Preoperative Patient Care A 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 B 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 C 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 Operative Techniques E 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 F 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 G 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. H 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 I 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 J 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 K 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 L 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 N 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 Postoperative Patient Care O 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 R Complex Patient Care 1 Develops unique, complex post-operative management plans
A 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 B 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 C 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
E 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 F 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 G 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. H 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 I 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 J 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 K 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 L 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 N 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
O 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 R Complex Patient Care 1 Develops unique, complex post-operative management plans