Intramedullary nailing of tibial shaft fractures is a mainstay of treatment for orthopedic surgeons managing these injuries. Innovation and modern technology have allowed for significant advances in implant design during a relatively short time period. As surgeons have gained more experience with this procedure, advances have also followed in the surgical approach.
In the recent past, the standard technique for intramedullary nailing of tibial shaft fractures required the use of either para-patellar or patellar tendon splitting approaches. More recently, the semi-extended and suprapatellar approaches have been developed with a substantial amount of research reported for the benefits of this technique.
The suprapatellar approach, when correctly performed, allows for less manipulation of the fractured extremity, less work against gravity, minimal intraoperative assistance, fewer and easier fluoroscopic views, and greater ease with instrumentation and implantation. Biomechanical testing has shown the specialized instruments required do not increase joint pressure significantly and do not cause cartilage injury. Arthroscopic evaluation post implantation identified no iatrogenic patellar-femoral injury. Studies have also reported lower OR and fluoroscopy times, no worse outcomes and clearly less anterior knee pain, an issue that is both well-reported and problematic when using standard infrapatellar approaches. We use this case of a 48-year-old man who sustained a closed distal third tibial shaft fracture (Figures 1 and 2) during a recreational hockey game to highlight our surgical technique using the suprapatellar approach. 