A 55-year-old man is involved in a high-speed motorcycle crash. Upon presentation to a level 3 trauma center, he is found to be hemodynamically unstable with a closed proximal third tibia fracture. He is indicated for an emergent exploratory laparotomy and application of an external fixator to the right leg. After a period of observation in the intensive care unit, he is transferred to a level 1 trauma center for definitive management. Radiographs of his right leg after application of an external fixator are shown in Figure 6–50A and B.

Figure 6–50 A–B

What is the common deformity seen when attempting to perform intramedullary nailing of proximal third tibia fractures?

1. Varus and apex anterior

2. Valgus and apex anterior

3. Varus and apex posterior

4. Valgus and apex posterior

Discussion

The correct answer is (B). The valgus and procurvatum deformity is seen commonly in proximal third tibia fractures and is secondary to several distinct factors. Apex anterior angulation occurs as a consequence of the extension moment induced by the patella tendon, which is exacerbated by knee flexion. Valgus deformity is often the result of a starting point that is too medial, resulting in eccentric direction of the nail in the proximal tibial metaphysis and the resulting lateral trajectory of the implant as it moves distally.

An adjunct to intramedullary nailing of proximal third tibia fractures involves the placement of blocking (poller) screws to prevent the predictable deformity of these fractures.

Which of the following accurately describes the appropriate position of two blocking screws when placed in the proximal segment?

1. Anterior and lateral to the nail

2. Anterior and medial to the nail

3. Posterior and lateral to the nail

4. Posterior and medial to the nail

Discussion

The correct answer is (C). In order to prevent the predictable valgus and apex anterior deformity seen with proximal third tibia fractures, blocking screws should be placed in the concavity of the deformity—posterior and lateral—to the nail in the proximal segment.

The patient is indicated for submuscular plating of the depicted fracture using a minimally invasive percutaneous plate osteosynthesis (MIPPO) technique.

Based upon the known complication of this technique for plating proximal third tibia fractures, which of the following physical examination findings might be expected in this patient who complains of a neurologic deficits postoperatively?

1. Weakness in great toe dorsiflexion

2. Numbness in the first web space

3. Numbness of the lateral plantar aspect of the foot

4. Numbness of the dorsum of the foot

Discussion

The correct answer is (D). Superficial peroneal nerve (SPN) injury, as manifested by numbness over the dorsum of the foot, is a described complication of percutaneous plating of proximal tibia fractures.