutting the plate around the stripped locking screw and twisting the plate with the screw and we removed 1 screw by the use of hallow reamer after cutting the plate. Twelve screw shafts were left except grinding of screw head by metal-cutting burr. There was one iatrogenic re-fracture in whom we have used with hallow reamer.
CONCLUSION
At the time of locking compression plate removal, difficulties of locking screw removal due to the stripping of the hexagonal recess should be expected and surgeon must prepare several methods to solve this problem.

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An inexpensive and rapid method for removal of multiple stripped locking screws following locking plating: A case report
Won Ro Park, Jae Hoon Jang
International Journal of Surgery Case Reports.2019; 57: 134. CrossRef

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The Usefulness of Blocking Screw in Intramedullary Nail on Proximal Tibial Fracture: Jun Young Yang, June Kyu Lee, Young Mo Kim, Chang Hwa Hong, Kyung Cheon Kim, Sung Hwan Ahn; J Korean Fract Soc 2005;18(1):17-21. Published online January 31, 2005; DOI: https://doi.org/10.12671/jkfs.2005.18.1.17

Abstract PDF: PURPOSE
To evaluate the effectiveness of a blocking screw in intramedullary nailing at the tibia proximal shaft fracture.
MATERIALS AND METHODS
63 tibia proximal shaft fractures from January 2000 to December 2002 treated with only intramedullary nailing were referred to as group I, and 8 fractures from January 2003 to December 2003 treated with both intramedullary nailing and the blocking screw were referred to as group II. Retrospective studies were done for group I and II. The incidence of nonunion and the postoperative angular alignments were compared. Malalignment was defined as an angle of 5 degrees anteroposteriorly or mediolaterally.
RESULTS
There were 7 nonunion (11%) in group I in compare with none in group II. There were 21 angular malalignments (33%) in group I and 1 in group II (12%) and most of them had valgus deformity or anterior anglulation. No complications were directly due to the use of the Blocking screw.
CONCLUSION
The technique of the blocking screw used to be one of the option for proximal tibial nailing at tibial proximal shaft fracture helps to overcome angular malalignments of bones.

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Segmental Breakage of Distal Interlocking Screw Complicating removal of broken nail: A Case Report: Kyu Hyun Yang, Seong Jin Park, Hyung Jung Kim; J Korean Soc Fract 2000;13(4):709-712. Published online October 31, 2000; DOI: https://doi.org/10.12671/jksf.2000.13.4.709

Abstract PDF: Metal failure (nail breakage) after locked intramedullary nailing results from delayed union or nonunion, which necessitates removal of nail and interlocking screws. Breakage of interlocking screw(s) can be associated with failure of the intramedullary nail. It usually breaks into two parts. Proximal part, which contains the screw head, can be removed by screwdriver without difficulties. Distal part can be removed from the far cortex or be left in place if it does not hinder further procedures. We experienced a case of segmental breakage of distal interlocking screw, which was associated with failure of the femoral nail and nonunion. Middle part of the broken screw obstructed the hollow of the nail and complicated the removal of the broken nail.

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Breakage of Interlocking Screw after Intramedullary Nailing of Femoral Shaft Fracture: Gun Il Im, Cheol Won Hyun, Joo Ho Shin, Do Young Kim, Won Ho Cho; J Korean Soc Fract 2000;13(3):463-469. Published online July 31, 2000; DOI: https://doi.org/10.12671/jksf.2000.13.3.463

Abstract PDF: PURPOSE
We analysed risk factors for failure of interlocking screws after femoral intramedullary nailing, and introduce tips for removing broken screw.
MATERIALS AND METHODS
Seventy-two closed femoral shaft fractures were treated with interlocking nail. We compared 7 patients in whom interlocking screw breakage occurred (Group I) with 65 patients without breakage of interlocking screw (Group II). Analytic parameters were age, weight, level of fracture, degree of comminution, nail diameter. We used Mann-Whitney U test & Chi-sqare test for statistical analysis.
RESULT
Upper one of distal interlocking screws was broken in 6 patients, both of distal screws were broken in one patient. All of the patients with broken screws had associated delayed union. The mean age of patients were 20 years in group I, 31 years in group II. The mean weight were 69.6 Kg in group I, 62.02kg in group II. Three patients had fractures in proximal half and four patients had fractures in distal half in group I. In group II, there were 25 proximal fractures and 40 distal fractures. There were 2 type I, 2 type II, 1 type III, 2 type IV fractures in group I, and 16 type I, 31 type II, 17 type III, 1 type IV fractures according to Winquist and Hansen classification. Nail diameters were 10mm in 4 patients, 11mm in 2 patients, 12mm in 1 patient for group I and 10mm in 8 patients, 11mm in 13 patients, 12mm in 25 patients, 13mm in 13 patients, and 14mm in 6 patients for group II. Age, weight, degree of comminution, nail diameter had statistically significant relation to the breakage of interlocking screw(p<0.05), but the level of fracture didn't(p>0.05). Broken screws were easily removed by advancing screw to medial compartment with S-pin and making short medial incision.
CONCLUSION
It is suggested from our study that combination of parameters may have contributed to the failure of interlocking screw ; narrower diameter nail for comminuted fracture in young, active patients with more body weight. Inserting two screws have advantage over one screw.

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A Prospective Study of Fractures of the Tibial Shaft Treated with Intramedullary Interlocking Nail : Comparing One versus Two Distal Screws: Eun Woo Lee, Ki Ser Kang, Soo Yong Kang, Eui Chan Jang, Jin Woo Lee; J Korean Soc Fract 1997;10(2):303-308. Published online April 30, 1997; DOI: https://doi.org/10.12671/jksf.1997.10.2.303

Abstract PDF: In non-randomized prospective study, 67 tibial fractures were treated with intramedullary inter-locking nail. Patients were divided into 2 groups based on the number of distal locking screw. Group I was consisted of 33 fractures treated with one distal locking screw Group II was consisted of 34 fractures treated with two distal locking screws. The patients were followed up for an average of 12 months. There was no statistically significant difference between group I and II with regard to total operation time, fracture union time. However fluoroscopic time was significantly longer at group II than group I. Serial radiographs of patients in both group were analyzed for change of hardware and fracture healing postoperatively. No significant difference was found between two groups in fracture union time, hardware failure and complications in proximal and middle tibial fracture. But the angulation and locking screw breakage were significant in group I in distal tibia fracture. We concluded that fracture of the proximal and middle third of the tibia that require interlocking nail can be successfully treated with a single distal locking screw. However, in fractures of the distal one third, two distal locking screws should be required to prevent of angular deformity in sagittal plane and for stablefixaton. The use of a single distal locking screw reduces operation time, radiation exposure, local soft tissue discomfort and cost without compromizing fracture union.

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A Simplified Technique of Distal Locking Screw Fixation of Interlocking Nail: Young Bok Jung, Ki Ser Kang, Boo Sup Kim, Han Jun Lee, Whui Jae Jin; J Korean Soc Fract 1995;8(1):248-253. Published online January 31, 1995; DOI: https://doi.org/10.12671/jksf.1995.8.1.248

Abstract PDF: Failure to determine distal femoral screw hole position can sometimes prolong operating time for placing interlocking screw and increased radiation hazard. We attempted to assess progress in the insertion of distal locking screw with target device. Insertion method of distal locking screw in femoral nail that uses target device improved the accuracy of distal screw placement and reduced the radiation exposure. The authors analyzed 30 patients(33 cases) of the femur shaft fractures that treated by interlocking IM nailing using target divice in the Department of Orthpaedic Surgery, Chung-Ang university from August 1990 to July 1994. Among these patients, except 6 cases, all of the distal femoral drill holes attempted were successfully made with the first pass of a dirll without image intensiner monitoring. Compared with the commonly used free-hand method, our target divice assisted screw placement offer a reduction in the amount of time and radiation exposure to insert distal locking femoral screws.

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