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Femoral Shaft Fracture Antegrade Intramedullary Nailing

Planning

B

Preoperative Plan

1

Template fracture reductions

  • draw key fragments of fracture and plan forces required to obtain reductions

2

Template instrumentation

  • measure diameter of intramedullary canal and approximate length.

3

Execute surgical walkthrough

  • resident can describe key steps of the operation verbally to attending prior to beginning of case.
  • describe potential complications and steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • antegrade femoral intramedullary nailing system
  • recon nailing system if femoral neck protection needed

2

Room setup and equipment

  • table options
  • radiolucent flat top table
  • fracture table
  • c-arm fluoroscopy
  • c-arm from contralateral side perpendicular to patient if on flat top table
  • c-arm from contralateral side at 45° towards hip if on fracture table
  • take initial biplanar flouroscopic images of hip to examine femoral neck

3

Patient positioning

  • if using flat top table, patient is supine with small bump under ipsilateral hip
  • patient's waist brought to edge of bed
  • ipsilateral arm on stack of blankets over chest and taped down, contralateral arm on arm board
  • if using fracture table
  • patient supine with feet padded with webril and placed firmly in fracture table boots if contralateral leg dropped down, if raising contralateral leg up 90° use thigh holder
  • 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
  • if traction pin in place, can remove prior to prep and drape, or alternatively can leave in place to use for traction during case (place sterile endcaps if using traction pin)
  • prep and drape entire leg up to iliac crest to make sure adequate working area

Technique

D

Lateral Approach to the Hip

1

Make incision approximately 3 cm above GT in line with femur

  • move incision superior if patient obese

2

Dissect down to greater trochanter

  • use cautery through subcutaneous tissue and sharp dissection through the fascia lata
  • palpate tip of greater trochanter.
E

Guidewire Entry

1

Choose and identify the guidepin starting point

  • trochanteric starting point is on the medial tip of the GT
  • piriformis starting point is on the piriformis fossa
  • confirm staring point with fluouroscopy
  • needs to be in center of medullary canal on AP radiograph and center of GT on lateral image
  • starting point can be different if trochanteric height/offset different
  • if difficulty with guidewire start point, use cannulated awl to get better control

2

Insert guidepin

  • Insert guidepin down to lesser trochanter and check biplanar images

3

Use entry reamer

  • place and push soft tissue protector so that reaming is parallel to femur
  • soft tissue tends to force eccentric medial reaming
F

Fracture Reduction

1

Reduce fracture before nail placement

  • use traction on extremity needed for reduction
  • ensure paralysis from anesthesia if having difficulties
  • use F-tool (see video) or mallets for externally-based force if needed
  • can use Steinmann pins to hold as well - needed for segmental fragments

2

Advance guidepin

  • manually push long balltip guidewire past fracture site using T-handle (with slight bend at tip)
  • seat guidewire down to distal physeal scar

3

Check biplanar imaging

4

Measure appropriate nail length

  • use ruler intraoperatively
  • can use a radiolucent ruler on contralateral side to measure intact femur preoperatively if segmental comminution exists
G

Reaming and Nail Placement

1

Ream intramedullary canal

  • start with size 9mm reamer, then ream up 0.5-1.0mm with each reamer
  • push through entry hole before reaming to avoid eccentric reaming
  • check chatter from reamer feedback and diaphyseal fit on AP radiograph
  • ream 1.5mm above size of final nail (i.e. size 12.5mm reamer head for size 11mm nail)
  • don’t stop reamer in canal (avoids incarceration of reamer head)

2

Build nail

  • build nail on backtable and make sure targeting guide lines up with holes in nail

3

Place nail into intramedullary canal

  • insert nail over guidewire, follow anterior bow of femur
  • start with handle pointing up and rotate down to parallel with femur as the nail is seated
  • hold nail by handle, not the targeting guide,

4

Advance nail in intramedullary canal

  • manually advance nail past the fracture site to avoid iatrogenic comminution or development of new fracture lines possible with use of the mallet
  • insert nail completely and seat fully, check seating in distal femur
  • lateral radiograph of the knee is the appropriate view to assess nail insertion unless using recon-style fixation (need AP hip view to determine depth of nail)

5

Remove long balltip guidewire

H

Proximal Locking Screws

1

Identify interlocking screw placement

  • use AP fluoroscopic view to see where interlock screws will be located
  • for recon style fixaton: inferior femoral neck screw to be along inferior neck

2

Place interlocking screw

  • incise skin, subcutaneous tissue and fascia at tip of trocar, spread down to bone
  • push guides down to bone, remove innermost sleeve, and insert K-wire or drill bit in inferior trocar
  • check wire or drill bit position on AP and lateral images
  • depending on the nailing system, repeat process for in the superior trocar

3

Remove top jig locking screw from nail and remove handle and targeting guide

I

Distal Locking Screws

1

Obtain perfect circles

  • obtain C-arm lateral images for perfect circle technique
  • move the C-arm or the leg as a unit to avoid iatrogenic malrotation
  • use scalpel to locate incision site
  • incise through skin and IT band
  • use hemostat to spread down to bone

2

Drill holes for interlocking screws

  • place drill on lateral cortex in the center of the hole
  • make drill perpendicular to C-arm beam and drill through cortices and nail

3

Place interlocking screws

  • use depth gauge for length and place first screw
  • repeat this technique for a second screw if needed

4

Take final biplanar imaging of distal and proximal aspects of nail and fracture

5

Take hip through a range of motion to assess for fracture

  • static or dynamic fluoroscopic evaluation is needed

6

Check limb lengths, rotation, and perform a knee exam under anesthesia

J

Wound Closure

1

Irrigation, hemostasis, and drain

  • strongly flush out nail insertion site and interlocking screw sites with saline bulb irrigation
  • irrigate until backflow is clear
  • cauterize peripheral bleeding vessels

2

Deep closure

  • close fascia lata and IT band with 0-vicryl

3

Superficial closure

  • subcutaneous and skin closure with 3-0 vicryl and suture or staples

4

Dressings

  • soft incision dressings over hip, proximal and distal femur

Patient Care

K

Preoperative H & P

1

Performs focused orthopaedic exam

  • check for ipsilateral femoral neck fracture
  • check thigh compartments (anterior, posterior, adductor)

2

Appropriately orders basic imaging studies

  • need biplanar radiographs of entire femur, hip, knee, and CT of femoral neck

3

Perform operative consent

  • describe complications of surgery including
  • anterior perforation of distal femoral cortex (nail-femur bow mismatch)
  • post-operative abductor weakness and limp
  • heterotopic ossification (rarely clinically significant)
  • delayed union, nonunion
  • malrotation of femur (common cause of litigation)
  • infection
  • hardware failure
  • iatrogenic fracture (under-reaming)
  • missed femoral neck fracture
L

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • serial compartment checks x 24 hours
  • advance diet as tolerated
  • pain control
  • prescribe appropriate DVT prophylaxis
  • wound management
  • remove dressings POD2
  • foley out when ambulating
  • check appropriate labs
  • antibiotics

2

Check radiographs in postop

  • check placement of implants

3

Initiate physical therapy on POD 1

  • weight-bearing as tolerated

4

Appropriate medical management and medical consultation

5

Discharges patient appropriately

  • pain meds
  • outpatient physical therapy
  • schedule 2 week follow up
  • weightbearing as tolerated
M

Outpatient Evaluation and Management

1

Obtains focused history and performs focused exam

  • document distal neurovascular status
  • concomitant and associated orthopaedic injuries

2

Interpret basic imaging studies

  • obtain biplanar radiographs of entire femur, hip, knee, and CT of femoral neck
  • 2-6% incidence of ipsilateral femoral neck fracture
  • usually basicervical, vertical, and nondisplaced

3

Stabilized length of diaphyseal fracture (immobilization vs. traction)

  • immobilization if time to surgery is acute
  • if potential delay in definitive fixation with intramedullary nail place distal femoral or proximal tibia traction pin with ~25lb inline traction to reduce amount of shortening
  • no tibial traction pin if ipsilateral knee injury suspected
  • place in femoral traction if time to surgery will be delayed
  • definitive stabilization within 24 hours associated with decreased pulmonary complications, thromboembolic events, and length of hospital stay

4

Make informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention

5

Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • continue physical therapy and range of motion exercises
  • wound check
  • repeat radiographs of femur
  • staples/sutures removed
  • diagnose and management of early complications
  • postop: ~ 3 month postoperative visit
  • repeat radiographs of the femur
  • diagnosis and management of late complications
  • postop: 1 year postoperative visit
N

Advanced Evaluation and Management

1

Prioritizes the needs of the polytrauma patient

  • timing of long bone fixation
  • works with consulting

2

Complex wound management and debridement

  • understanding need for consultation for flap coverage

3

Capable of treating complications both intraoperatively and post-operatively

  • manages post operative infection
O

Complex Patient Care

1

Develops unique, complex post-operative management plans

 

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