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 Interprets basic imaging studies obtain biplanar radiographs of entire femur, hip, knee, and/or CT of femoral neck 2-6% incidence of ipsilateral femoral neck fracture often basicervical, vertical, and nondisplaced 3 Stabilized length of diaphyseal fracture (immobilzation 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 is associated with decreased pulmonary complications, thromboembolic events, and length of hospital stay 4 Makes 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 wound check diagnose and management of early complications staples/sutures removed continue physical therapy and range of motion exercises repeat radiographs of femur postop: ~ 3 month postoperative visit diagnosis and management of late complications repeat xrays of femur postop: 1 year postoperative visit obtain one year radiographs document outcome with appropriate standardized scoring system 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 History and Physical 1 Perform focused orthopedic exam check ipsilateral femoral neck check thigh compartments (anterior, posterior, adductor) document distal neurovascular status 2 Order basic imaging studies need AP and lateral radiographs of entire femur, hip, knee CT of femoral neck 3 Perform operative consent describe complications of surgery including post-operative knee pain heterotopic ossification delayed union, nonunion femoral nerve or artery injury (insertion of proximal interlocking screws) increased risk if screws placed inferior to lesser trochanter malrotation of femur infection hardware failure missed femoral neck fracture iatrogenic fracture (under-reaming, femoral neck fracture) iatrogenic damage to cruciate ligaments Operative Techniques E Preoperative Plan 1 Template fracture reduction draw key fragments of fracture and plan forces required to obtain reductions 2 Template instrumentation measure diameter intramedullary canal and approximate length 3 Execute surgical walkthrough resident can describe the key steps of the procedure verbally to the attending prior to the start of the case description of potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation make sure retrograde intramedullary nailing system is present. 2 Room setup and equipment radiolucent flat-top table c-arm fluoroscopy c-arm from contralateral side perpendicular to the bed take initial AP and lateral of hip to examine femoral neck 3 Patient positioning patient supine with feet at the end of the bed small bump under ipsilateral thigh if traction pin in place, can remove prior to prep and drape alternatively can leave in place to use for traction during case prep and drape entire leg up to iliac crest G Anterior Knee Aproach 1 Position the knee and mark out the anatomy place knee in ~30° flexion over radiolucent triangle knee flexion also prevents distal fragment from being pulled into more flexion by gastrocnemius mark out inferior pole of patella and borders of patella tendon 2 Expose the intercondylar notch make incision, dissect through subcutaneous tissues, and perform arthrotomy transtendinous approach make 2cm incision from inferior pole of patella distal through tendon perform tenotomy to develop paratenon layer, sharply dissect or cauterize through paratenon then patellar tendon insert self-retainers and suction out synovial fluid once in joint, remove small amount of fat pad to minimize guidepin deflection parapatellar approach 2 cm incision along medial third of patellar tendon cut through subcutaneous tissue and retract tendon/paratenon laterally insert self retainer 3 Visualize intercondylar notch H Guidewire entry 1 Identify guidewire starting point guidepin start point is in center of intercondylar notch, just superior to Blumensaat’s line 2 Use entry reamer with soft tissue protector 3 Insert guidepin to distal metaphysis check C-arm image to ensure pin is in center of medullary canal 4 Place balltip guiewire remove starting pin and reamer, and place balltip guidewire in canal with T-handle place gentle bend at tip of balltip wire, manually push in to distal aspect of fracture site I Fracture Reduction and Reaming 1 Reduce fracture by pulling traction can use small blue towel bump to add flexion to distal segment if pulling straight inline traction on foot you will cause more flexion deformity of the distal segment due to pull of the gastrocnemius need to pull traction at 30° angle over triangle 2 Advance guidewire manually push guidewire past fracture site and up to lesser trochanter insert guidewire past lesser trochanter by 3-4cm 3 Check placement of wire with AP and lateral radiographs 4 Measure nail length use radiolucent ruler to measure appropriate nail length use ruler on contralateral side to measure intact femur if segmental comminution exists 5 Ream intramedullary canal start with 9mm reamer, then ream up 0.5-1.0mm with consecutive reamer 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 reamer head from becoming incarcerated) if eccentric reaming/wire position is seen, can place blocking screws J Nail Insertion 1 Assemble femoral nail attach jig to nail on backtable and check that targeting guide lines up with holes in nail 2 Insert nail over guidewire cover holes closest to nail handle with hand to make sure blood doesn't pressurize out of nail during insertion insert nail with jig lateral to thigh hold nail by handle, not the targeting guide, mallet or manually advance to fracture site 3 Advance the nail manually advance nail past the fracture site to avoid iatrogenic comminution or development of new fracture lines possible with use of the mallet seat nail fully 4 Confirm nail depth lateral radiograph of the knee is the appropriate view to assess nail insertion depth 5 Remove guidewire before placing interlocking screws K Distal Interlocking Screws 1 Place trocar onto bone use targeting guide to place most distal interlock first mark skin with sleeve, incise through skin, spread down to bone with hemostat, and place trochar on bone 2 Place interlocking screw drill bicortically through the nail leave drill bit in until screw arrives to hold nail/bone position remove drill bit then quickly place the screw repeat process above for placement of other interlocking screws if indicated 3 Remove jig use attachment to remove nail jig, then take out triangle to lay leg flat 4 Check femoral neck again on C-arm L Proximal Interlocking Screws 1 Obtain perfect circles ensure no rotation of the distal femur is done while getting these views move the C-arm, not the leg magnification of the fluoroscopic view can be used if desired 2 Identify placement of interlocking screws incise through skin, careful blunt spreading down to bone, especially if distal to lesser trochanter start with most proximal interlocking hole (screw will be longer than the more distal screw) 3 Drill holes for interlocking screws ensure drill bit placed over center of hole, parallel to C-arm beam to measure can use a second drill bit or depth gauge alternatively use a 34 or 36mm screw 4 Insert interlocking screws remove drill quickly and insert screw when available use locking screwdriver or place silk suture around screw head so it doesn’t get lost in soft tissues 5 Repeat above process for 2nd proximal interlocking screw 6 Take final radiographs raise leg up off of bed, 90° bend in knee, then take final AP and lateral radiograph of proximal, middle, and distal aspects of femur 7 Take hip through a range of motion to assess for fracture fluoroscopic evaluation is key, whether static or dynamic at the end of the procedure 8 Check limb lengths and rotation 9 Perform a knee examination under anesthesia N Wound Closure 1 Irrigation, hemostasis, and drain place knee under triangle and strongly flush out reamings with saline bulb irrigation irrigate until backflow is clear cauterize peripheral bleeding vessels 2 Fascia closure transtendinous close patellar tendon and paratenon layers with 0-vicryl subcutaneous and skin closure parapatellar close peripatellar arthrotomy subcutaneous and skin closure 3 Dressing Soft dressings over knee, distal, and proximal femur Postoperative Patient Care O Perioperative Inpatient Management 1 Write comprehensive admission orders advance diet as tolerated pain control wound management remove dressings POD2 foley out when ambulating check appropriate labs antibiotics prescribe DVT Prophylaxis 2 Appropriately orders and interprets basic imaging studies obtain radiographs of the femur and knee in postop 3 Initiate physical therapy POD 1 weight bear as tolerated immediate range of motion exercises to hip and knee 4 Appropriate medical management and medical consultation 5 Discharges patient appropriately pain meds outpatient PT schedule follow up visit 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 Interprets basic imaging studies obtain biplanar radiographs of entire femur, hip, knee, and/or CT of femoral neck 2-6% incidence of ipsilateral femoral neck fracture often basicervical, vertical, and nondisplaced 3 Stabilized length of diaphyseal fracture (immobilzation 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 is associated with decreased pulmonary complications, thromboembolic events, and length of hospital stay 4 Makes 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 wound check diagnose and management of early complications staples/sutures removed continue physical therapy and range of motion exercises repeat radiographs of femur postop: ~ 3 month postoperative visit diagnosis and management of late complications repeat xrays of femur postop: 1 year postoperative visit obtain one year radiographs document outcome with appropriate standardized scoring system 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 History and Physical 1 Perform focused orthopedic exam check ipsilateral femoral neck check thigh compartments (anterior, posterior, adductor) document distal neurovascular status 2 Order basic imaging studies need AP and lateral radiographs of entire femur, hip, knee CT of femoral neck 3 Perform operative consent describe complications of surgery including post-operative knee pain heterotopic ossification delayed union, nonunion femoral nerve or artery injury (insertion of proximal interlocking screws) increased risk if screws placed inferior to lesser trochanter malrotation of femur infection hardware failure missed femoral neck fracture iatrogenic fracture (under-reaming, femoral neck fracture) iatrogenic damage to cruciate ligaments
E Preoperative Plan 1 Template fracture reduction draw key fragments of fracture and plan forces required to obtain reductions 2 Template instrumentation measure diameter intramedullary canal and approximate length 3 Execute surgical walkthrough resident can describe the key steps of the procedure verbally to the attending prior to the start of the case description of potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation make sure retrograde intramedullary nailing system is present. 2 Room setup and equipment radiolucent flat-top table c-arm fluoroscopy c-arm from contralateral side perpendicular to the bed take initial AP and lateral of hip to examine femoral neck 3 Patient positioning patient supine with feet at the end of the bed small bump under ipsilateral thigh if traction pin in place, can remove prior to prep and drape alternatively can leave in place to use for traction during case prep and drape entire leg up to iliac crest G Anterior Knee Aproach 1 Position the knee and mark out the anatomy place knee in ~30° flexion over radiolucent triangle knee flexion also prevents distal fragment from being pulled into more flexion by gastrocnemius mark out inferior pole of patella and borders of patella tendon 2 Expose the intercondylar notch make incision, dissect through subcutaneous tissues, and perform arthrotomy transtendinous approach make 2cm incision from inferior pole of patella distal through tendon perform tenotomy to develop paratenon layer, sharply dissect or cauterize through paratenon then patellar tendon insert self-retainers and suction out synovial fluid once in joint, remove small amount of fat pad to minimize guidepin deflection parapatellar approach 2 cm incision along medial third of patellar tendon cut through subcutaneous tissue and retract tendon/paratenon laterally insert self retainer 3 Visualize intercondylar notch H Guidewire entry 1 Identify guidewire starting point guidepin start point is in center of intercondylar notch, just superior to Blumensaat’s line 2 Use entry reamer with soft tissue protector 3 Insert guidepin to distal metaphysis check C-arm image to ensure pin is in center of medullary canal 4 Place balltip guiewire remove starting pin and reamer, and place balltip guidewire in canal with T-handle place gentle bend at tip of balltip wire, manually push in to distal aspect of fracture site I Fracture Reduction and Reaming 1 Reduce fracture by pulling traction can use small blue towel bump to add flexion to distal segment if pulling straight inline traction on foot you will cause more flexion deformity of the distal segment due to pull of the gastrocnemius need to pull traction at 30° angle over triangle 2 Advance guidewire manually push guidewire past fracture site and up to lesser trochanter insert guidewire past lesser trochanter by 3-4cm 3 Check placement of wire with AP and lateral radiographs 4 Measure nail length use radiolucent ruler to measure appropriate nail length use ruler on contralateral side to measure intact femur if segmental comminution exists 5 Ream intramedullary canal start with 9mm reamer, then ream up 0.5-1.0mm with consecutive reamer 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 reamer head from becoming incarcerated) if eccentric reaming/wire position is seen, can place blocking screws J Nail Insertion 1 Assemble femoral nail attach jig to nail on backtable and check that targeting guide lines up with holes in nail 2 Insert nail over guidewire cover holes closest to nail handle with hand to make sure blood doesn't pressurize out of nail during insertion insert nail with jig lateral to thigh hold nail by handle, not the targeting guide, mallet or manually advance to fracture site 3 Advance the nail manually advance nail past the fracture site to avoid iatrogenic comminution or development of new fracture lines possible with use of the mallet seat nail fully 4 Confirm nail depth lateral radiograph of the knee is the appropriate view to assess nail insertion depth 5 Remove guidewire before placing interlocking screws K Distal Interlocking Screws 1 Place trocar onto bone use targeting guide to place most distal interlock first mark skin with sleeve, incise through skin, spread down to bone with hemostat, and place trochar on bone 2 Place interlocking screw drill bicortically through the nail leave drill bit in until screw arrives to hold nail/bone position remove drill bit then quickly place the screw repeat process above for placement of other interlocking screws if indicated 3 Remove jig use attachment to remove nail jig, then take out triangle to lay leg flat 4 Check femoral neck again on C-arm L Proximal Interlocking Screws 1 Obtain perfect circles ensure no rotation of the distal femur is done while getting these views move the C-arm, not the leg magnification of the fluoroscopic view can be used if desired 2 Identify placement of interlocking screws incise through skin, careful blunt spreading down to bone, especially if distal to lesser trochanter start with most proximal interlocking hole (screw will be longer than the more distal screw) 3 Drill holes for interlocking screws ensure drill bit placed over center of hole, parallel to C-arm beam to measure can use a second drill bit or depth gauge alternatively use a 34 or 36mm screw 4 Insert interlocking screws remove drill quickly and insert screw when available use locking screwdriver or place silk suture around screw head so it doesn’t get lost in soft tissues 5 Repeat above process for 2nd proximal interlocking screw 6 Take final radiographs raise leg up off of bed, 90° bend in knee, then take final AP and lateral radiograph of proximal, middle, and distal aspects of femur 7 Take hip through a range of motion to assess for fracture fluoroscopic evaluation is key, whether static or dynamic at the end of the procedure 8 Check limb lengths and rotation 9 Perform a knee examination under anesthesia N Wound Closure 1 Irrigation, hemostasis, and drain place knee under triangle and strongly flush out reamings with saline bulb irrigation irrigate until backflow is clear cauterize peripheral bleeding vessels 2 Fascia closure transtendinous close patellar tendon and paratenon layers with 0-vicryl subcutaneous and skin closure parapatellar close peripatellar arthrotomy subcutaneous and skin closure 3 Dressing Soft dressings over knee, distal, and proximal femur
O Perioperative Inpatient Management 1 Write comprehensive admission orders advance diet as tolerated pain control wound management remove dressings POD2 foley out when ambulating check appropriate labs antibiotics prescribe DVT Prophylaxis 2 Appropriately orders and interprets basic imaging studies obtain radiographs of the femur and knee in postop 3 Initiate physical therapy POD 1 weight bear as tolerated immediate range of motion exercises to hip and knee 4 Appropriate medical management and medical consultation 5 Discharges patient appropriately pain meds outpatient PT schedule follow up visit weightbearing as tolerated R Complex Patient Care 1 Develops unique, complex post-operative management plans