3. A high quality A P radiograph of the hip is required before nailing
ensues in order to rule out femoral neck fracture. In most situations
the CT scan done for evaluation of the abdomen and pelvis should be
reviewed for occult femoral neck fractures.
4. The leg is free-draped from the calf to the ASIS
5. Proximal Distal
A small incision, usually no more than 15mm, is made over the medial
aspect of the patellar tendon. This incision is brought paratendinous
through the deep tissue so as not to go through the patellar tendon.
6. PATELLA
TENDON
PATELLA
Proximal Distal
The portal may be made using many methods including
guidewire followed by a reamer, a straight awl, or a step
drill as seen here.
7. The knee should be in approximately 40 degrees of flexion to
avoid damaging the inferior patella or proximal tibia as the
portal and reaming is performed.
8. For the starter reamer, guidewire, or awl the direction of insertion must
be in the center and parallel with the formal shaft in both the AP and
lateral views. The perfect starting portal is just at the intersection of
Blumensaat’s line, with the line representing the the trochlear groove
on the perfect lateral radiograph.
9. On the AP it should be in the center of the notch directed toward the
center of the shaft rather than perpendicular to the condyles, which
would direct the nail toward the medial cortex.
11. The guidewire should have a bend in it and is rotated
such that it will pass across the fracture with gentle
taps on the jig.
12. The guidewire is passed across by
gently tapping without rotating the wire.
13. Once across the fracture, the guidewire can be rotated
180 degrees to effect a reduction in the bone.
14. PIRIFORMIS
FOSSA
The guidewire is introduced to its most proximal
extent, which is just inferior to the piriformis fossa,
as visualized on the AP radiograph.
15. Each system may be different, but a direct measurement of length
using a second guidewire of the same length as the first is always
appropriate. This figure demonstrates the second guidewire being
introduced into the hole to the depth that the nail should be seated.
16. A clamp is then placed on the second guidewire at the end
of the first guidewire and the residual is measured.
17. This will give the exact measure of the longest possible
nail that can be placed. After measurements are taken,
the reaming process is begun.
18. The reamer is advanced in the direction of the femur,
with care taken to advance gently through subchondral
bone.
19. An excellent fit in the area of the isthmus is
seen with the reamer.
20. After reaming is complete, an exchange tube is placed
over the beaded-tip guidewire, which is removed and
replaced with a straight guidewire.
21.
22. Before the nail is inserted, the locking jig should be
attached to the nail and the accuracy of the locking
holes in the jig confirmed.
23.
24. After the nail is advanced to its appropriate depth, as
visualized on the lateral radiograph, distal locking is
performed through the jig.
25. Only one screw near the knee is necessary for mid-shift and
isthmal fractures that do not extend into the wide area of the
distal femur. This should be the proximal of the two holes.
26. Only one screw near the knee is necessary for mid-shift and
isthmal fractures that do not extend into the wide area of the
distal femur. This should be the proximal of the two holes.
27. Only one screw near the knee is necessary for mid-shift and
isthmal fractures that do not extend into the wide area of the
distal femur. This should be the proximal of the two holes.
28. Only one screw near the knee is necessary for mid-shift and
isthmal fractures that do not extend into the wide area of the
distal femur. This should be the proximal of the two holes.
29. This figure demonstrates the AP and lateral views with the locking
screw placed. This hole is not visible on the lateral view. Notice
that the nail is advanced beneath the area of the subchondral bone,
as evidenced by the interface between the nail and the jig (arrow). The
dotted line indicates the trochlea groove and Blumensaat’s line, which
represents the subchondryl bone under the articular surface at this
level.
30. Proximal locking requires some rotation of the C-arm due to the
anterior bow of the femoral nail. A perfect circle technique is
utilized for the proximal locking.
31. The C-arm should be raised to its maximal height in order to
enlarge the perfect circle and give freedom for placement of
the drill and screw.
33. The incision required for proximal locking is approximately
2cm long as significant penetration through the quadriceps
mechanism is necessary. The use of a locking screwdriver
will help to avoid losing a screw deep in the tissues.
34. It is very important that during the process of proximal locking
the drill or any device never strays medially to the femoral shaft
as the femoral artery lies only 1 cm medial tot he shaft at this
level.
35. AP and lateral view demonstrating an appropriately
Locked femoral nail at the level of a lesser trochanter.
