Titanium elastic nailing can be performed on either a fracture table or a radiolucent table. The fracture table is often preferred as it allows the surgeon to get the fracture out to length and optimally reduced before prepping and draping. Others report good results without the use of a fracture table. When the radiolucent table is used (as may be necessary for children with a femur fracture and other lower-extremity fractures or severe short-tissue injuries), an assistant pulls traction, which complicates the process of getting AP and lateral images in fractures where it is difficult to pass the nail across the fracture site. In addition to the need for assistance with this technique, considerable patience may be required as well.

On the fracture table, both feet are padded with Webril and placed into the foot holders. The uninjured leg is abducted widely out of the way so that the image intensifier can be positioned between the legs, with sufficient room remaining for an assisting surgeon (Fig. 8-1). The C-arm monitor is positioned next to the patient’s contralateral shoulder, so that the monitor is in the direct line of sight for both the surgeon and the assistant. Alternatively, some surgeons prefer to have the uninjured leg scissored, rather than widely abducted, to allow the C-arm to come in perpendicularly from opposite the injured limb. Prior to preparing and draping the injured leg, the surgeon uses the C-arm image to visualize the fracture site. Traction is used to get the fracture out to length. This is a good time for the surgeon to rehearse the maneuver that aligns the fracture for nail passage and to note the position of the image intensifier that will yield good AP and lateral images of the fracture. Proper rotation can be ensured by noting the position of the patella and compensating for any external rotation of the hip, especially in the more proximal fracture. The entire injured extremity is then prepped from the upper thigh down to the foot holder. Circumferential drapes are used so that the entire leg is accessible from both the medial and the lateral sides.

The first step in the surgical procedure is selecting the proper nail entry sites. The C-arm image intensifier is used to obtain an AP image of the knee. The distal femoral physis is visualized, and its position is marked on the skin to warn the surgeon to avoid deep dissection in this area. The proper nail entry point for the standard retrograde technique is 2 to 3 cm proximal to the distal femoral
physis, just below the metaphyseal-diaphyseal junction. A longitudinal skin incision is made on both the medial and lateral leg extending from the site of bony insertion distally 1 to 2 cm to minimize soft-tissue damage during nail insertion (Fig. 8-2). The incisions are deepened with electrocautery, and a hemostat is used to spread down to the bone. The same hemostat may be used to palpate the femur to get a sense of the AP dimension. Ideally, the starting points should be in the center of the femur in the sagittal plane. A drill (with a soft-tissue protector) is used to open the femoral cortex at the medial and lateral insertion sites. Although an awl is available, a drill offers better control and can give the exact hole size needed. The size of the drill bit should be larger than the size of the nail; thus, a 4.5-mm drill would be used to place a 4.0-mm nail. The drill is first directed perpendicular to the cortex; once the cortex is breached, the drill (still running) is slowly angled sharply up the shaft of the femur (Fig. 8-3). This creates a track that greatly facilitates nail insertion. The cancellous bone of the distal femur can be very dense in young, active children. If the surgeon drills too transversely across the femur, the nail will follow that track, and it will be quite difficult to turn the nail up the femur. An oblique track, aiming up the shaft, will allow the surgeon to quickly pass the nail up to the fracture site.

Prior to insertion, the elastic nails are bent by hand into a gentle C shape, such that the apex of the bend will be at the fracture site (Fig. 8-4). It is often easier to use the T-handle chuck rather than doing this by hand.

After prebending, the first nail is introduced through the lateral drill hole. Sometimes, it is easier to find the hole and enter the femur if the hooked tip is turned caudal. Under image-intensifier control, the tip is then turned cranial and tapped up the femur toward the fracture site (Fig. 8-5). The same technique is used to insert and advance the second nail through the medial femoral cortex (Fig. 8-6). Some surgeons prefer to pass one nail across the fracture site before introducing the

second nail. If there is any question as to the position of the nails, a lateral view should be consulted. The nail tips are sharp enough to penetrate the cortex (Fig. 8-7).