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Femoral Shaft Fractures
Updated: Oct 9 2017

Femoral Shaft Fracture Retrograde Intramedullary Nailing

Preoperative Patient Care
Operative Techniques
E

Preoperative Plan

1

Template fracture reduction

  • draw key fragments of fracture and plan forces required to obtain reductions

2

Template instrumentation

  • measure diameter intramedullary canal and approximate length

3

Execute surgical walkthrough

  • resident can describe the key steps of the procedure verbally to the attending prior to the start of the case
  • description of potential complications and steps to avoid them
F

Room Preparation

1

Surgical instrumentation

  • make sure retrograde intramedullary nailing system is present.

2

Room setup and equipment

  • radiolucent flat-top table
  • c-arm fluoroscopy
  • c-arm from contralateral side
  • perpendicular to the bed
  • take initial AP and lateral of hip to examine femoral neck

3

Patient positioning

  • patient supine with feet at the end of the bed
  • small bump under ipsilateral thigh
  • if traction pin in place, can remove prior to prep and drape
  • alternatively can leave in place to use for traction during case
  • prep and drape entire leg up to iliac crest
G

Anterior Knee Aproach

1

Position the knee and mark out the anatomy

  • place knee in ~30° flexion over radiolucent triangle
  • knee flexion also prevents distal fragment from being pulled into more flexion by gastrocnemius
  • mark out inferior pole of patella and borders of patella tendon

2

Expose the intercondylar notch

  • make incision, dissect through subcutaneous tissues, and perform arthrotomy
  • transtendinous approach
  • make 2cm incision from inferior pole of patella distal through tendon
  • perform tenotomy to develop paratenon layer, sharply dissect or cauterize through paratenon then patellar tendon
  • insert self-retainers and suction out synovial fluid
  • once in joint, remove small amount of fat pad to minimize guidepin deflection
  • parapatellar approach
  • 2 cm incision along medial third of patellar tendon
  • cut through subcutaneous tissue and retract tendon/paratenon laterally insert self retainer

3

Visualize intercondylar notch

H

Guidewire entry

1

Identify guidewire starting point

  • guidepin start point is in center of intercondylar notch, just superior to Blumensaat’s line

2

Use entry reamer with soft tissue protector

3

Insert guidepin to distal metaphysis

  • check C-arm image to ensure pin is in center of medullary canal

4

Place balltip guiewire

  • remove starting pin and reamer, and place balltip guidewire in canal with T-handle
  • place gentle bend at tip of balltip wire, manually push in to distal aspect of fracture site
I

Fracture Reduction and Reaming

1

Reduce fracture by pulling traction

  • can use small blue towel bump to add flexion to distal segment
  • if pulling straight inline traction on foot you will cause more flexion deformity of the distal segment due to pull of the gastrocnemius
  • need to pull traction at 30° angle over triangle

2

Advance guidewire

  • manually push guidewire past fracture site and up to lesser trochanter
  • insert guidewire past lesser trochanter by 3-4cm

3

Check placement of wire with AP and lateral radiographs

4

Measure nail length

  • use radiolucent ruler to measure appropriate nail length
  • use ruler on contralateral side to measure intact femur if segmental comminution exists

5

Ream intramedullary canal

  • start with 9mm reamer, then ream up 0.5-1.0mm with consecutive reamer
  • ream 1.5mm above size of final nail (i.e. size 12.5mm reamer head for size 11mm nail)
  • don’t stop reamer in canal (avoids reamer head from becoming incarcerated)
  • if eccentric reaming/wire position is seen, can place blocking screws
J

Nail Insertion

1

Assemble femoral nail

  • attach jig to nail on backtable and check that targeting guide lines up with holes in nail

2

Insert nail over guidewire

  • cover holes closest to nail handle with hand to make sure blood doesn't pressurize out of nail during insertion
  • insert nail with jig lateral to thigh
  • hold nail by handle, not the targeting guide, mallet or manually advance to fracture site

3

Advance the nail

  • manually advance nail past the fracture site to avoid iatrogenic comminution or development of new fracture lines
  • possible with use of the mallet
  • seat nail fully

4

Confirm nail depth

  • lateral radiograph of the knee is the appropriate view to assess nail insertion depth

5

Remove guidewire before placing interlocking screws

K

Distal Interlocking Screws

1

Place trocar onto bone

  • use targeting guide to place most distal interlock first
  • mark skin with sleeve, incise through skin, spread down to bone with hemostat, and place trochar on bone

2

Place interlocking screw

  • drill bicortically through the nail
  • leave drill bit in until screw arrives to hold nail/bone position
  • remove drill bit then quickly place the screw
  • repeat process above for placement of other interlocking screws if indicated

3

Remove jig

  • use attachment to remove nail jig, then take out triangle to lay leg flat

4

Check femoral neck again on C-arm

L

Proximal Interlocking Screws

1

Obtain perfect circles

  • ensure no rotation of the distal femur is done while getting these views
  • move the C-arm, not the leg
  • magnification of the fluoroscopic view can be used if desired

2

Identify placement of interlocking screws

  • incise through skin, careful blunt spreading down to bone, especially if distal to lesser trochanter
  • start with most proximal interlocking hole (screw will be longer than the more distal screw)

3

Drill holes for interlocking screws

  • ensure drill bit placed over center of hole, parallel to C-arm beam to measure
  • can use a second drill bit or depth gauge
  • alternatively use a 34 or 36mm screw

4

Insert interlocking screws

  • remove drill quickly and insert screw when available
  • use locking screwdriver or place silk suture around screw head so it doesn’t get lost in soft tissues

5

Repeat above process for 2nd proximal interlocking screw

6

Take final radiographs

  • raise leg up off of bed, 90° bend in knee, then take final AP and lateral radiograph of proximal, middle, and distal aspects of femur

7

Take hip through a range of motion to assess for fracture

  • fluoroscopic evaluation is key, whether static or dynamic at the end of the procedure

8

Check limb lengths and rotation

9

Perform a knee examination under anesthesia

N

Wound Closure

1

Irrigation, hemostasis, and drain

  • place knee under triangle and strongly flush out reamings with saline bulb irrigation
  • irrigate until backflow is clear
  • cauterize peripheral bleeding vessels

2

Fascia closure

  • transtendinous
  • close patellar tendon and paratenon layers with 0-vicryl
  • subcutaneous and skin closure
  • parapatellar
  • close peripatellar arthrotomy
  • subcutaneous and skin closure

3

Dressing

  • Soft dressings over knee, distal, and proximal femur
Postoperative Patient Care
Private Note