Scott D. Cordes

1. Closed displaced femoral shaft fractures

2. Open grade 1 or 2 femoral shaft fractures (can be done acutely after a thorough irrigation and debridement of the open wound)

1. Gross wound contamination

2. Nonviable soft tissue envelope

3. Proximal or distal shaft fractures with significant metaphyseal extension

1. Appropriate extremity radiographs including hip and knee joints

2. Template radiographs to ensure that femoral nails of the appropriate length and diameter are available

3. Neurovascular exam with emphasis on assessing arterial blood flow and distal nerve function

4. Assessment of the skin and soft tissues; evaluate for compartment syndrome.

1. General or regional anesthesia; avoid long-acting regional anesthesia because they make assessment of compartment syndrome difficult.

2. Position patient supine on a fracture table.

3. Check the fluoroscopy prior to draping the patient to ensure that it is in working order and that the C-arm can be positioned to obtain adequate AP and lateral images from the hip to the knee.

1. Position the patient on the fracture table with adequate leg and torso adduction. The exact amount of adduction depends on patient size and body habitus. Extremity adduction allows optimal access to the piriformis fossa and minimizes rod impingement during insertion.

2. Make sure the skin over the entry point for the distal screws is not “draped out” of the operative field.

3. Make sure adequate radiographs of the femoral neck have been obtained and reviewed. Concurrent femoral neck fractures are not uncommon and can be difficult to detect.

5. Initial passage of the blunt tip guide rod can be difficult through the proximal third of the femur. Consider “choking up” on the blunt-tipped guide rod with the T-handle or vise grip. This will make rod passage easier with less chance of bowing or bending of the guide rod.

1. Attempt to avoid internal or external rotational malalignment of the fracture when impacting the femoral nail. The patella should be directed toward the ceiling to grossly adjust the rotational alignment of the limb. Reconfirm alignment prior to distal locking.

2. Avoid reckless passes with the guide rod. Slow meticulous passage across the fracture site using proprioceptive feel is imperative.

3. Avoid allowing the guide rod to “back out” past the fracture site during reaming.

1. Initially, most patients are allowed to ambulate either non-weight bearing (NWB) or toe-touch weight bearing (TTWB).

2. Depending on the stability of the fracture, protected weight bearing can be advanced approximately 6 weeks after surgery. This is dependent on radiographic evaluation and clinical symptoms.

1. Transport the patient to the operating room. Appropriate anesthesia is administered.