Surgical Discussion

Patient positioning:  Supine position on a radiolucent table to facilitate imaging and access for both nail removal and subsequent fixation procedures.

Anatomical surgical approach:  A longitudinal medial approach to the tibia was utilized for removal of the intramedullary nail and application of the external fixator. For open reduction and internal fixation, a direct anterior approach was employed to access the proximal tibial fracture and tubercle fragment.

The surgeon noted the importance of meticulous planning due to the complexity of the fracture pattern and the presence of the intramedullary nail. Removal of the nail was achieved without complication, allowing for precise application of the external fixator. The open reduction of the main segment required careful alignment to address shear displacement, while placement of the tension band plate on the tubercle fragment required strategic screw placement to avoid interference with subsequent nailing. The final step involved careful intramedullary nailing, ensuring that screws did not obstruct nail placement.

Postoperative protocol:   Postoperative rehabilitation included non-weight bearing with crutches for 6 weeks, followed by progressive weight bearing as tolerated. Range of motion exercises were initiated immediately postoperatively to prevent stiffness.

Follow up:   Not specified.

Orthopaedic implants used:   External fixator, buttress plate, tension band plate, intramedullary nail.