• Alexander M Keppler, Konstantin Küssner, Eduardo M Suero, Veronika Kronseder, Wolfgang Böcker, Christian Kammerlander, Christian Zeckey, and C Neuerburg.
• Department for General, Trauma and Reconstructive Surgery, University Hospital LMU Munich, Munich, Germany.
• Eur J Trauma Emerg Surg. 2022 Oct 1; 48 (5): 3659-3667.

AimIntramedullar nailing of tibial mid-shaft fractures is a common surgical treatment. Fracture reduction, however, remains challenging and maltorsion is a common discrepancy which aggravates functional impairment of gait and stability. The use of radiographic tools such as the cortical step sign (CSS) and the diameter difference sign (DDS) could improve fracture reduction. Therefore, the validity of the CSS and DDS was analyzed to facilitate detection of maltorsion in tibial mid-shaft fractures.MethodsTibial mid-shaft fractures were induced in human cadaveric tibiae according to the AO classification type A3. Torsional discrepancies from 0° to 30° in-/external direction were enforced after intramedullary nailing. Fluoroscopic-guided fracture reduction was assessed in two planes via analysis of the medical cortical thickness (MCT), lateral cortical thickness (LCT), tibial diameter (TD), anterior cortical thickness (ACT), posterior cortical thickness (PCT) and the transverse diameter (TD) of the proximal and distal fracture fragment.ResultsThe TD, LCT and ACT have shown a highly significant correlation to predict tibial maltorsion. While a model combining ACT, LCT, PCT and TD lateral was most suitable model to identify tibial maltorsion, a torsional discrepancy of 15°was most reliably detected with use of the TD and ACT.ConclusionThe present study has shown, that maltorsion can be reliably assessed by the CSS and DDS during fluoroscopy. Thus, torsional discrepancies in tibial mid-shaft fractures can be most reliably assessed in the lateral plane by analysis of the LCT and TD.© 2021. Springer-Verlag GmbH Germany, part of Springer Nature.

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