Anterograde itramedulary nailing

8/12/2019 Anterograde itramedulary nailing.

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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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Anterograde itramedulary nailing