Intramedullary Nailing of Diaphyseal Femur Fractures


Intramedullary Nailing of Diaphyseal Femur Fractures


Patient Selection



Preoperative Imaging




  • AP and lateral radiographs of entire femur, including hip and knee; evaluate femoral neck for associated fracture


  • In severe comminution, image contralateral side to evaluate length and alignment; in bilateral fractures, fix simpler side first to assess length of comminuted side


  • Assess rotation by comparing lesser trochanter profile on uninjured side on AP view obtained with patella straight anterior or by obtaining a perfect lateral of the knee and rotating the C-­arm 90° to obtain an AP of the hip maintaining the same position of the leg


  • Assess femoral anteversion by comparing angulation of proximal femur on lateral radiograph between injured and noninjured sides

Procedure


Room Setup/Patient Positioning


image

Figure 1Photograph shows patient positioning and room setup for intramedullary nailing of a femoral shaft fracture. The patient is supine on a Jackson table. The 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.


Special Instruments/Equipment/Implants




  • Traction setup for Jackson table


  • Leg ramp and sacral bump


  • Traction bow, sterile rope, 5/64-­in Kirschner wire (K-­wire)


  • Femoral nail, reamers, appropriate insertion equipment


  • Reduction devices (eg, ball-­spike pusher, shoulder hook)

Surgical Technique


image

Figure 2Images demonstrate the guidewire placement and starting point location for intramedullary nailing of a femoral shaft fracture. A, Intraoperative lateral fluoroscopic image shows the anterior starting point for the 5/64-­in Kirschner wire placement. B, Intraoperative lateral fluoroscopic image shows the traction bow in front of the ball-­tipped guidewire. Distal placement of the ball-­tipped guidewire also is visible, with the wire well centered in the femur. C, Illustration of the axial view shows proper locations for piriformis and trochanteric entry sites. When a piriformis entry site is used, the nail should not be placed too far anteriorly because of the risk of iatrogenic fracture. When a trochanteric entry site is used, the nail should be placed medially on the trochanteric tip to avoid lateral wall blowout. D, Intraoperative AP fluoroscopic image of a right hip shows a dynamic hip screw reamer used to place the piriformis entry hole. E, Intraoperative lateral fluoroscopic image of a right hip shows proper placement of the piriformis starting point. F, Intraoperative AP fluoroscopic image of a right distal femur. Note the curved tip of the ball-­tipped guidewire; the overall trajectory of the wire is toward the medial tibial spine.

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May 13, 2023 | Posted by in Uncategorized | Comments Off on Intramedullary Nailing of Diaphyseal Femur Fractures

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