C Preoperative H & P 1 Performs focused orthopaedic exam check for ipsilateral femoral neck fracture check thigh compartments (anterior, posterior, adductor) neurovascular exam (evaluate distal circulation) 2 Appropriately orders basic imaging studies need biplanar radiographs of entire femur, hip and knee 3 Perform operative consent describe complications of surgery including delayed union, nonunion malunion soft tissue irritation at entry site infection leg length discrepancy
E Preoperative Plan 1 Template fracture evaluate key fragments of fracture and plan technique to obtain reduction 2 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 3 Execute surgical walkthrough describe key steps of the operation describe potential complications and steps to avoid them 4 Exam under anesthesia Evaluate knee stability Evaluate rotation of contralateral hip F Room Preparation 1 Surgical instrumentation flexible nailing system 2 Room setup and equipment radiolucent table (or fracture table) c-arm fluoroscopy c-arm from contralateral side (if using fracture table- 45° towards hip) 3 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 G Medial and Lateral Incision 1 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 2 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 3 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 H Breach the Femoral Cortex 1 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 I Nail Placement 1 Prebend nail prebend the nails to a gentle C shape 2 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 J Fracture Reduction and Nail Advancement 1 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 K Final Positioning of Nail 1 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 2 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) 3 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 4 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 L Wound Closure 1 Irrigation and hemostasis copiously irrigate the wound 2 Deep closure use 2-0-vicryl to close deep fascia 3 Superficial closure use 2-0 vicryl for subcutaneous tissue use 3-0 monocryl on skin 4 Immobilizaton 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
O Perioperative Inpatient Management 1 Write comprehensive admission orders serial compartment checks x 24 hours advance diet as tolerated pain control if foley used, dc pod 1 antibiotics ( if closed fracture- generally ancef x 24h) 2 Initiate physical therapy on POD 1 weight-bearing as tolerated for transverse/length stable fractures toe touch weight bearing if comminuted or spiral fracture pattern 3 Discharges patient appropriately pain meds schedule 2 week follow up