Nail Femur Vda

8/3/2019 Nail Femur Vda

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David Haryadi

Departemen Orthopaedi dan Traumatologi

RS. Dr. Soetomo


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A femoral shaft fracture is a diaphyseal

fracture of the femur that does not extend

into the articular or metaphyseal region


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Winquist & Hansen classification:

Based on the degree of comminution

Type I: minimal or no comminutionType II: comminution at least 50% of the

circumference of the cortices of

two major fr fragments intact

Type III: 50 to 100% of the circumference

of two major fracture fragments

is comminuted

Type IV: all cortical contact is lost


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The femoral shaft is subjected

to major muscular forces thatdeform the thigh after a

fracture:

A.Abductors mm : abduct the

proximal femur

B.Iliopsoas : flexes & externally

rotates the prox fragment

C.Adductors mm: medial

angulated the distal fragment

D.Gastrocnemius : flexes the

distal fragment

E.Fascia lata : as tension band

vs adductors


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Restore the alignment and length of thefemur

Restore cortical contact for axial stability

Preservation of the blood supply to aidunion and prevent infection

Restore and maintain full range ofmotion of the knee and hip

Improve the strength of the muscles thatare affected by fracture

Restore normal gait pattern


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NON OPERATIF

Skin traction

in adult only for emergency fracture immobilization inthe field & to facilitate transportation

for definitive fracture management, indicated only inyoung children

Skeletal traction

for early fracture care before a definitive operation

for patient who are too sick for surgery

to restore femoral length, to limit rotational & angulardeformity

union rates 97-100%, delayed union up to 30%

problems :

knee stiffness, limb shortening, malunion, prolonged

hospitalization, respiratory & skin problems


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Cast brace

an external support device permits progressiveweight bearing

best used after skeletal traction

high rates of union (>90%)

problems :

lost of reduction & subsequent malunion,shortening, & angulation


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External fixation

load-sharing device

excellent bony fixation & wound access

early mobilization

treatment of choice for open fracture gr IIIB &IIIC

may be placed laterally or anteriorly

possible complications :distraction of the fracture, pin-tract infection(up to 50%), pin loosening & lost of kneemotion (due to tethering of quadriceps

muscle to the shaft)


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load/stress-sharing device

stress-sharing system if the

nail is dynamically locked;

partial stress shielding if it is

statically locked

mode of bone healing :

secondary

benefits :

less extensive exposure &

dissection, lower infectionrates, less quadriceps

scarring, early mobilization,

rapid fracture healing, & low

refractured rate


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reamed locked nails are the best treatment for

most shaft fracture for weight-bearing bones, it is fixation method

superior to plates or external fixation

it guarantees proper axial alignment androtational alignment. Can be ensured by using

interlocking screws union rate 98%, infection rate


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Intramedullary nail

1.Open technique

2.Closed technique


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involves inserting the nail after exposing

the fracture.


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1. Pre-operative Planning

a. Diagnostic radiograph must be sufficient quality

to assess the extend of fracture comminutionb. Dimensions of the femoral shaft must be assessed

on plain radiograph

c. A systemic antibiotic is administered 30 minutesbefore skin incision and continued for 24 hours

after the surgery (usually a 1st

generationcephalosporin)

d. Length of the nail is determined pre-operativelyon the normal extremity measuring tip of thegreater trochanter to the lateral epicondylus


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Length of the nail isdetermined pre-

operatively on the

normal extremity

measured from the

proximal portion of

the greater

trochanter to thelateral epicondylus


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Positioning

- Position the patients on his side withthe injured limbs upwards.

- Flex the hip and the knee


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Surgical technique

The fracture is

exposed through a

straight lateral

incision made alongan imaginary line

joining the posterior

aspect of the greater

trochanter with the

lateral epicondyle

(posterolateral

incision)


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Incise the fasciaof the thigh in linewith its fibers andthe skin incision

Identify the vastuslateralis under the

incised fascia lata


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Elevate the vastus lateralis anteriorly,separating the muscle from the septum

Detach those portion of the vastus lateralis thatarise from the septum until the femur and linea

aspera are reached.


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Expose the shaft ofthe femur and

debride the fractureends of frayed soft

tissue that is impaled

on sharp bone edges

and irrigate


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Deliver the distal

fragment from the

wound, check thesize of the

medullary canal

with medullary

reamer to find theone that fits snugly

in the opening.

By using reamers

of progressively

increasing size,

ream medullary

canal proximal

fragment


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Mobilize the fragments and reduce the

fracture to correct rotary alignment


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After reducing fracture, make sure thelength of nail by measure from the greater

trochanter tip to epicondylus lateralis


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Inserting guide nail Insert it proximally through the upper end of the femur until its

point resides in a subcutaneous position. Adduct and full flexion the hip as this is done so that the guide

pin will emerge subcutaneously just proximal to the trochanter

The guide pin should exit from the superior neck at the base of

trochanter

Details of insertion ofmedullary nail. Guide

pin emerges throughsmall incisionin upper outerquadrant of buttock.


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Introduce intramedullary nail over the guide pin withthe extraction eye of the nail facing posteromedially

and drive the nail into trochanteric region of femur

Kntscher nail

inserted into proximalfemoral fragmentover guide pin. Whennail has been drivendown to level of

fracture guide pin isremoved and fracturereduced.Nail is then drivencorrect distance intodistal

fragment


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As the advancing nail in

the proximal fragment

approaches the fracture

site, reduce the fracture

under direct vision


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Reduce the fracture

Maintain the reduction while an assistant

drives the nail with steady blows on the

driver at the proximal end. As the nail is driven into the distal fragment

of the femur, fair resistance is desirable

because it indicates a snug fit


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Its eye faces posteromedially and its proximalend does not extend more than 2.5cm

proximal to the trochanter The distal end of nail should extend to level of

proximal pole patella

Before closing the wound, check

anteroposterior and lateral roentgenograms ofthe distal end of the femur and manuallycheck the stability of the fracture fixation,especially the stability of rotation


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terimakasih.

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Nail Femur Vda