Please confirm topic selection

Are you sure you want to trigger topic in your Anconeus AI algorithm?

Please confirm action

You are done for today with this topic.

Would you like to start learning session with this topic items scheduled for future?

Femoral Shaft Fractures
Updated: Oct 9 2017

Femoral Shaft Fracture Retrograde Intramedullary Nailing

Preoperative Patient Care
Operative Techniques

Preoperative Plan


Template fracture reduction

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


Template instrumentation

  • measure diameter intramedullary canal and approximate length


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

Room Preparation


Surgical instrumentation

  • make sure retrograde intramedullary nailing system is present.


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


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

Anterior Knee Aproach


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


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


Visualize intercondylar notch


Guidewire entry


Identify guidewire starting point

  • guidepin start point is in center of intercondylar notch, just superior to Blumensaat’s line


Use entry reamer with soft tissue protector


Insert guidepin to distal metaphysis

  • check C-arm image to ensure pin is in center of medullary canal


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

Fracture Reduction and Reaming


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


Advance guidewire

  • manually push guidewire past fracture site and up to lesser trochanter
  • insert guidewire past lesser trochanter by 3-4cm


Check placement of wire with AP and lateral radiographs


Measure nail length

  • use radiolucent ruler to measure appropriate nail length
  • use ruler on contralateral side to measure intact femur if segmental comminution exists


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

Nail Insertion


Assemble femoral nail

  • attach jig to nail on backtable and check that targeting guide lines up with holes in nail


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


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


Confirm nail depth

  • lateral radiograph of the knee is the appropriate view to assess nail insertion depth


Remove guidewire before placing interlocking screws


Distal Interlocking Screws


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


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


Remove jig

  • use attachment to remove nail jig, then take out triangle to lay leg flat


Check femoral neck again on C-arm


Proximal Interlocking Screws


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


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)


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


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


Repeat above process for 2nd proximal interlocking screw


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


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


Check limb lengths and rotation


Perform a knee examination under anesthesia


Wound Closure


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


Fascia closure

  • transtendinous
  • close patellar tendon and paratenon layers with 0-vicryl
  • subcutaneous and skin closure
  • parapatellar
  • close peripatellar arthrotomy
  • subcutaneous and skin closure



  • Soft dressings over knee, distal, and proximal femur
Postoperative Patient Care
Private Note

Attach Treatment Poll
Treatment poll is required to gain more useful feedback from members.
Please enter Question Text
Please enter at least 2 unique options
Please enter at least 2 unique options
Please enter at least 2 unique options