IM Nailing Technique for Femoral Shaft Frx: Surgical Incision



- Technique:

     - at a point 3-5 cm above post. tip of greater troch., an incision is made which extends obliquely (proximally & posteriorly) for 10 cm;
           - for obese pts begin incision well above greater troch. (7-10 cm) & again extend proximally and posteriorly;
           - otherwise one will be fighting w/ a thick layer of subQ fat;
     - incise tensor fascia & split gluteus max in line w/ its fibers;
           - this incision needs to be at least as long as the skin incision;
     - define interval between insertions of piriformis & tendinous posterior aspect of medius into greater trochanter;
     - the surgeon can run his long finger along the posterior edge of the proximal femur to accurately judge the direction of the femur w/o need for flouro;
           - the surgeon's index finger can simultaneously palpate the gluteus medius tendon about 2 cm from its posterior edge at the level of the greater trochanter;
                   - this marks the location for splitting the tendon w/ a tonsil clamp;
           - when the lateral position is used, the hip can be flexed which allows nail to be inserted behind the tendon (hence no splitting is required);

- Hazards:
    - trochanteric pain and stiffness may occur in over 40% of patients and may be related due to rough handling of the gluteus medius tendon;
    - it is essential to carefully split the medius tendon no higher than 5 cm above the greater trochanter inorder to avoid injury to the superior gluteal nerve;
    - after the gluteus medius tendon is split for the first time, further trauma to the tendon should be avoided



Gluteus medius tendon injury during reaming for gamma nail insertion.



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Wednesday, November 14, 2012 2:40 pm