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These images demonstrate a distal femoral shaft fracture
occurring from blunt trauma.
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Before performing antegrade femoral nailing, a high-quality
AP radiograph of the hip is necessary to rule out occult
femoral neck fracture.
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Many patients with femoral shaft injuries have CT scans performed
to rule out intraabdominal injury. The CT scan cuts through the
femoral neck should also be reviewed to rule out fracture.
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Lateral decubitus position is preferred for antegrade femoral
nailing in the patient with normal pulmonary status and no
spine or pelvic injury. The affected leg is flexed, exposing the
piriformis fossa without steric interference from the patients
torso.
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The downside leg is well supported and padded to
avoid neuropraxia. The surgeon is pointing to the
starting point for the piriformis entry point.
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View of the area that is prepped out for
performing the nailing.
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PIRIFORMIS
FOSSA
The piriformis fossa entry portal is directly in line with the canal
of the shaft. However, it is slightly posterior to the femoral neck.
It is curvilinear and angled posteriorly.
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Because the piriformis entry portal is on a sloped surface, a
straight awl must be introduced first at an angle to the femoral
shaft directly anteriorly
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and then as its introduced, the hand is raised up to
go in line with the femoral shaft.
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The skin incision, which can be approximately 1 to 1-1/2cm in length,
should be made at a distance away from the piriformis fossa to allow
for direct entry into the fossa. This can be best estimated by looking
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at the AP radiograph to determine how proximal the incision
needs to be with respect to the trochanter. The heavier the
patient, the more proximal in the buttocks the incision needs to
be in order to be in line with the femoral shaft.
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The fascia of the Tensor fascia Lata muscle is
divided, exposing some of the musculature.
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The perfect lateral radiograph of the hip demonstrates the
neck to be colinear with the shaft and slightly anterior to it.
The piriformis fossa is easier visualized.
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The straight awl is introduced through the incision, then
gently placed against the piriformis fossa directed anteriorly.
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The awl is introduced into the femoral canal; as it enters
the bone, the awl is adjusted to be in line with the femoral
shaft by moving the hand and awl anteriorly.
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The awl is introduced into the femoral canal; as it enters
the bone, the awl is adjusted to be in line with the femoral
shaft by moving the hand and awl anteriorly.
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Once the awl has been introduced gently, it is tapped
down past the calcar to allow for easy passage of the
guidewire.
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Once the awl has been introduced gently, it is tapped
down past the calcar to allow for easy passage of the
guidewire.
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The guidewire should have a gentle distal bend to allow
easy passage across the fracture site. The guidewire is
introduced down the femoral shaft..
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A soft tissue protector can be used to minimize muscle injury
proximally.
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The guidewire is advanced down the canal. Note the
colinearity of the entry point with the center of the shaft.
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The guidewire is introduced to the level of the fracture.
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The fracture is reduced and the guidewire is passed across and
distally until it is just shy of the epiphyseal scar in the center of
the femur on the AP radiograph. This is particularly important
for distal fractures.
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Once the guidewire is fully introduced, length may be
measured in many ways. While some systems have
jigs to measure length, a foolproof system is to
measure a residual of a guidewire of the same length.
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The above image demonstrates a second guidewire of the
same length introduced to the level of the trochanter.
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A Kocher clamp is placed on the guidewire so
that the residual can be directly measured.
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Measuring the residual from this guidewire will give an
exact measurement of the longest nail that is possible for
this patient. After measurement is obtained, the femoral
canal is reamed.
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After reaming is complete, the appropriate size nail is chosen.
Before the nail is inserted, as with any nailing procedure, the
proximal jig needs to be checked for appropriate alignment of
the locking mechanism.
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An exchange tube is placed over the ball-tip guidewire, which
is then removed. A straight guidewire is then placed through
the exchange tube, which is then removed,allowing for placement
of the nail over the straight guidewire.
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The nail is gently tapped down the canal. Any significant
resistance warrants biplanar radiographic confirmation of
appropriate position of both the guidewire and the nail, as
well as areas of the femoral neck for possible fracture.
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After the nail is appropriately seated, with the jig at thelevel of the greater trochanter, the proximal jig is used to
lock the nail. Distal locking is generally performed using
a freehand technique via perfect circles.
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The above image demonstrates the C-arm in a
position to view a perfect circle.
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This image shows the distal end of the nail with the
screws in place, the blackout radiograph.
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AP and lateral radiographs of the nail in place.
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