How to obtain the desired results from distal tibial nailing based on anatomy, biomechanics, and reduction techniques

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.