Extra-articular proximal tibial fractures: nail or plate?

The surgical goals for treating proximal tibial fractures are to restore articular congruity, the mechanical axis, and knee motion while avoiding soft-tissue complications. The fracture pattern should be correctly identified and understood. For fractures with minimal intra-articular extension, fracture fixation with an intramedullary nail can decrease the risk of infection because it uses a small incision that is not placed directly over the injured soft tissue, and it provides better axial load sharing than a plate. Using the semi-extended technique, choosing the correct starting portal, incorporating blocking screws or stability screws into the fixation construct, and using mini-open reduction and internal fixation of the fracture will help achieve the goals of fracture fixation with an intramedullary nail. All proximal tibial fractures can be treated successfully with a plate or multiple plates. When a plate is used, the surgical approach and technique should minimize soft-tissue damage and account for future surgical procedures that may be needed. Fractures with intra-articular involvement and/or comminution of the medial metaphyseal region are appropriately treated with dual plating. Extra-articular fractures without major medial comminution may be treated with a locked lateral plate. Final union rates for patients treated with either intramedullary nail or plate fixation are reported at 96% and 97%, respectively. A prospective, randomized, multicenter study is currently in progress to further clarify and advance the treatment of proximal tibial fractures.