CASE REPORT

Firelands Health Sandusky Orthopedics

Ohio Health Orthopedic Trauma and Reconstructive Surgery

Malrotation of femoral shaft fractures is easy to overlook, and one of the most common complications after IM nailing. I would prefer positioning the patient supine on a fracture table. Prior to distal locking, I would obtain fluoroscopy shots of the contralateral uninvolved limb with the toes point...ing straight up. I would obtain an AP of the hip, ensuring I can see the lesser trochanter. I would then move the c-arm distal without moving the leg, and then take an AP of the knee, ensuring I can see the fibular head. Then I would move to the injured limb and match the AP hip of contralateral side, specifically matching the amount of lesser trochanter exposed. This can be done with moving the c-arm as opposed to the leg since rotating the leg isn't going to work as well with the fracture. Once lined up, then I would move the c-arm distal to the knee, and rotate the leg until the degree of fibular head overlap matches the contralateral knee. Once it matches, then I would lock the nail in that position, knowing you are now radiographically rotated pretty close to the contralateral side.

Was this an isolated injury? Timing of the case? Any preop CT of the femoral neck? Also ditto on Dr. Riehl's questions.I like the proximal configuration, and don't see any issue with this. I'd personally throw in a second distal interlocking screw as it increases the fatigue strength of a constr...uct, esp with a comminuted fracture like this. You may be able to get away with just one screw, however, as you have a decent isthmal fit. This case was a few months ago - any follow up xrays?

PMID: 10565645

J Bone Joint Surg Am. 1999 Nov;81(11):1538-44.

Immediate weight-bearing after treatment of a comminuted fracture of the femoral shaft with a statically locked intramedullary nail.

J Bone Joint Surg Am. 1999 Nov

R J Brumback | T R Toal Jr | M S Murphy-Zane | V P Novak | S M Belkoff

PMID: 7838494

Orthop Clin North Am. 1995 Jan;26(1):139-46.

A prospective study of fractures of the femoral shaft treated with a static, intramedullary, interlocking nail comparing one versus two distal screws.

Orthop Clin North Am. 1995 Jan

J Grover | D A Wiss

Thanks for the comments. In initial management of this patient at our institution we work with the general surgery trauma team who is the admitting and clearing team. We do obtain serial lactates on trauma patients and rely on other consulting services for clearance when needed. All trauma patients ...here are pan scanned with CT CAP and you can assess femoral neck pre op. This was an isolated injury for this patient and these injuries are typically fixed within 24 hours if there is no need for clearance or concomitant chest injury. For operative set up, if performing piriformis nailing, I prefer large bump under hip initially to make start point more accessible. Incisions are made as small as possible so typically I'll get a good idea of my starting incision using the guide wire percutaneously. Depending on fracture type or alignment your bump can be removed once reaming and initial nail passage are done to assess rotation in whichever manner you prefer. I do feel lesser trochanter profiling is fairly simple and using fluorscopy before prepping is most helpful to me. You can use this to pre measure the contralateral femoral shaft length and isthmus diameter, as well as assess your rotation profiles before you drape. Secondarily you can always assess cortical width in different rotations as a method to double check your reduction. In this particular case we reamed rather aggressively in order to get a tight distal isthmic fit. This did cause the medial spike to displace, whether iatrogenic or non-displaced, but we had an excellent fit distal to the fracture. Intraoperatively I do like to get IR/ER spots and live fluoroscopy to look at the femoral neck. We did not suspect a femoral neck component in this case but with the medial spike displacement I wanted to be safe and protect the neck in case there was a spiral component into the intertrochanteric region. This is the reason for the proximal configuration. Distally we felt a singe screw in the proximal static hole, which gets better cortical purchase, in addition to our isthmic fit was sufficient. As with most patients at our institution this patient was made WBAT. I'll look back to see if I can upload some follow up films. Thanks for all the questions and comments.

Thanks for posting the case. My initial thought based on the x-rays was that this is a fracture which in isolation could be treated with a retrograde or antegrade nail. I would prefer an antegrade piriformis nail to help prevent mal reduction. A troch nail can be used as well but I would cheat the s...tarting point medially. Your intra op films show an even more proximal fracture fragment. Was that just non displaced initially and just propagate during reaming/nail insertion?

PMID: 16314714

J Orthop Trauma. 2005 Nov-Dec;19(10):681-6. [PMID]16314714[/PMID]

A critical analysis of the eccentric starting point for trochanteric intramedullary femoral nailing.

J Orthop Trauma. 2005 Nov-Dec

Robert F Ostrum | Andrew Marcantonio | Robert Marburger

How did you position this patient? I have the same questions as below regarding your choice of interlocking fixation. My only concern is that usually the superior screw in the head/neck can be locked to the nail creating a fixed angle construct, which is useful in comminuted subtrochs. Thanks for s...haring.