A Tip to Make Your IM Tibial Nails More Resistant to Load — What Now?

The CORRelations post “A Tip to Make Your IM Tibial Nails More Resistant to Load” suggests impacting the tibial nail down to the distal physeal scar to increase stability. I agree with the suggestion. For as long as I’ve been doing tibial nails, I’ve tried to place the nail as close to the physeal scar as possible.

I think the main reason surgeons don’t place nails down to the physeal scar is the concern that they might choose a nail that’s too long, resulting in the cost and time of wasted hardware. I applaud the impulse toward fiscal responsibility; we all should be mindful of the needless waste that occurs at our hands. Out-of-date surgical preference cards (which result in needless trays and supplies being opened) should be replaced and “routine” but unneeded sterile peel pack items should be challenged and removed when appropriate.

Wasted intramedullary implants are expensive, and no surgeon wants to be tagged on efficiency reports as someone who throws these nails away. Perhaps these tips can help readers feel confident in selecting a longer nail:

• Measure the wire using fluoroscopy. When the depth gauge for the wire is in place, first check the tip of the wire fluoroscopically (to ensure it hasn’t moved), the fracture (to ensure its still reduced), and the tip of the intramedullary depth gauge (to ensure it is down on the tibial insertion site). Most nails come in 15-mm increments, so we can usually get the length almost perfect.
• Measure more than once to ensure your length is correct.

As shown in the CORRelations post on the topic, getting this right should help your patients, and with a little care in measurement, you can do it without fear.