Download Femoral Shaft fractures - Peggers Super Summaries

Peggers’ Super Summary Femoral Shaft Fractures
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Indications:
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Antegrades nails are the treatment of choice for femoral shaft
fracture
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Reamed in Gustillo I
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Unreamed in sever open fractures II – III
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Risk of fat emboli
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Bone necrosis
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Medullary blood supply damage
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Solid vs tubular nails
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Decrease infection with solid nails
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Retrograde relative indications are as follows
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Ipsilateral femoral neck fractures
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Ipsilateral acetabular fractures
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Ipsilatreal tibial shaft fracture i.e. floating knee
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Morbid obesity
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Pregnancy
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Plating
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Nailing CI
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Small canals
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Sclerotic Canals
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Comminuted fracture pattern
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Operative Room Planning
INTRODUCTION
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Confirm Consent / Mark / WHO form / Abx at induction
POSITION
SUPINE
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150 adduction to facilitate guide wire and nail entrance
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Keep leg on edge of table to avoid impingement of instruments
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Raised right hemipelvis with 3L saline bag +/- leg raise/wedge
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If limited assistants need traction table
DRAPING
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Will depend on final postioning
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Antiseptic solution from iliac crest to below knee
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Supine drape like a DHS with distal femur exposed to allow
locking screw insertion distally
Anatomy:
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Superior gluteal nerve is 5cm proximal to GT
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Lateral ascending branch of the circumflex artery runs medial to
Piriformis fossa – may be at risk
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Natural anterior bowing may increase with age
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Abductor muscles cause varus of distal portion
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Iliopsoas causes flexion of proximal portion of femur
Surgical alignment
AXIAL ALIGNMENT
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Extend knee, patella should face anteriorly.
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Place the II directly vertical above the patella/knee
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Use the cable of the cautery device to make a straight line through
the centre of femoral head/knee/centre of the ankle joint.
Associated injuries
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Vascular and sensation of ipsilateral foot
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Compartment syndrome
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Assc Bony injuries
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Pelvis
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Knee
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Foot
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Femoral compartments
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Anterior – quads, Sartorius, iliopsoas, femoral n/v
structures and lateral femoral cutaneous nerve
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Medial – adductors, gracilis, Obturator externus,
Profunda artery, obturatory artery, vein and nerve
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Posterior – biceps femoris,
semitendinosus/membranosus, part of adductor magnus,
sciatic nerve and posterior femoral cutaneous nerve
Preoperative Planning:
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Often flexed and in varus
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Review imaging to see fracture extension
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Extension or second fracture of the femoral neck
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Femoral properties
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Femoral length
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Canal diameter
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Neck shaft diameter
Equipment
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Prosthesis
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Intramedullay
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Proximal Femoral nail (short or long)
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Gamma nail
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Recon Nail
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Extramedullary
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plate
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radiolucent table
Flannel blanket or 3L saline to raise ipsilateral hemipelvis
II
Femoral distractor
Haygroves and reduction tools if fracture site needs to be reduced
via open technique
Schanz pins are useful for percutaneous reduction of distal
fragment
ROTATIONAL ALIGNMENT
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Shape and size of the lesser trochanter, large in ER, smaller in IR
Surgical Approach
NAILING
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Reduce fracture on table before to allow simpler fixation
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Marking the proximal and distal ends of the femur on the patient
aids anatomical landmarks
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A skin start point midway between the GT and iliac crest and
slightly posteriorly in line with the femur insert the guide wire to
find the Piriformis fossa
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After this 2cm incision is made to incorporate the guide wire
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Incise the gluteus maximus fascia and split the fibres in line with
the fibres
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Check guide position on both AP/Lat II
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Insert the guide wire to the level of the LT
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A cannulated drill is then used to drill over the guide wire to open
the proximal femur
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A ball tipped reaming wire in then inserted in replace of the guide
wire
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Insert the ball tipped wire as far as the fracture site
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Use your assistants to reduce the fracture in the sagital plane
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Hammer and towel around the fracture site
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Or percutaneous ball spiked pusher or unicortical
schanz pin
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Pass the ball tipped wire past the fracture site and check distal
placement on AP / Lat II
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Measure the canal length intra-operatively
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Ream sequentially keeping fracture reduced to avoid eccentric
reaming
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Ream 1.0 size larger than the required nail and stop when the
chatter at the isthmus occurs
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Peggers’ Super Summary Femoral Shaft Fractures
On placement of the nail look on lateral II to avoid perforating the
anterior cortex as the implant goes in
Before locking check alignment and rotation
Lock proximately and distally
Findings :
Midshaft Fracture with butterfly segment
Procedure :
PLATING
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Low compression dynamic compression plate (LC-DCP) or
(Minimally Invasive Percutaneous Plate Osteosynthesis) MIPPO
technique to minimally disturb periosteal tissues and blood supply
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Cortical screws 4.5, cancellous screws 6.5mm
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Compression side of plate with open tension side of bone, can be
overcome with bending at the fracture site
FLEXIBLE NANCY NAILS IN PAEDIATRICS
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Benefits from minimal scarring no risk of AVN of the femoral
head and no growth plate damage
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Suitable for children <50Kg
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To reduced fracture prep whole of lower leg with lower leg in sock
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May need femoral distracter
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Each nail must be roughly 1/3 of canal diameter and no bigger
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Retrograde insertion, with distal cut more distal to allow angled
entry into femur, blunt dissection down through fascia lata and
onto bone
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Using a 4.5mm drill piece to make a drill hole 2cm proximal to
distal growth plate at a 300 angle to the vertical
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3cm of pre-bending from apex to tip
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The apex of the bend should lie at the fracture
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Mount the nancy nail onto a t chuck handle and advance
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The same is repeated on the medial side of the knee
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If after several attempts of closed reduction and passes open a 4cm
window on the lateral femur over the fracture site
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Advance as far as the GT
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Leave the end of the nail for ease of removal
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Check for reduction and rotation
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Close skin only
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Remove 3-6 months only after good radiographic evidence of
callus formation
Finishing off:
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Check alignment
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Check for femoral neck fracture
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Check knee ligaments
Closure
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Irrigate ++
Haemostasis
No1 vicryl for fascia
2/0 vicryl for fat and subcutaneous
3/0 nylon or vicryl rapide for the skin
Dressings
Bony entry point made tip of trochanter under xray guidance,
Guidewire inserted across fracture, then femur reamed to 11.5mm,
Synthes 420mm long 10mm diameter lateral femoral nail inserted, locked
distally with 2 bolts then hammered back to close fracture site and impact the
fracture. Proximal bolt inserted to lock nail. Xray to check position of all
screws and fracture reduction
Closure :
3/0 caprosyn to skin
Mepore dressings
Examination of left knee : knee stable, full range of motion, no ligamentous
laxity.
No rotational malalignment of knee or foot. No shortening.
Post Op Instructions :
Tinzaparain
Mobilize full weight bearing
Wound check at GP nurse in 5-7 days
clinic 6 weeks, xray on arrival
Evidence:
Decrease pulmonary morbidity in early femoral fixation. Bone LB et al.
Clin Ortho Related Research 1998
4.5x relative risk of non union in undreamed femoral canals. Canadian
Orthopaedic Trauma Society. JBJS (Am) 2003
No increase in ARDS with Reaming (small study). Canadian Orthopaedic
Trauma Society. J Ortho Trauma 2006
Complications:
Early
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Infection
Periprosthetic fracture
Damage to superior gluteal nerve
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Proximal screw cut out or failure
Non or Malunion
Nail breakage
Late
Operative Note
Preparation and Position:
Supine, GA, WHO checks, IV antibiotics, traction table, fracture reduced
under xray guidance, sterile prep and drape
Incision and Approach :
3cm cut over greater trochanter, two stab incision for distal bolts, 1 stab
incision for proximal bolt
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