Proximal Tibial Fractures



Metaphysical / extra-articular



- abductors/hamstrings (pes) = varus of proximal fragment = valgus of fracture

- patella tendon = extension of proximal fragment = procurvatum of fracture


Prox tibia 1Prox tibia lateral

Characteristic valgus deformity with extension of the proximal fragment


Treatment options







Jindal et al. Indian J Orthop 2020

- systematic review

- no different in malunion

- infection more common in plate

- anterior knee pain more common with nail

- faster time to weight bearing and union with nail


Meena et al. J Orthop Traumatol 2015

- RCT plate v IMN for proximal tibial fractures

- 58 patients

- reduced time to union and weight bearing IMN
- no significant different for infection / nonunion / malunion


IMN Proximal tibial fractures




High incidence malunion

- coronal plane valgus 

- saggital plane flexion / procurvatum

- posterior translation of distal segment


Proximal Tibial Fracture Poorly NailedProximal Tibial MalunionProximal Tibial Malunion

Residual proximal tibial fragment flexion - entry point too anterior


Valgus 1Valgus 2

Residual valgus - entry point too medial




Standard medial and anterior entry points

- mismatch to distal canal 

- canal becomes triangular

- pushes fracture into the above deformities




1.  Change entry point

- match entry point to distal IM canal

- lateral in line with lateral tibial spine

- posterior


2.  Blocking screws

- also lateral and posterior

- functionally narrow IM canal

- on concave side of deformity at the level of the fracture

- same positions as entry point

- posterior in proximal segment

- lateral in proximal segment


Smith and Nephew Tibial Meta Nail with Blocking Screws


3.  Supra-patellar approach with leg semi-extended

- flexed tibia tends to accentuate the deformity

- semi-extended reduces the deformity

- also easier to get lateral and posterior entry point


Smith & Nephew Semi-extended nail


Vumedi Proximal Tibial Nailing Presentation




Kulkarni et al. Injury 2020

- series of 43 proximal tibial fractures

- treated with suprapatella nail in semi-extended position

- malunion in 4/43 (9%)

- nonunion in 1/43 (2%)


Plate Proximal Tibia Fractures


Proximal tibia fracture 1Proximal Tibial Fracture


Proximal Tibial PlateProximal tibial plate