3. Skin incision
An incision is made along an imaginary line
between the lateral femoral epicondyle and the
greater trochanter, along the length of the femur
required by the specific fracture pattern.
4. Opening the fascia lata
The fascia lata is incised with a scalpel and
split with scissors parallel to the skin incision,
along its fibers.
The muscle fascia over the vastus lateralis is
exposed.
5. SEPARATION OF VASTUS
LATERALIS FROM FASCIA LATA
In the next step, the vastus lateralis is separated
by blunt dissection from the fascia lata.
6. Incision of the fascia vastus lateralis
The vastus lateralis is now retracted
anteromedially.
The muscle fascia investing the vastus lateralis is
incised about 1 cm anterior to the intermuscular
septum.
7. Mobilization of vastus lateralis from
intermuscular septum
The muscle is detached from the lateral
intermuscular septum and the linea aspera with a
periosteal elevator.
8. Ligation of perforating vessels
The perforating vessel bundles must be identified.
These vessels perforate the lateral intermuscular
septum from the posterior side and run anteriorly,
remaining closely applied to the femoral shaft.
9. Larger vessel bundles must be ligated, smaller
ones can be alternatively cauterized with the
diathermy.
10. Exposure of the bone
After further detachment of the vastus
lateralis, using the elevator, the femoral
shaft is exposed extraperiosteally
11. Exposure of the proximal femoral shaft
If exposure of the proximal femoral shaft is necessary, mostly only
for subtrochanteric fractures, the origin of the vastus lateralis must
be identified.
The muscle is retracted anteriorly and an L-shaped incision is made
down to the bone. The muscle origin is then dissected off with the
periosteal elevator.
12. The proximal femoral shaft is exposed after the
L-shaped detachment of the vastus lateralis has
been performed. The vertical part of the incision
lies in the interval between gluteus medius and
vastus lateralis.
13. ORIF plateORIF plate
Compression plating provides fixation with
absolute stability for two-part fracture
patterns, where the bone fragments can be
compressed.
Compression plating can only be applied by an
open procedure.
The objective of compression plating is to
produce absolute stability, eliminating all
interfragmentary motion.
15. The screw head slides down the inclined plate
hole as it is tightened, with the head forcing the
plate to move along the bone, thereby
compressing the fracture.
Plate position on the femur / tension band principle
As a general rule the plate should be positioned on the lateral aspect of the
femur.
A plate acts as a dynamic tension band when applied to the tension side of
the bone and when stable cortical contact is present on the opposite side to
the plate.
With vertical load, the curved femur creates a tension force laterally and a
compression force medially.
A plate positioned on the side of the tensile force resists it at the fracture
site, provided there is stable cortical contact opposite to the plate.
16. Plate selection
For an A3-type fracture of the femoral shaft, at
least three bicortical screws must be inserted into
each fragment. Preferably, a nine-hole broad 4.5
mm plate is chosen. In this way, the second to
the last screw hole at each plate end, as well as
one plate hole over the fracture, can be left
unoccupied.
17. Reduction
After extraperiosteal exposure of the lateral aspect of the
femur, the direct reduction is carried out by using
manual traction/traction table, and/or bone reduction
forceps. With purely transverse fractures, it is rarely
possible to achieve reduction by forceful longitudinal
traction alone. It is usually necessary to increase the
angulation (apex anteriorly) to reduce the posterior
cortices, and then straighten the bone to reduce the
whole fracture
18. Anatomical fracture reduction can be
observed directly.
The plate will be positioned on the
lateral aspect of the femur.
19. Contouring the plate
Fitting the plate to the bone
Depending on the planned plate location, some contouring of the plate
may become necessary. This applies distally as well as proximally.
Contouring is aided by a stable provisional reduction and a malleable
template that can be shaped along the bone surface. The malleated
template is then used as a guide for shaping the plate to the bone.
20. Drilling for the first screw
The first screw hole is drilled close to the
fracture site. Its depth is measured
through the plate, and tapping is required
if non self-tapping screws are used.
21. Fixation of the plate with a first screw
The plate should be attached with one screw to
the predrilled fragment. The screw should not be
tightened completely. The surgeon should check
that the plate fits properly and that the alignment
as well as the fracture reduction are adequate.
Next proceed to drill the other fragment
22. Insert a second screw eccentrically
A second screw is inserted eccentrically into the
other fragment, near the fracture
23. Tighten screws to compress fracture
As shown in this illustration, tightening the eccentrically placed screw
compresses the fracture by pulling the proximal fragment towards the
fracture.
It should be confirmed that the fracture surfaces are anatomically
reduced, and that both ends of the plate fit satisfactorily.
Both screws should be tightened, and the reduction should be secured
and compressed satisfactorily.
24. Finish screw insertion
The remaining screws are inserted.
If the femur has a strong cortex, three cortical
screws should be sufficient in each fracture
fragment. In case of an osteoporotic bone, it
may be safer to fill all screw holes.
26. Reduction
General considerations
In more proximal fractures, due to the pull of the iliopsoas muscle, the
upper main fragment may be flexed and externally rotated, and the
distal segment lies posteriorly due to gravity.
Several options for fracture reduction can be considered:
Elevation of the distal fragment by use of a crutch.
Lowering of the proximal fragment by external pressure from a mallet.
A wrap around the femur.
A Schanz screw inserted into one of the fragments.
Use of a bone hook.
(Manual reduction)
28. Elevation of the distal fragment by use of a crutch
This option may only be used if the patient is on traction.
A crutch is slid beneath the distal main fragment in order
to elevate it to the level of the proximal fragment.
29. Lowering of the proximal fragment
by external pressure from a mallet
Firm manual pressure is usually
required to achieve fracture reduction
30. A wrap around the femur
Based on the nature of the fracture, the wrap is usually placed around
the larger fragment.
Reducing the fracture using a wrap
31. A Schanz screw inserted into one of the fragments
A monocortical Schanz screw (preferably 5 mm) can be
helpful for providing direct control of the displaced
fragments. It is superior to reduction maneuvers through
the skin.
32. Bone hook
Direct reduction with a bone hook may be helpful
for securing an anatomic alignment. Careful
insertion and manipulation must be performed, in
order to minimize soft-tissue trauma and to
prevent injury to the femoral artery.
33. Reduction using a bone hook.
Manual reduction
Manual reduction may be attempted, but
radiation of the surgeon‘s hands may be
unavoidable.
34. Guide wire insertion
A guide wire is advanced into the distal main fragment
until it is about 5 mm proximal to the intercondylar notch.
It is important that the guide wire be centered in order to
prevent eccentric reaming and subsequent malposition of
the nail, which can result in
varus/valgus/antecurvatum/retrocurvatum malalignment.
35. Unreamed nailing does not require a guide
wire. When unreamed nailing is
performed, the nail is used as a reduction
tool.
To ensure maintenance of alignment of the K-wire
throughout the reaming process, it may be gently be
tapped in order to provide purchase in the cancellous
subchondral bone. If this is not achieved, the guide
wire may displace on removal and exchange of the
reamers.
36. Nail diameter
It is important to measure the medullary diameter at the mid portion
of the femur, which represents the narrowest segment of the
medullary canal.
The inner cortical edge should touch with the inner numbered disk of
the ruler aperture. In the illustration an inner cortical diameter of 14
mm is shown.
37. Reaming
Insertion of reaming rod
After the tissue protector has been introduced, the
reaming shaft, fitted with the first reamer head, is
inserted over the guide wire. Usually reaming begins
with a 9 mm medullary reamer.
38. SEQUENTIAL REAMER SIZE
INCREASE
Reaming is performed in sequential steps by
increments of 0.5 mm each.
As soon as chatter from cancellous bone can be
felt and heard, the inner cortex has been reached.
This may not be the case in segmental fractures
or when severe comminution is present.
Adequate reaming must be performed in order to
allow for smooth nail insertion. For example, for
a nail width of 10 mm, drill bits of up to 10.5 or
11 mm diameter are used. If a very tight fit of the
reamer can be detected before the desired
reaming size is reached, one should consider
using a smaller nail than previously planned.
39. Pitfalls: eccentric and overaggressive reaming
Eccentric reaming
Eccentric reaming can cause weakening of the adjacent cortex which may
interfere with healing or even cause a fatigue fracture.
Trapping of reamer by slow spinning
If the reamer becomes trapped while reaming, it must be gently removed by the
most senior surgeon, because breakage of the reamer tip in this situation can be a
devastating complication.
Heat necrosis by overaggressive reaming
Overaggressive reaming should be avoided because it may cause heat necrosis
of the femoral canal. This applies especially for narrow midshaft canals (9 mm or
less in diameter).
40. Rapid thrusting/systemic fat embolization
Care should be taken to use sharp reamers, to
advance the reamers slowly, and to allow
sufficient time between reaming steps in order
for the intramedullary pressure to normalize.
Rapid thrusting of the reamer may worsen the
intramedullary pressure increase that is
observed during nailing. This image
demonstrates fat extrusion in a human cadaver
specimen with a window in the proximal section.
This may cause pulmonary embolization of
medullary fat, which in turn may lead to
pulmonary dysfunction (lower image in the
enlarged view shows an example of fat
embolization through the right atrium).
41. Nail insertion
Connecting handle to nail
The insertion handle is connected to the nail by the corresponding
connecting screw. It is attached using the hexagonal screwdriver through
the hole in the insertion handle. It is recommended that the nail be inserted
manually and rotated about 90 degrees from its point of entry to its final
orientation.
42. Introduction of nail
Under control with the image intensifier, the nail is pushed down as far as the
fracture zone. After the driving cap has been fixed to the insertion handle, the
nail is further advanced into the medullary cavity by gentle hammer blows,
whilst verifying the position of the tip of the nail under the image intensifier.
In this intraoperative view, the nail is about to pass the fracture site in the
intensifier image.
43. In this intraoperative view an unreamed nail is
inserted and the external fixator is used as a
joystick to help to reduce the fracture
anatomically.
44. Once past the fracture, the nail is advanced by
hand or by gentle hammer blows.
45. Passing the fracture zone
It is important that the tip of the nail does not become
trapped in the distal main fragment because blow out
fractures can occur. Each gentle hammer blow should
advance the nail. Do not force the nail through a tight canal –
if necessary, re-ream to another 0.5 mm diameter.
In many cases, the nail will help to align the fracture.
46. Nail locking
General considerations
Purpose of locking
Locking was developed in order to provide and maintain
rotational stability and length. It can also be used to finalize
fracture reduction.
47. Assessment of alignment
Before the patient is moved from the fracture table, rotation of
the leg is observed clinically and compared to the contralateral
leg. With the femur now stable, it is possible to perform a
thorough examination of the knee joint to rule out additional
ligamentous injuries.
48. Wound closure and assessment of alignment
Wound closure
The procedure ends with the closure of the fascia and the skin
as separate layers.
