Intramedullary Nailing of Diaphyseal Femur Fractures

Anna N. Miller, MD

Dr. Miller or an immediate family member serves as a paid consultant to or is an employee of Synthes and has received nonincome support (such as equipment or services), commercially derived honoraria, or other non-research-related funding (such as paid travel) from Smith & Nephew.

INTRODUCTION

This chapter will review the basics of intramedullary nailing for diaphyseal femur fractures as well as pearls to improve your technique. The chapter includes patient selection, preparation (including preoperative imaging and positioning), and execution of the technique. The chapter includes multiple images to further illustrate these points.

PATIENT SELECTION

Diaphyseal femur fractures (fractures of the femoral shaft) necessitate surgical fixation for several reasons. Surgical fixation allows patients with these injuries to mobilize more quickly after surgical fixation. Surgical treatment also decreases the risks of prolonged recumbency, including fat emboli syndrome, decubitus ulcers, and muscle atrophy.¹

Contraindications

Intramedullary nailing is contraindicated in patients who cannot tolerate surgical intervention. Relative contraindications include pediatric femur fractures (in some cases), highly contaminated open wounds (which may necessitate a staged procedure), and femoral fractures with proximal or distal involvement that may necessitate other fixation.² In addition, retrograde intramedullary nailing may be used in extremely obese patients or considered in cases of either bilateral femur fractures or ipsilateral femur and tibia fractures at the surgeon’s discretion.

PREOPERATIVE IMAGING

Adequate AP and lateral images of the entire femur, including the hip and knee joints, must be obtained before proceeding with surgical fixation. The surgeon should evaluate the femoral neck carefully for associated fractures.³ In cases with comminution, it is advisable to get the same views of the uninjured femur if possible, to assess length and alignment for the fractured side.⁴ In addition, if both legs are fractured, it is recommended that the simpler side be fixed first, when possible, to better assess length for the comminuted side. With comminution, rotation is also difficult to assess. The lesser trochanter rotational profile has been shown to be a reliable intraoperative evaluation tool. It is important to first obtain a preoperative radiographic examination of the lesser trochanter on the uninjured side with the leg positioned in the same way (ie, on bumps or ramps) that the injured leg will be positioned. To obtain this view, first perform a perfect lateral of the knee with the C-arm horizontal. While holding the leg in this exact position, rotate the C-arm 90° to an AP view, then take an image of the lesser trochanter at the hip. Save this for comparison with your intraoperative view of the same image on the injured side.⁵ An alternative technique is to assess femoral anteversion by obtaining a direct lateral view of the knee, then rotating the C-arm to get a direct lateral view of the proximal femur on the uninjured side. The same amount of C-arm rotation should match the version on the injured side intraoperatively.⁶^,⁷

PROCEDURE

Room Setup/Patient Positioning

This procedure may be performed on multiple types of operating room tables; however, the preferred one for ease of mobility of the leg and minimal complications is a flat Jackson table. The use of a traction table increases the risks of complications because of traction and the perineal post.⁸ The patient is positioned supine at the edge of the table such that the buttock/hip of the injured leg is hanging over the edge of the table (Figure 1, A). A bump is placed under the sacrum to elevate and provide complete access to the hip. A modified device that can easily be built in the hospital’s machine shop can be attached to the table to provide intraoperative traction while keeping the leg free for manipulation (Figure 1, B). The patient’s leg is elevated on a ramp to allow adequate lateral fluoroscopic imaging. The fluoroscopy unit is placed on the opposite side from the injured leg and rotated to approximately 10° above the horizontal to obtain the lateral image of the femur at the hip.

FIGURE 1 Photographs show patient positioning and room setup for intramedullary nailing of a femoral shaft fracture. A, The patient is supine on a Jackson table. His injured (left) hip has been moved laterally over the edge of the table, and the leg is elevated on a ramp (encased in plastic drapes). Traction is shown in place as an example. B, The traction setup that is attached to the Jackson table at the distal end on the opposite side of the injured leg to allow for adduction.

Special Instruments/Equipment/Implants

For this procedure, the following equipment should be available:

Traction setup for the Jackson table
Leg ramp and sacral bump
Traction bow and sterile rope with 5/64-in Kirschner wire (K-wire) for traction
Femoral nail and appropriate insertion equipment, reamers
Reduction devices per surgeon’s discretion (eg, ball-spike pusher and shoulder hook)

Surgical Technique

After the patient is positioned as described previously, the entire proximal femur is exposed; drapes should allow access up to the iliac crest and to the entire leg. A 5/64-in K-wire is placed in the distal femur. Care should be taken to place it very anterior to allow for intramedullary nail placement posterior to the wire (Figure 2, A and B). The tensioned traction bow is placed on the wire, a sterile rope is hung off the field on the pole at the end of the table, and approximately 10 to 15 lb of weights are hung from the rope. Traction is placed on the opposite side of the table from the fractured leg to allow for adduction.

Only gold members can continue reading. Log In or Register to continue