OT notes · Orthopaedics

Intramedullary interlocking nailing of tibia

Usual anaesthesia
Spinal (subarachnoid block)
Position
Supine, knee flexed over a bolster or radiolucent triangle (infrapatellar); semiextended for suprapatellar or proximal-third fractures
Setting
emergency

Operative note template for interlocking nailing of a tibial shaft fracture, with a filled example for closed reamed infrapatellar nailing of a transverse midshaft fracture under spinal anaesthesia.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • anterior knee pain, especially on kneeling (about half of patients)
  • compartment syndrome needing fasciotomy
  • malalignment or malrotation, more with proximal and distal fractures
  • infection, higher in open fractures
  • delayed union or nonunion needing further surgery
  • breakage of locking screws
  • injury to nerves, vessels or tendons at locking screw sites
  • later removal of implant

Pre-operative details for this operation

  1. Side and fracturelevel (proximal / middle / distal third), pattern, AO/OTA type; fibula fractured or intact
  2. Open or closedif open: Gustilo-Anderson grade, wound size and site, time of injury, debridement
  3. Compartments before surgerysoft / tense, pain on passive stretch; pressure and diastolic difference if measured
  4. Distal neurovascular status before surgerypulses, deep and superficial peroneal and tibial nerve function
  5. Knee, ankle and posterior malleolus checkedon X-ray / CT in distal third fractures
  6. Nail system and sizes availablediameters, lengths; suprapatellar instruments if planned; distractor or external fixator in room

Anaesthesia and position

  1. AnaesthesiaSpinalGeneraltype of block and drugs as per anaesthesia chart
  2. PositionKnee flexed over bolster / triangleSemiextendedFracture table with calcaneal pinpadded support under thigh; leg draped free including proximal thigh
  3. Rotation referencemethod: iliac crest, patella and second toe in line, or C-arm torsion of normal side
  4. TourniquetNot usedApplied, deflated before reamingif used: pressure, inflation and deflation times; never inflated during reaming

Operative findings

  1. Fracture on C-armpattern, comminution, butterfly fragment, extension into metaphysis or joint
  2. ReductionClosedWith pointed clamps / distractorOpen
  3. Canalsize at first chatter
  4. Open wound findings (if open)contamination, muscle viability, periosteal stripping, bone loss

Procedure (steps)

  1. Painting and drapingantiseptic; leg free from upper thigh
  2. Approach to entry pointMedial parapatellar tendonTranspatellar tendon splitLateral parapatellar tendonSuprapatellarSemiextended medial parapatellar arthrotomyincision length; joint capsule not opened for infrapatellar approaches
  3. Entry point and guide wirejust medial to lateral tibial spine on AP, at anterior edge of articular surface on lateral; true AP confirmed
  4. Entry openedCannulated entry reamerCurved awl
  5. Reduction and ball-tip guide wirecentral in distal fragment on AP and lateral, 0.5 to 1 cm short of ankle joint
  6. Blocking (Poller) screwsNoneUsedposition (lateral / posterior etc.) and number
  7. ReamingReamedUnreamedstart size, size at chatter, final size; knee flexed; fracture held reduced; tourniquet down
  8. Nail length measureddepth gauge or two-wire method, on lateral view, fracture out to length
  9. Nail inserteddiameter x length; manual with twisting or light mallet; proximal end 0.5 to 1 cm below entry cortex; tip 0.5 to 2 cm above ankle subchondral bone
  10. Traction released and fracture checked for gapif distracted: distal locking first then backslap
  11. Distal lockingFreehand, perfect circleJig-guidednumber of screws, direction (medial-lateral / AP), lengths
  12. Proximal lockingStaticDynamicOblique screwsnumber and lengths, through jig
  13. Alignment and rotation checkedAP and lateral C-arm of whole tibia; clinical rotation vs other leg
  14. End capInsertedNot used
  15. Final C-arm images savedknee, fracture, ankle, all screws in AP and lateral; number of images; screening time

Closure, drains and dressing

  1. Wounds washedsaline
  2. Paratenon / retinaculum / tendon splitsuture material
  3. Subcutaneous tissue and skinsuture material or staples
  4. Open fracture woundclosed / left open / negative pressure dressing; plan for cover
  5. Compartments at endSoftTense, pressures measured / fasciotomy done
  6. SplintRemovable posterior splintNone
  7. Neurovascular status at enddorsalis pedis and posterior tibial pulses, capillary refill; toe movement and sensation when block allows

Specimens and implants

  1. Nailtype, diameter x length, make, lot / batch number, sticker in case sheet
  2. Proximal locking screwsnumber, lengths, lot / batch, sticker
  3. Distal locking screwsnumber, lengths, lot / batch, sticker
  4. Blocking screws and end capsize, lot / batch, sticker
  5. Specimen / cultureNoneTissue for culture (open fracture)

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Compartment watchpain out of proportion, pain on passive toe stretch, tense leg: check hourly for 24 hours; inform at once
  2. Vitals and distal neurovascular checkpulses, toe movement, sensation; hourly for 4 hours then 4-hourly
  3. Limb elevationleg on pillow as ordered
  4. Check X-rayfull-length AP and lateral tibia with knee and ankle
  5. Analgesiadrug, dose, frequency
  6. Antibioticsprophylaxis only for closed; open fracture as per protocol
  7. Mobilisationearly knee and ankle motion; weight bearing as tolerated for axially stable patterns, touch-down for unstable or metaphyseal fractures
  8. Thromboprophylaxisas per unit protocol
  9. Follow-upsuture removal at 2 to 3 weeks; review at 6 weeks, then every 6 to 8 weeks until union

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. K.R., 34 years, two-wheeler accident, closed transverse fracture of the left tibial shaft at the middle third (AO/OTA 42A3) with fibula fracture at a different level, compartments soft.

Case details

Date: 14/08/2026. Emergency list, day 1 of injury. OT 2.

In OT 16:00. Spinal given 16:10. Skin incision 16:35. Skin closed 17:40.

Surgeon: Dr A. (2nd-year resident, Orthopaedics). Assistant: Dr B. (1st-year resident). Consultant: Dr C., present in OT.

Anaesthetist: Dr D. Scrub nurse: Sr E. C-arm technician: Mr F.

Indication and pre-op

Indication: closed transverse midshaft fracture left tibia, 42A3, fibula fractured at junction of middle and lower thirds. Skin intact, no blisters.

Leg compartments soft, no pain on passive toe stretch. Dorsalis pedis and posterior tibial pulses palpable. Toe movement and sensation normal. Knee and ankle X-rays normal.

Hb 13.2 g/dl. Blood group A positive, 1 unit cross-matched.

Consent: general, procedure-specific and anaesthesia consent taken in Kannada from patient, wife as witness. Anterior knee pain, compartment syndrome, malalignment and nonunion explained.

Left leg marked. WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 16:20, before skin incision.

Anaesthesia and position

Spinal anaesthesia. Supine, left knee flexed to about 90 degrees over a radiolucent triangle, padded. Tourniquet not used.

Rotation reference: iliac crest, patella and second toe in line; right leg checked for comparison before draping.

Parts painted with povidone-iodine and chlorhexidine-alcohol. Leg draped free from upper thigh.

Procedure

4 cm incision along the medial border of the patellar tendon from the tibial tubercle upwards. Retinaculum split, tendon retracted laterally. Joint capsule not opened.

Threaded guide wire at the entry point just medial to the lateral tibial spine on true AP and at the anterior edge of the articular surface on lateral. Entry opened with cannulated entry reamer and sleeve.

Fracture reduced closed by manual traction. Ball-tip guide wire passed across the fracture, central on AP and lateral, to 1 cm above the ankle joint.

Reamed with knee flexed and fracture held reduced, from 8.5 mm in 0.5 mm steps. Chatter at 10 mm. Final reamer 11 mm.

Nail length on lateral view with depth gauge: 345 mm.

Tibial interlocking nail 10 mm x 345 mm inserted by hand with twisting, knee flexed. Proximal end 0.5 cm below entry cortex on lateral; tip 1 cm above ankle subchondral bone. Guide wire removed once nail was in the distal fragment.

No gap at fracture. Distal locking first, freehand perfect-circle technique: two medial-to-lateral screws, 36 mm and 34 mm. Nail backslapped gently under C-arm to close fracture.

Proximal locking through jig: two static screws, 44 mm and 40 mm.

End cap 0 mm inserted. Alignment satisfactory on full-length AP and lateral. Rotation equal to the right side clinically.

Final C-arm images of knee, fracture and ankle with all screws saved (8 images). Screening time 1 min 45 s.

Closure

Wounds washed with saline. Retinaculum closed with polyglactin 910 (Vicryl) No. 1. Subcutaneous tissue with Vicryl 2-0. Skin with interrupted polyamide (Ethilon) 2-0 at all incisions. Sterile dressing.

Compartments soft at end. Removable posterior splint applied.

Specimens and implants

Tibial interlocking nail 10 x 345 mm. Proximal locking screws 44 mm and 40 mm. Distal locking screws 36 mm and 34 mm. End cap 0 mm.

Make and lot / batch numbers as on the implant stickers. All 6 stickers pasted on the implant page of the case sheet and entered in the OT implant register.

No specimen. No tourniquet. No cement.

End of procedure

Estimated blood loss 150 ml (mops). No transfusion.

Mop, needle and instrument count correct, confirmed by scrub nurse.

No intra-operative complications.

Left foot warm, dorsalis pedis and posterior tibial pulses palpable, capillary refill under 2 seconds. Toe movement and sensation to be rechecked as block wears off.

Shifted to recovery in stable condition. Pulse 80/min, BP 124/76 mmHg.

Post-op orders

Compartment check hourly for 24 hours: pain, pain on passive toe stretch, tense leg. Inform resident on call at once.

Distal pulses, toe movement and sensation hourly for 4 hours, then 4-hourly.

Leg on pillow.

Analgesia as per unit acute pain protocol (drug, dose and times written on the drug chart).

Thromboprophylaxis as per unit protocol.

Full-length X-ray left tibia AP and lateral with knee and ankle.

Knee and ankle motion from POD 1. Walk with walker, weight bearing as tolerated, from POD 1 (axially stable transverse fracture).

Suture removal at 2 weeks. Review with X-ray at 6 weeks.

Signature

Dr A., JR-2, Orthopaedics. Reg. no. ________. 14/08/2026, 17:55.

Must document for this operation

  • Compartment status before surgery and at the end. Compartment syndrome can occur in closed and open tibial fractures, and a missed case is a common medicolegal claim.
  • Approach and entry point used. Knee pain is common, and the next surgeon removing the nail needs to know the approach.
  • Reamed or unreamed, final reamer size, nail diameter and length. Needed for exchange nailing if the fracture does not unite and for implant removal.
  • Number, direction and lengths of locking screws, static or dynamic, and any blocking screws. They decide weight bearing and whether later dynamisation is possible.
  • Tourniquet use and times, and confirmation that it was down during reaming. Reaming with the tourniquet inflated can cause thermal necrosis of bone.
  • Implant make and lot / batch numbers with stickers pasted, and C-arm images saved. Needed for recall, the implant register and proof of final position.
  • Distal neurovascular status at the end. Locking screws and swelling can injure nerves and vessels, and a baseline is needed.

Common mistakes in these notes

  • Writing 'tibia ILN done' without nail size, length or number of screws.
  • Not recording the compartment check at the end or in the post-op orders.
  • No mention of whether the tourniquet was used and deflated before reaming.
  • Implant stickers missing or screw lengths not written.
  • Not recording how rotation was checked.
  • No distal pulses or toe movement recorded at the end.

Indian practice and paperwork

  • Record the batch and serial number of the nail and every screw in the case sheet; NABH also expects them in the OT implant master logbook and the discharge summary. (NABH Hospital Standards 5th ed., MOM.10(d))
  • When the nail is removed later, the metal implant goes into the blue (metallic body implants) biomedical waste container. (CPCB/MoHFW guidelines under Bio-Medical Waste Management Rules 2016, blue (b))

Sources

  • Azar FM, Beaty JH, eds. Campbell's Core Orthopaedic Procedures. 2nd ed. Elsevier; 2024, Technique 25 Intramedullary nailing of tibial shaft fractures (Rudloff MI), pp. 122-127.
  • Tornetta P III, ed. (Wiesel SW, editor-in-chief). Operative Techniques in Orthopaedic Trauma Surgery. 2nd ed. Wolters Kluwer, Ch 51 Intramedullary nailing of the tibia (Lee MA, Eastman JG, Crist B), pp. 547-575.
  • Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier; copyright 2027, Ch 59 Fractures of the lower extremity: tibial shaft fractures, intramedullary fixation (reamed versus unreamed, suprapatellar portal), pp. 2592-2599.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Table 1: cefazolin 2 g IV (3 g if 120 kg or more) within 60 min before incision; if a tourniquet is used, the whole dose before inflation. academic.oup.com/ajhp/article/70/3/195/5112717
  • Operative Techniques in Orthopaedic Trauma Surgery 2e, Ch 51, printed p. 549: diastolic pressure minus compartment pressure below 30 mmHg is an indication for four-compartment fasciotomy.

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

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