The use of Poller screws as blocking screws
in stabilising tibial fractures treated with
small diameter intramedullary nails
C. Krettek, C. Stephan, P. Schandelmaier, M. Richter,
H. C. Pape, T. Miclau
From Hannover Medical School, Germany
ntramedullary nailing of metaphyseal fractures may
I be associated with deformity as a result of
instability after fixation. Our aim was to evaluate the
clinical use of Poller screws (blocking screws) as a
supplement to stability after fixation with statically
locked intramedullary nails of small diameter.
We studied, prospectively, 21 tibial fractures, 10 in
the proximal third and 11 in the distal third in 20
patients after the insertion of Poller screws over a
mean period of 18.5 months (12 to 29).
All fractures had united. Healing was evident
radiologically at a mean of 5.4 ± 2.1 months (3 to 12)
with a mean varus-valgus alignment of -1.0° (-5 to 3)
and mean antecurvatum-recurvatum alignment of 1.6°
(-6 to 11). The mean loss of reduction between
placement of the initial Poller screw and follow-up
was 0.5° in the frontal plane and 0.4° in the sagittal
plane. There were no complications related to the
Poller screw.
The clinical outcome, according to the
Karström-Olerud score, was not influenced by
previous or concomitant injuries in 18 patients and
was judged as excellent in three (17%), good in seven
(39%), satisfactory in six (33%), fair in one (6%), and
poor in one (6%).
J Bone Joint Surg [Br] 1999;81-B:963-8.
Received 11 March 1999; Accepted 29 April 1999
C Krettek, MD, Professor
C. Stephan, MD, Registrar
P. Schandelmaier, PD, MD, Senior Registrar
M. Richter, MD, Registrar
H. C. Pape, PD, MD, Senior Registrar
Trauma Department, Hannover Medical School, D 30623 Hannover,
Germany.
T. Miclau, MD
Department of Orthopaedic Surgery, San Francisco General Hospital,
1001 Potrero Avenue, Room 3A36, San Francisco, California 94110,
USA.
Correspondence should be sent to Professor C. Krettek at the Department
of Surgery, Monash University, The Alfred Hospital, Commercial Road,
Melbourne, Victoria 3181, Australia.
©1999 British Editorial Society of Bone and Joint Surgery
0301-620X/99/610000 $2.00
VOL. 81-B, NO. 6, NOVEMBER 1999
Unlike intramedullary fixation of diaphyseal fractures of
the tibia, nailing of metaphyseal fractures with a short
proximal or distal fragment is associated with an increase
in malalignment, particularly in the coronal plane. The
cause has been attributed both to displacing muscular
1
forces and residual instability. As there is a large differ-
ence between the size of the implant and the metaphyseal
diameter with no nail-cortex contact, the nail may trans-
late laterally along coronally placed locking screws. Poller
2-5
screws acting as blocking screws, placed adjacent to the
nail, have been proposed as a possible solution by prevent-
2,4 3,5
ing translation in both the tibia and the femur. The
term ‘Poller’ is derived from small metal devices placed in
roads to block or guide traffic. These Poller screws
decrease the width of the medullary cavity, physically
block the nail, and increase the mechanical stiffness of the
6
bone-implant construct. The efficacy of blocking screws,
in terms of clinical outcome, has not been described.
Our aim was to evaluate the use of Poller screws as a
supplement to the fixation of fractures of the proximal and
distal third of the tibia treated with intramedullary nails of
small diameter.
Patients and Methods
We studied prospectively 23 fractures of the tibial shaft in
22 patients between July 1993 and July 1996; two patients
were lost to follow-up leaving 21 fractures in 20 patients
(12 men and 8 women) with a mean age of 44 ± 17 years
7
(18 to 76). The patients’ mean Injury Severity Score was
5.6 ± 4.7 (2 to 13). In ten patients the fracture was the only
injury; in ten there were additional injuries.
Poller screws were selected for use by the surgeon for
one or more of the following reasons: 1) to correct align-
ment after insertion of the nail (7 fractures); 2) to maintain
alignment or to improve the stability of the bone-implant
complex (21); and 3) to control the nail during insertion
(4). The indications for intramedullary nailing included
acute fractures (13), delayed unions (3) and malaligned
fractures (5) treated previously with external fixation (2)
or intramedullary nailing (5). A total of 31 Poller screws
was used. In 15 fractures, the screws were placed during
the nailing procedure, and in six, they were added during
a revision procedure within 28 days of nailing. In 13
963
964 C KRETTEK, C. STEPHAN, P. SCHANDELMAIER,
fractures a single Poller screw was used, placed on the
concave side of the deformity. In the rest of the cases,
either two (6) or three (2) Poller screws were placed.
The patients selected for placement of Poller screws had
displaced fractures of the proximal (10) or distal (11) third
which were either extra-articular or had a non-displaced
intra-articular extension. The mean length of the proximal
fragment was 93 ± 30 mm (33 to 135) and that of the distal
fragment 62 ± 36 mm (27 to 140). The mean length of the
fracture was 87 ± 68 mm (3 to 305). We used the AO
classification for the fracture pattern (A, 5; B, 9; C, 7), the
8
Tscherne classification for soft-tissue injuries in closed
9
fractures (10), and the Gustilo classification for soft-
tissue injuries in open fractures (11).
The metaphyseal fractures were stabilised with a stat-
ically locked tibial nail of small diameter placed using an
unreamed technique, on a standard radiolucent table with
4
manual traction. The implants used were stainless steel or
titanium solid tibial nails (Stratec, Oberdorf, Switzerland) of
diameter 8 (3), 9 (14) or 10 mm (4). Depending on the
amount of correction needed, the screws used for ‘blocking’
were locking screws of different sizes (18), 3.5 mm cortical
screws (11), or other types of screw (4.5 mm cortical screws
or 6.5 mm cancellous screws). The introduction of the nail
was carried out within 48 hours of the injury in 13 cases
Fig. 1
Schematic drawing of distal fracture of the tibia stabilised
with an intramedullary nail of small diameter before (left)
and after insertion of Poller screws (arrows, right).
M. RICHTER, H. C. PAPE, T. MICLAU
and delayed in eight (mean, 48 days; 7 to 270). The mean
time for the operation was 113 ± 51 minutes (50 to 220).
Operative technique. The Poller screws were placed on
the concave side of the deformity between the cortex and
nail (Fig. 1). In all cases, placement was carried out using
image intensification and a radiolucent drill. A drill bit with
a shortened fluted tip reduced nail damage (Fig. 2). In cases
of malalignment and instability, the screw holes were dril-
led with the nail in place while applying manual over-
correction. For fractures which were stable, but malaligned,
the nails were temporarily removed, the Poller screws were
placed, and the nails re-inserted (Fig. 3). This technique
was also used in those fractures (5) in which the previous
path of the removed nail caused malalignment of the
fracture (Fig. 4).
Postoperative treatment. After operation, patients were
partially weight-bearing (15 to 20 kg) for six to eight
weeks. Thereafter, weight-bearing was increased based on
the absence of pain and a study of the radiographs on
follow-up. Two patients were unable to bear partial weight
because of concomitant injuries. In four patients with prox-
imal fractures, a long-leg cast was applied for up to six
weeks. In one, high-energy ultrasound was given to stim-
ulate healing of the fracture.
Complications. Complications were divided into those
which were related to the Poller screws and those which
were not. Potentially related complications included
mechanical instability leading to nonunion, new fracture
lines through the holes for the Poller screws, nail failure
due to damage by the drill and breakage of the Poller
screws. Nerve, tendon or vascular injury would be con-
sidered related, whereas all other complications related to
the fracture or intramedullary nail such as compartment
syndrome, infection, rotational malalignment, breakage of
the locking screw and nerve or vascular injuries, present
before insertion of the Poller screws, were not considered
to be related to them.
Follow-up. Patients were followed through to union of the
fracture with clinical and radiological examinations at
intervals of six or eight weeks and always at a year after
Fig. 2
Photograph of a modified drill bit. The shortened cutting tip
reduces the risk of damage to the IM nail during drilling of
the contralateral cortex.
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 THE USE OF BLOCKING SCREWS IN STABILISING TIBIAL FRACTURES TREATED WITH SMALL DIAMETER INTRAMEDULLARY NAILS 965

Fig. 3
Radiographs and photographs of an open segmental fracture of the proximal tibia. Figure 3a – Radiograph showing the oblique fracture line of a
proximal metaphyseal fracture. Figure 3b – The image intensifier radiograph shows a lateral shift and valgus deformity after the insertion of an unreamed
tibial nail of small diameter. An intraoperative stress test showed a large amount of instability. Figure 3c – Temporary removal of the nail and insertion
of a Poller screw in the previous nail path. Figure 3d – During reinsertion of the nail, the blocking screw prevents the nail from re-entering the previous
nail path. Figure 3e – After insertion of the nail there is correct alignment and a clinically significant increase in stability. Figure 3f and 3h– A
postoperative radiograph shows maintenance of the correct alignment in both planes (3f) and uneventful fracture healing (3h). Figure 3i – Photograph
showing correct alignment. The soft-tissue dissection for the insertion of the blocking screws is minimal.

VOL. 81-B, NO. 6, NOVEMBER 1999

966 C KRETTEK, C. STEPHAN, P. SCHANDELMAIER, M. RICHTER, H. C. PAPE, T. MICLAU

Fig. 4b

Fig. 4a Fig. 4c Fig. 4d Fig. 4e

Figure 4 – Anteroposterior radiographs showing the use of blocking screws as a manipulation tool in the distal tibia. A refracture
of the distal tibia; the initial fracture had been treated with an intramedullary nail, which was later removed (a). The magnification
shows a sclerotic nail path (b). The attempt to stabilise the refracture with an intramedullary nail resulted in a valgus deformity, as
the new nail followed the sclerotic path of the initial fixation (c). The nail was removed temporarily and the sclerotic path blocked
with a Poller blocking screw. A hand reamer was used to create a fresh path for the new nail. On introduction this abutted against
the screws and was directed along the coned path giving proper alignment (d). At 12 months the fracture has healed in correct
alignment (e).

surgery. The mean period of follow-up was 18.5 months Results

(12 to 29); two patients were lost to follow-up. One patient,
with a grade-IIIB open segmental fracture, developed an
infected nonunion caused by oxacillin-resistant Staphyl-
ococcus aureus which was refractory to several surgical
debridements and intravenous antibiotics. He was recom-
mended to have a below-knee amputation but was then lost
to follow-up. The second patient moved to an unknown
address.
Follow-up assessment included neurovascular examina-
tion, evaluation of the axial alignment and a functional
analysis. The functional outcome was quantified using the
10
Karlström-Olerud score. The radiographs obtained pre-
operatively, postoperatively and at each follow-up included
anteroposterior and lateral views of the whole tibia with the
knee and ankle. In the 15 fractures in which the Poller
screws had been placed at the initial fixation, the post-
operative and follow-up radiographs were analysed for
coronal and sagittal alignment. Varus and antecurvatum
angulation were expressed as positive values and valgus
and recurvatum as negative values. The radiographs were
also analysed for correction, maintenance of position or
loss of reduction. A fracture was defined as healed when
the patient was able to bear full weight on the limb without
pain and without support, and when radiographs showed
callus bridging three of four cortices.
All fractures eventually united. Healing was seen at a mean
of 5.4 ± 2.1 months (3 to 12). In one patient extracorporeal
lithotripsy and, in one other, an autogenous bone graft,
were additional treatments. In 18 patients, the Karlström-
Olerud score was not influenced by pre-existing or concom-
itant injuries. The outcome was excellent in three patients
(17%), good in seven (39%), satisfactory in six (33%), fair
in one (6%) and poor in one (6%).
Radiologically, the mean postoperative varus-valgus
alignment in the 15 fractures initially treated with intra-
medullary nails and Poller screws was -0.7 ± 3.1° (-6 to 3).
The mean postoperative varus-valgus alignment in the six
fractures with delayed placement of the Poller screw was
-8.1 ± 3.7° (-15 to -4) initially and -0.2 ± 2.1° (-3 to 3) after
the revision procedure to insert the Poller screws. At the
time of follow-up, the mean varus-valgus alignment, for all
21 fractures was -1.0 ± 2.4° (-5 to 3). The mean loss of
reduction between initial placement of the Poller screw and
follow-up examination was 0.5 ± 1.7°.
The mean postoperative antecurvatum-recurvatum align-
ment in the 15 fractures treated with a nail and a primary
blocking screw was 1.3 ± 4.8° (-6 to 9). The mean post-
operative antecurvatum-recurvatum alignment in the six
fractures with delayed placement of the Poller screw was
THE JOURNAL OF BONE AND JOINT SURGERY
 THE USE OF BLOCKING SCREWS IN STABILISING TIBIAL FRACTURES TREATED WITH SMALL DIAMETER INTRAMEDULLARY NAILS
-1.8 ± 3.3° (-5 to 2) initially and 1.0 ± 4.7° (-5 to 8) after
the revision procedure. At the time of follow-up, the mean
antecurvatum-recurvatum alignment, in all 21 fractures,
was 1.6 ± 4.9° (-6 to 11). The mean loss of reduction
between initial placement of the Poller screw and follow-up
examination was 0.4 ± 2.1°.
No complications with the Poller screws were observed
during or after the operation. None of the nails or blocking
screws broke. Three nails have since been removed and,
apart from minor surface scratches, no changes were
observed. In two patients, the locking screws broke during
the later phases of treatment without clinical consequences.
At follow-up, the skin wound for each insertion site of the
screw had healed uneventfully. There was no evidence of
injury to tendons or arteries. Three patients reported
decreased sensation in some parts of the distribution of the
superficial and deep peroneal nerve and one had a motor
deficit of the deep peroneal nerve. In two of these patients
the deficits were associated with a compartment syndrome.
The other two patients had large soft-tissue defects. In one
a rotational malalignment greater than 15° was observed.
Discussion
The stabilisation of fractures of the proximal and distal
tibia is associated with a high incidence of malalign-
1,11-13
ment. This has been attributed to muscular forces
1
which displace the fracture and to instability which results
4
from the play of a nail along the interlocking screws.
Contributing factors include poor bone-nail contact in the
metaphysis and nails with locking screw holes placed in a
single plane. Since the locking screws are usually
orientated in the coronal plane, varus-valgus malalignment
may follow. Deformities in the sagittal plane, usually better
tolerated, are less common if the fracture is reduced at the
time of initial locking.
Poller screws, placed adjacent to the nail and perpendic-
ular to the interlocking screw holes, usually in an antero-
posterior direction, have been suggested as one possible
method for improving the stability of metaphyseal frac-
4,5
tures and have been described as a reduction tool used to
overcome the displacing forces at the time of introduction
4 schaftfrakturen mit dem UTN. Unfallchirurg 1994;97:575-99.
of the intramedullary nail. The screws functionally
decrease the width of the metaphyseal medulla and are
particularly useful with nails of smaller diameter. To the
authors’ knowledge, the clinical results of the use of Poller
screws have not been described. In 1983, Donald and
14
Seligson referred to a “blocking screw” for “fractures
predisposed to bending”, but appeared to describe locking
screw across the intramedullary nail. In 1994, Krettek et
2,4
al described the clinical application of blocking screws,
termed ‘Poller screws’, as a tool for the prevention of axial
deformities of proximal and distal fractures of the tibia
during intramedullary nailing. The same technique descri-
3,5
bed here for the tibia has been used for the femur.
All the fractures in our series treated by blocking screws,
VOL. 81-B, NO. 6, NOVEMBER 1999
967
healed with a mean varus-valgus alignment of -1.0° (-5 to
3) and a mean antecurvatum-recurvatum alignment of 1.6°
(-6 to 11). These results appear to be superior to others
reported for the stabilisation of metaphyseal fractures with
1,15 11
intramedullary nails. Ahlers and von Issendorf ana-
lysed 386 fractures of the tibia; in 32 fractures of the
proximal third there was an incidence of 59% of varus-
valgus malalignment greater than or equal to 2° and in 138
fractures of the distal third 47% showed this deformity. In
both proximal and distal groups, less than one-third had
alignments less than 3° and one-quarter to one-third had
varus-valgus deformities greater than 4°. Anatomical align-
ment was observed in 40% of fractures of the shaft, but
only in 31% of the proximal and 30% of the distal
fractures.
In six of our cases, Poller screws were applied during
revision surgery when malalignment or mechanical instab-
ility had been diagnosed after nailing. For this reason, the
authors recommend a stress test of any stabilised fracture
intraoperatively. Similarly, the alignment of the fracture
should be examined radiologically in two planes during the
operation after placement of the nail to ensure proper
alignment. If the mechanical stability of the limb is inade-
quate, application of a Poller screw can be carried out in the
same procedure.
The current study has several limitations. It is a non-
randomised, non-controlled clinical trial. There were sev-
eral different surgeons carrying out the technique, although,
given the good results of our study, the relative simplicity
of the techiques is demonstrated. We conclude that Poller
screws can correct and maintain alignment, improve the
primary stability of the bone-nail complex, and enhance the
surgeon’s ability to perform effective nailing of fractures of
of the proximal or distal third of the tibia.
No benefits in any form have been received or will be received from a
commercial party related directly or indirectly to the subject of this
article.
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THE JOURNAL OF BONE AND JOINT SURGERY