1. Proximal femoral nailing (PFN) requires thorough pre-operative planning including imaging and assessment of fracture pattern and patient comorbidities. 2. It is important to reduce the fracture before making the entry point, as the entry point will determine surgical success. 3. Factors such as varus reduction, medializing the shaft, high tip-apex distance, and penetration of the femoral head can lead to poor outcomes like nonunion.

1. Tips, tricks and pitfalls of
proximal femoral nailing
(PFN)
Dr Puneeth K Pai
Senior Resident
Department of Orthopedics
Government Medical College,
Kozhikode

2. Classification of PFN

3. Surgical steps
1.Incision
2.Determination of the
entry point
3.Using awl to make an
entry
4. Passing the guide wire
5. Reaming
6.Passing the nail
7.Guide wires and proximal
screws(Head screw and
anti-rotation screw)
8.Distal Locking

4. Tip / Trick/ Pitfall 1
Plan and Prepare before you perform.
1. Adequate X-rays – 2 joints, 2 Views.
2. Comparison to opposite side.
3. Analysing the fracture pattern. CT??
4. Mapping the fragments.
5. Check the implants.
6. Optimising the general status and co-
morbidities of the patient
7. Neurovascular status of the limb.
8. Check the SIDE before you START.

5. Case
68 YEAR OLD MALE WITH CA LUNG.

6. Tip/Trick/Pitfall 2
• PFN is a tool for fixation, not reduction.
• Supine vs lateral.
• Traction table – with or without?
• Closed vs Open.
• Assisted closed reduction.
Reduce the fracture before the entry

7. Tip/Trick/Pitfall 3
Entry point decides the surgeon’s and the fracture’s fate

9. Tip/trick/Pitfall 4
Never accept a Varus reduction.
How to know whether fracture is in
Varus?
1.Superior opening up of fracture
2. Too long screws (>100mm)
3. Screw in Superior aspect of the
head but in center or inferior part of
the neck.
4. Medial beak in the canal
5. Comparison with the screw and
nail angle.
6.Nail tip hitting the medial cortex at
or below the lesser trochanter.

10. Tip/trick/Pitfall 5
Maintain the reduction before reaming.
External methods
1. Manual compression
2. Using mallet ,reamer
handle.
Internal methods
1. Reduction clamps
2. Bone holding forceps
3. Lever
4. Bone hooks
5. Ball spike pusher

11. Case

12. Case
35 year old male .H/O RTA. Suffered # S/T with
intertrochantric extension.

13. Case
50Year old male .H/O RTA. Otherwise fit.

14. Positive medial cortex support (PMCS):
Medial calcar beak is outside the
femoral canal and may slightly overlap
the distal femur.
Negative medial cortex support (NMCS):
the head–neck fragment is displaced
laterally to the upper medial edge of the
shaft fragment

15. NEG “-” POSITIVE “+”
NEUTRAL “=”

16. 65 year old lady . H/O fall. Brought to MCH
Case

17. 10 days
POD 1

18. Tip/trick/Pitfall 6
Thou shall not medialise the shaft
Pathogenesis
Reduced area of bone contact
Abnormal biomechanical forces
Delayed union/Non-union
Implant failure
% Medialisation(A/B X100) = % Failure of fixation.
Parker, M. J. (1996). Trochanteric hip fractures Fixation failure commoner with femoral medialization, a comparison of 101
cases. Acta Orthopaedica Scandinavica, 67(4), 329–332. doi:10.3109/17453679609002325

20. Tip/trick/Pitfall 7
Place the head screw in Inferior portion of the head
rather than Center.

21. Tip/Trick/Pitfall 8
High TAD is BAD

22. Tip/Trick/Pitfall 9
Z effect Reverse Z effect
1. Lateral buttress
deficiency
2. Unstable medial
cortex
3. Constant friction
within the femoral
head and axial
loading in varus
4. Osteoporotic head
5. Compensation

23. Tip/Trick/Pitfall 10
Penetration
(1) Unstable
(2) Posterolateral fracture fragment
(3) Medial type of reduction pattern
(4) Intramedullary type of reduction pattern
(5) Unstable position of the screw
(6) a TAD of ≥20 mm
Cut-out Breakage
1. Osteoporosis
2. Reduced TAD <10mm
3. Breach of subchondral
bone while reaming

24. Summary
1. Plan and Prepare before you perform.
2. Reduce the fracture before the entry.
3. Entry point decides the surgeon’s and the fracture’s fate.
4. Never accept a Varus reduction.
5. Maintain the reduction before reaming.
6. Never medialize the shaft.
7. Place the head screw in Inferior portion of the head rather than center
8. High TAD is BAD
9. Z and Reverse Z effect
10.Penetration/ Cut-out / Breakage