1、1AP radiograph of the femoral shaft fracture.2A high quality A P radiograph of the hip is required before nailing ensues in order to rule out femoral neck fracture.In most situations the CT scan done for evaluation of the abdomen and pelvis should be reviewed for occult femoral neck fractures.3The l
2、eg is free-draped from the calf to the ASIS4A small incision,usually no more than 15mm,is made over the medial aspect of the patellar tendon.This incision is brought paratendinous through the deep tissue so as not to go through the patellar tendon.DistalProximal5The portal may be made using many met
3、hods including guidewire followed by a reamer,a straight awl,or a step drill as seen here.PATELLATENDONPATELLADistalProximal6The knee should be in approximately 40 degrees of flexion toavoid damaging the inferior patella or proximal tibia as the portal and reaming is performed.7For the starter reame
4、r,guidewire,or awl the direction of insertion must be in the center and parallel with the formal shaft in both the AP and lateral views.The perfect starting portal is just at the intersection of Blumensaats line,with the line representing the the trochlear grooveon the perfect lateral radiograph.8On
5、 the AP it should be in the center of the notch directed toward thecenter of the shaft rather than perpendicular to the condyles,which would direct the nail toward the medial cortex.9A beaded-tipped guidewire is advanced to the fracture.10The guidewire should have a bend in it and is rotatedsuch tha
6、t it will pass across the fracture with gentletaps on the jig.11The guidewire is passed across by gently tapping without rotating the wire.12Once across the fracture,the guidewire can be rotated 180 degrees to effect a reduction in the bone.13PIRIFORMISFOSSAThe guidewire is introduced to its most pr
7、oximalextent,which is just inferior to the piriformis fossa,as visualized on the AP radiograph.14Each system may be different,but a direct measurement of length using a second guidewire of the same length as the first is always appropriate.This figure demonstrates the second guidewire beingintroduce
8、d into the hole to the depth that the nail should be seated.15A clamp is then placed on the second guidewire at the endof the first guidewire and the residual is measured.16This will give the exact measure of the longest possiblenail that can be placed.After measurements are taken,the reaming proces
9、s is begun.17The reamer is advanced in the direction of the femur,with care taken to advance gently through subchondralbone.18An excellent fit in the area of the isthmus isseen with the reamer.19After reaming is complete,an exchange tube is placedover the beaded-tip guidewire,which is removed andrep
10、laced with a straight guidewire.2021Before the nail is inserted,the locking jig should be attached to the nail and the accuracy of the locking holes in the jig confirmed.2223After the nail is advanced to its appropriate depth,asvisualized on the lateral radiograph,distal locking isperformed through
11、the jig.24Only one screw near the knee is necessary for mid-shift and isthmal fractures that do not extend into the wide area of the distal femur.This should be the proximal of the two holes.25Only one screw near the knee is necessary for mid-shift and isthmal fractures that do not extend into the w
12、ide area of the distal femur.This should be the proximal of the two holes.26Only one screw near the knee is necessary for mid-shift and isthmal fractures that do not extend into the wide area of the distal femur.This should be the proximal of the two holes.27Only one screw near the knee is necessary
13、 for mid-shift and isthmal fractures that do not extend into the wide area of the distal femur.This should be the proximal of the two holes.28This figure demonstrates the AP and lateral views with the locking screw placed.This hole is not visible on the lateral view.Notice that the nail is advanced
14、beneath the area of the subchondral bone,as evidenced by the interface between the nail and the jig(arrow).The dotted line indicates the trochlea groove and Blumensaats line,whichrepresents the subchondryl bone under the articular surface at thislevel.29Proximal locking requires some rotation of the
15、 C-arm due to the anterior bow of the femoral nail.A perfect circle technique is utilized for the proximal locking.30The C-arm should be raised to its maximal height in order toenlarge the perfect circle and give freedom for placement ofthe drill and screw.31Fluoroscopy shot of the perfect circle vi
16、ew.32The incision required for proximal locking is approximately2cm long as significant penetration through the quadricepsmechanism is necessary.The use of a locking screwdriver will help to avoid losing a screw deep in the tissues.33It is very important that during the process of proximal locking t
17、he drill or any device never strays medially to the femoral shaft as the femoral artery lies only 1 cm medial tot he shaft at this level.34AP and lateral view demonstrating an appropriatelyLocked femoral nail at the level of a lesser trochanter.35The small incision is closed in layers and skin staples.36The AP and lateral views after nailing.37A high quality radiograph of the femoral neck shouldbe performed after nailing in the operating room toconfirm that the femoral neck is intact.38
