Flexible Intramedullary Nailing Femur

Indications

Supine on the radiolucent fracture table with legs scissored.
- Bump underneath ipsilateral buttocks to prevent patient external rotation
- Contralateral leg lower to aid in radiographic lateral imaging
  
  Figure 21-11 ▪ Clinical photo for positioning of flexible nailing on a fracture table.
- Ipsilateral arm across chest over pillow to clear operative side
- Avoid malrotation by placing the hip and the knee cap to the ceiling. Look longitudinally from the foot and the limb position of the anterior hip and anterior knee should match and make sense. Significant internal or external rotation of the foot and the distal fracture should be a cause of concern and reevaluation.
- Prep should include the entire femur and both sides of knee should be accessible so that a medial knee incision can be made as well as lateral
Complete fluoroscopic AP and lateral views at the hip, fracture, and knee to assure ability to visualize femur completely and obtain provisional reduction.
- Alternative positioning is supine on the radiolucent table (Figure 21-12).
- Bump underneath ipsilateral buttocks and flank with prep extending to the level of lilac crest
- Longitudinal traction maintained by assistant

Surgical Approaches

In general, proximal exposure with placing nails from proximal to distal is best for distal fractures
- Incision (3 cm) centered over the lateral femur distal to horizontal line from tip of trochanter
- Split IT band and expose lateral area of femur at the bottom of proximal trochanteric metaphyseal flare
Fractures in the distal third diaphyseal region and above including the subtrochanteric region and below should be treated by placing nails from distal to proximal (Figure 21-13)