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Preoperative Patient Care
Operative Techniques

Preoperative Plan


Template fracture

  • evaluate key fragments of fracture and plan technique to obtain reduction


Template instrumentation

  • measure diameter of intramedullary canal by looking at the narrowest part of isthmus
  • flexible nail should be 40% the width of the narrowest part of the canal


Execute surgical walkthrough

  • describe key steps of the operation
  • describe potential complications and steps to avoid them


Exam under anesthesia

  • Evaluate knee stability
  • Evaluate rotation of contralateral hip

Room Preparation


Surgical instrumentation

  • flexible nailing system


Room setup and equipment

  • radiolucent table (or fracture table)
  • c-arm fluoroscopy
  • c-arm from contralateral side (if using fracture table- 45° towards hip)


Patient positioning

  • If a radiolucent table is used
  • patient is positioned supine
  • make sure the entire femur can be imaged
  • If a fracture table is used
  • patient supine with feet padded with webril and placed firmly in fracture table boots
  • abduct the injured leg widely (30 degrees) and abduct uninjured leg as needed to allow c-arm to come in perpendicularly opposite the injured leg
  • padded post deep into groin, move genitals and Foley catheter out of the way
  • ipsilateral arm on stack of blankets over chest and taped down, contralateral arm on arm board
  • prep and drape entire leg up to iliac crest to ensure adequate working area- use circumferential draping of foot to allow access to medial and lateral sides
  • apply enough traction to get the fracture out to length and confirm with C-arm

Medial and Lateral Incision


Identify the distal femoral physis

  • usually at junction of the upper and middle third of the patella
  • confirm site of physis with c-arm fluoroscopy
  • mark the location on the skin


Mark and make 2 cm incision both medially and laterally with distal aspect at the level of the distal physis

  • carry incision through the fascia in line with the incision
  • elevate the vastus medialis or lateralis anteriorly and spread with hemostat to develop plane down to bone


Alternatively for fractures that are very distal one nail may be advanced from the lateral entry and one advanced antegrade through the greater troch apophysis


Breach the Femoral Cortex


Identify starting point

  • the entry point is 2 cm superior to the physis
  • place a drill with a soft tissue protector through the incision against the distal metaphysis of the femur
  • the drill bit used should be slightly larger than the nail being used
  • alternatively an awl may be used
  • breach the femoral cortex with drill
  • once cortex is breached, angle the drill obliquely
  • it is imperative to angle the drill or awl proximally once the cortex is breached. if the drill or awl are advanced to far transversely instead then it will be very difficult to advance the nail up the femoral shaft

Nail Placement


Prebend nail

  • prebend the nails to a gentle C shape


Place the nails

  • place the nail through the breached cortex
  • gently tap the first nail to the fracture site
  • gently tap the second nail to the fracture site
  • check AP and lateral views of the femur to ensure proper placement of the nail
  • caution should be used when advancing the nails as the tips are sharp enough to penetrate the cortex

Fracture Reduction and Nail Advancement


Reduce the fracture

  • the F tool or a mallet can be used to manipulate the fracture
  • AP and lateral flour images should be obtained confirming the fracture is being held reduced before advancing the nails
  • once a satisfactory reduction is achieved then the nails are advanced across the fracture site

Final Positioning of Nail


Check AP and lateral films to ensure that nails have crossed the fracture site

  • check AP and lateral films to ensure that nails have crossed the fracture site


Advance to final position

  • the lateral nail should end near the greater trochanter apophysis
  • the medial nail should end at the lesser trochanter or can be advanced up the femoral neck (especially in cases of proximal femur fractures)


Evaluate position of nails with AP and lateral fluoro

  • confirm fracture alignment
  • evaluate nail position
  • confirm that there are no rotational issues (that an AP of the hip is in line with an AP of the knee and a lateral of the knee is in line with a lateral of the hip


Back nails out a few centimeters, cut them at the level of the skin and then advance with a tamp until only approximately 1 cm is outside the cortex


Wound Closure


Irrigation and hemostasis

  • copiously irrigate the wound


Deep closure

  • use 2-0-vicryl to close deep fascia


Superficial closure

  • use 2-0 vicryl for subcutaneous tissue
  • use 3-0 monocryl on skin



  • place in knee immobilizer immediately postop
  • in cases where there is a length unstable component and significant motion remains even after placement of flexible nails, a walking spica may be used for reinforcement
Postoperative Patient Care
Private Note

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