Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Peggers’ Super Summary Femoral Shaft Fractures Indications: Antegrades nails are the treatment of choice for femoral shaft fracture o Reamed in Gustillo I o Unreamed in sever open fractures II – III Risk of fat emboli Bone necrosis Medullary blood supply damage o Solid vs tubular nails Decrease infection with solid nails Retrograde relative indications are as follows o Ipsilateral femoral neck fractures o Ipsilateral acetabular fractures o Ipsilatreal tibial shaft fracture i.e. floating knee o Morbid obesity o Pregnancy Plating o Nailing CI Small canals Sclerotic Canals Comminuted fracture pattern Operative Room Planning INTRODUCTION Confirm Consent / Mark / WHO form / Abx at induction POSITION SUPINE 150 adduction to facilitate guide wire and nail entrance Keep leg on edge of table to avoid impingement of instruments Raised right hemipelvis with 3L saline bag +/- leg raise/wedge If limited assistants need traction table DRAPING Will depend on final postioning Antiseptic solution from iliac crest to below knee Supine drape like a DHS with distal femur exposed to allow locking screw insertion distally Anatomy: Superior gluteal nerve is 5cm proximal to GT Lateral ascending branch of the circumflex artery runs medial to Piriformis fossa – may be at risk Natural anterior bowing may increase with age Abductor muscles cause varus of distal portion Iliopsoas causes flexion of proximal portion of femur Surgical alignment AXIAL ALIGNMENT Extend knee, patella should face anteriorly. Place the II directly vertical above the patella/knee 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 Vascular and sensation of ipsilateral foot Compartment syndrome Assc Bony injuries o Pelvis o Knee o Foot Femoral compartments o Anterior – quads, Sartorius, iliopsoas, femoral n/v structures and lateral femoral cutaneous nerve o Medial – adductors, gracilis, Obturator externus, Profunda artery, obturatory artery, vein and nerve o Posterior – biceps femoris, semitendinosus/membranosus, part of adductor magnus, sciatic nerve and posterior femoral cutaneous nerve Preoperative Planning: Often flexed and in varus Review imaging to see fracture extension o Extension or second fracture of the femoral neck Femoral properties o Femoral length o Canal diameter o Neck shaft diameter Equipment Prosthesis o Intramedullay Proximal Femoral nail (short or long) Gamma nail Recon Nail o Extramedullary plate 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 Shape and size of the lesser trochanter, large in ER, smaller in IR Surgical Approach NAILING Reduce fracture on table before to allow simpler fixation Marking the proximal and distal ends of the femur on the patient aids anatomical landmarks 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 After this 2cm incision is made to incorporate the guide wire Incise the gluteus maximus fascia and split the fibres in line with the fibres Check guide position on both AP/Lat II Insert the guide wire to the level of the LT A cannulated drill is then used to drill over the guide wire to open the proximal femur A ball tipped reaming wire in then inserted in replace of the guide wire Insert the ball tipped wire as far as the fracture site Use your assistants to reduce the fracture in the sagital plane o Hammer and towel around the fracture site o Or percutaneous ball spiked pusher or unicortical schanz pin Pass the ball tipped wire past the fracture site and check distal placement on AP / Lat II Measure the canal length intra-operatively Ream sequentially keeping fracture reduced to avoid eccentric reaming Ream 1.0 size larger than the required nail and stop when the chatter at the isthmus occurs Page 1 of 2 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 Low compression dynamic compression plate (LC-DCP) or (Minimally Invasive Percutaneous Plate Osteosynthesis) MIPPO technique to minimally disturb periosteal tissues and blood supply Cortical screws 4.5, cancellous screws 6.5mm Compression side of plate with open tension side of bone, can be overcome with bending at the fracture site FLEXIBLE NANCY NAILS IN PAEDIATRICS Benefits from minimal scarring no risk of AVN of the femoral head and no growth plate damage Suitable for children <50Kg To reduced fracture prep whole of lower leg with lower leg in sock May need femoral distracter Each nail must be roughly 1/3 of canal diameter and no bigger Retrograde insertion, with distal cut more distal to allow angled entry into femur, blunt dissection down through fascia lata and onto bone Using a 4.5mm drill piece to make a drill hole 2cm proximal to distal growth plate at a 300 angle to the vertical 3cm of pre-bending from apex to tip The apex of the bend should lie at the fracture Mount the nancy nail onto a t chuck handle and advance The same is repeated on the medial side of the knee If after several attempts of closed reduction and passes open a 4cm window on the lateral femur over the fracture site Advance as far as the GT Leave the end of the nail for ease of removal Check for reduction and rotation Close skin only Remove 3-6 months only after good radiographic evidence of callus formation Finishing off: Check alignment Check for femoral neck fracture Check knee ligaments Closure 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 Infection Periprosthetic fracture Damage to superior gluteal nerve 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 Page 2 of 2