Intramedullary Nailing of Tibial Stress Fractures

Diaphyseal stress fractures of the tibia usually can be managed by nonoperative means. Internal fixation is appropriate in a small minority of cases when other treatments have failed. Intramedullary nailing is effective and appropriate for complete and posteromedial stress fractures. Other fixation techniques may be considered for fractures on the anterior, tension side of the tibia, but intramedullary nailing can be used in this situation as well. The risk of postoperative knee pain continues to be a significant limitation to the technique and must be considered in the athlete, including the possibility of pain that proves refractory to nail removal. Standard surgical techniques for intramedullary nailing are appropriate, but venting the distal tibia before reaming is appropriately considered as when reaming the length of any intact long bone. The location and character of the stress reaction are critical determinants of whether or not intramedullary nailing is the most appropriate treatment. The distinction between a stress fracture and a posteromedial stress reaction is vital to determining the appropriate operative intervention.