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Gamnail
1.
2. AP view of the pelvis of a multiple trauma patient, demonstrating
the subtrochanteric fracture of the right hip as well as fracture
dislocation of the left hip.
3. AP view of the hip and femur on the affected side.
4. Positioning for the long gamma nail. The patient is supine on the
fracture table, with the affected leg in skeletal traction and the hip
slightly flexed.
5. The contralateral leg is in slight extension, allowing for good
lateral radiographs. The arm on the affected side is draped
over the body.
8. FLEXION
AP and lateral radiographs of the femoral fracture, demonstrating
A good reduction on the AP and the typical flexion deformity of
the proximal fragment.
9. Cartoon drawing on the outside of the leg of
the flexed position of the proximal fragment.
10. A 2cm incision is made slightly proximal to the trochanter, attempting
to be in an area that is between the anterior third and posterior two thirds
of the greater trochanter. The muscle fascia is split, allowing access to
the greater trochanter.
11. A curved awl is introduced to the tip of the greater trochanter and
driven in gently in line with the femoral shaft of the proximal
fragment. An alternative technique is the use of a starter reamer
over a guidewire.
17. To correct the flexion deformity, many methods have been devised.
In this case, a clamp is placed through a percutaneous incision onto the
anterior aspect of the femur, and used to lever the proximal fragment
posteriorly to gain alignment with the distal fragment.
18.
19. The AP radiographs before and after the reduction maneuvers
using the clamp and a laterally applied force on the shaft
20. The proximal and distal fragments are
lined up using the clamp as a lever.
21. AP and lateral views: with the fracture aligned, the guide
wire is passed down the shaft.
22. With the reduction being held, reamers are passed in 1mm
increments to size 12-1/2 for the shaft and size 18 or 18 1/2
for the proximal segment to accommodate the size 17 nail
proximally.
24. Passing the nail will maintain the correction in the lateral radiograph.
25.
26. The nail is passed until the proximal locking screw hole allows
for placement of the screw in the inferior to central portion of
the neck.
27. Once the nail is at its proper depth, a perfect lateral radiograph
must be obtained using the following sequence:
1. Rotate the x-ray machine until the nail is in the center of the
head and neck.
2. Rotate the jig until the jig is centered about the nail, which is
centered within the head and neck.
3. This figure is depicted here.
With the nail centered within the jig and both centered within
the head and neck), the screw must be in the center of the head
when placed. This rotation must be maintained while the guidewire
is advanced.
28. The perfect lateral radiograph demonstrating the nail centered within
the jig and both centered within the neck and head. This will direct
the screw into the center of the head on the lateral view.
29. The perfect lateral radiograph demonstrating the nail centered within
the jig and both centered within the neck and head. This will direct
the screw into the center of the head on the lateral view.
