- See:
retrograde IM nailing
- Discussion:
- Workup for Femoral Shaft Frx
-
PreOp Planning: Implant Selection:
Synthes Femoral Nail
-
IM nailing of pediatric femur frx:
- Positioning:
-
Frx Reduction:
-
Proximal Frx;
-
Distal Frx;
-
Rotational Alignment:
- a true lateral will define the plane of version;
- epicondylar axis is int rotated 20 deg (for 20 deg of anteversion)
- while obtaining true lateral, take time to mark out incision w/ ruler;
- acceptable reduction includes 8 deg of varus, 15 deg of valgus, malrotation of IR 15 deg and malrotation of ER 20 deg;
- Surgical Incision:
- Location of Canal Entry Point:
- hole is located just medial to greater troch in piriformis fossa;
- have assistant adduct proximal fragment (to better expose piriformis)
- use awl instead of steinman pin for initial entry:
- w/ steinman pin entry may be thwarted by a prominent trochanter;
- typically, must drop hand approx 20 deg and position awl up against the pts torso;
- then insert guide pin thru cannulated awl, and use awl to direct guide pin centrally thru medullary canal (avoiding medial cortex)
- Intramedullary Reaming:
- Determination of Leg / Nail Length:
- appropriate nail length is determined intraoperatively by direct measurement of depth of the guide wire insertion;
-
non-comminuted frx:
- w/ non comminuted frx it is assumed that leg length descrepancy is not an issue, and
therefore it is important to maximize frx opposition;
- once the nail is driven across the frx site, release traction and apply compress the frx
fragments (by pushing the distal fragment proximally), while the nail is driven distally;
-
comminuted frx:
- w/ marked comminution, measure the uninjured side against nails of known length under the image intensifier,
and then adjust traction on the injured side to fit this predetermined nail length;
- once proper leg length has been determined, it is important to stick with the measured nail length, rather
than compressing the fracture ends which can lead to gross shortening at the frx site;
- the nail is driven into the distal fragment to the appropriate depth and then the
distal interlocking screws are inserted;
- subsequently traction is applied while the nail continues to be driven in with the slap hammer until the
proximal end of the nail reaches the greater trochanter;
- Nail Insertion Down Medullary Canal:
-
Synthes IM Nail;
- insert nail to frx site, & use it to assist w/
reduction;
- once nail is across the fracture,
release traction and apply manual compress across
the frx site as the nail is driven distally;
- achieve
rotational alignment; (afterwards, don't rotate distal frag);
- as nail is driven down the distal frag, its important to shift the distal fragment either laterally
or medially to avoid varus or valgus deformity at frx site;
- if proximal end of nail is below tip of greater troch, then use proximal end cap (can be extended up to 20 mm)
- Distal Interlocking;
- may be performed prior to proximal interlocking;
- it is important not to rotate the leg to obtain a perfect circle, rather, the flouro machine
should be rotated to obtain a perfect circle;
- the former will result in a malrotation deformity of the leg;
- Fracture Alignment and Compression:
- release traction;
- ensure that knee and foot are in proper rotational alignment;
- manually compess distal frag to the proximal fragment;
- Proximal Inter-Locking;
- gently tap the trochar assembly to cortex surface, but do not penetrate cortex)
- Post Operative Care:
- patients are generally kept either touch down or partial wt bearing depending on the stability of the fracture;
- in the experimental report by RJ. Brumback MD et al JBJS Vol 81-A 1999, the authors found that statically locked nails
should provide enough stability (even in unstable fractures) to allow protected wt bearing as tolerated;
- Complications of IM Nails:
-
compartment syndrome of thigh
-
infected IM nails:
-
fat embolism syndrome
-
Mortality after reamed intramedullary nailing of bilateral femur fractures.
-
avascular necrosis from IM nailing:
-
non union: (see
general discussion of non union)
- in the report by MJ Weresh et al (Journal of Orthop Trauma Vol 14. No 5. p 335), the authors noted that a
significant number of patients undergoing reamed exchange nailing of femoral shaft non unions required
additional procedures to achieve fracture healing;
- they noted that exchange nailing by itself may not be sufficient for fracture healing;
- in the report by C. Bellabarba et al, the authors report on a consectutive series of 23 femoral non unions
of femoral shaft fractures treated by previous IM nailing;
- surgical treatment consisted of indirect fracture reduction techniques using 95 deg condylar blade plate;
- 21 of 23 non unions healed without further intervention (two other fractures had hardware failure);
Abduction and Intramedullary Nailing of the Femur. G.I. Bain et al.
J. Orthop Trauma, Vol 11. No. 2. 1997.
Clinical determination of femoral anteversion. A comparison with established techniques.
The anatomy and functional axes of the femur.
Femoral anteversion
Immediate Weight-Bearing After Treatment of a Comminuted Fracture of the Femoral Shaft with a Statically Locked Intramedullary Nail*
RJ. Brumback MD et al JBJS Vol 81-A. No 11 1999. p 1538.
Results of indirect reduction and plating of femoral shaft non unions after IM nailing. C. Bellabarba et al.
Journal of Orthopaedic Trauma. Vol 15. No 4. p 254.
Rotational malalignment after intramedullary nailing of femoral fractures.
