The surgeon elects to treat both fractures with reamed intramedullary nailing. 70kg male, 6' tall, typically 420mm if using long nail) check proximal fluoro on GT to make sure ruler is sitting flush on bone. What change in position (with the C-arm stationary) would be expected to produce a perfect lateral view of the interlocking hole? Tested Concept, (OBQ12.51) Tested Concept, Use of a piriformis entry nail through a greater trochanteric entry portal, Use of a greater trochanteric entry nail through a piriformis entry portal, Use of a lateral entry nail through a piriformis entry portal, Use of a femoral distractor device to obtain reduction, Use of a fracture table to obtain reduction, (OBQ07.74) At revision surgery, in order to correct the rotational malalignment, the right distal femur must be rotated which of the following? Tested Concept, Retrograde nailing of the femur, intramedullary nailing of the tibia, ankle debridement and casting, External fixation of the femur, intramedullary nailing of the tibia, ankle debridement and ORIF, Antegrade nailing of the femur, external fixation of the tibia and ankle after debridement, Retrograde nailing of the femur, intramedullary nailing of the tibia, ankle debridement and ORIF, External fixation of the tibia and femur, and ankle debridement and external fixation, (OBQ05.57) You tell him that retrograde nailing is your preferred technique over antergrade nailing for diaphyseal femoral fractures because it has been shown to have which of the following? associated with life-threating conditions, often basicervical, vertical, and nondisplaced, lack of displacement due to majority of energy dissipated through femoral shaft, significant risk of pulmonary complications, increased rate of mortality as compared to unilateral fractures, rule-out coexisting femoral neck fracture, immediate retrograde or antegrade nailing is safe for early treatment of gunshot femur fractures, no difference in union rates and infections rates with acute nailing, infection rate does increase if ex-fix left in place >28 days, reduced risk of ARDS and fat embolism sydnrome, insert femoral nail with 90° of internal rotation, leverages the anterior bow of the nail to direct the tip of the nail into the canal, avoids medial comminution with nail contact along medial cortex, increased rate of interlocking screw irritation, converted to IM fixation within 2-3 weeks, femoral artery is medial to femur if proximal locking screw is placed proximal to lesser trochanter in retrograde nails, can occur when inserting proximal interlocking screws during a retrograde nail, most accurately determined by the Jeanmart method, up to 15 degrees is usually well tolerated, use of a fracture table increases risk of, antegrade starting point 6mm or more anterior to the intramedullary axis, however, anterior starting point improves position of screws into femoral head, failure to overream canal by at least .5 mm, lengthening along the anatomical axis of the femur leads to lateral MAD, shortening along the anatomical axis of the femur leads to medial MAD, Adult Knee Trauma Radiographic Evaluation, Proximal Humerus Fracture Malunion and Nonunion, Distal Radial Ulnar Joint (DRUJ) Injuries, ipsilateral femoral neck fractures, tibial shaft fracture, cerebral hemorrhage, thoracic injuries, treatment involves reamed, statically locked, intramedullary nails that is associated with >95% union rates, often a result of high-speed motor vehicle accidents, early surgical treatment of femur fracture can lead to ARDS, treatment can proceed when patient is appropriately resuscitated, early surgical treatment can exacerbate neurologic injury, intraoperative hypotension can decrease brain perfusion, rough crest of bone running down middle third of posterior femur, attachment site for various muscles and fascia, acts as a compressive strut to accommodate anterior bow to femur, musculature acts as a deforming force after fracture, gluteus medius and minimus abduct as they insert on greater trochanter, iliopsoas flexes fragment as it inserts on lesser trochanter, adductors inserting on medial aspect of distal femur, gastrocnemius attaches on distal aspect of posterior femur, blood loss in closed femoral shaft fractures is 1000-1500ml, for closed tibial shaft fractures, 500-1000ml, blood loss in open fractures may be double that of closed fractures, examination for ipsilateral femoral neck fracture often difficult secondary to pain from fracture, must record and document distal neurovascular status, may be considered in midshaft femur fractures to rule-out associated femoral neck fracture, Ipsilateral femoral neck rule-out protocol, dedicated 10° internal rotation AP hip radiographs, intraoperative fluoroscopic exam of the ipsilateral hip, dedicated post-operative radiographs of the affected while patient is still in operating room, most sensitive to the presence of a occult infection, nondisplaced femoral shaft fractures in patients with multiple medical comorbidities, decreased length of stay and cost of hospitalization, exception is a patient with a closed head injury, critical to avoid hypotension and hypoxemia, does not compromise surgical approach to acetabulum, avoids difficult of antegrade start point with obesity, results are comparable to antegrade femoral nails, ipsilateral neck fracture requiring screw fixation, fracture at distal metaphyseal-diaphyseal junction. Copyright © 2021 Lineage Medical, Inc. All rights reserved. Your 25-year-old patient complains of anterior knee pain after retrograde femoral nailing for a diaphyseal fracture and asks you why you didn’t perform antegrade nailing as he has seen on the internet. … Three weeks after surgery, CT scans are performed to assess for rotational malalignment. There were 124 Tested Concept, (OBQ06.41) Tested Concept, Platelet rich plasma with allograft cancellous bone carrier, (OBQ04.188) Three weeks after surgery, CT scans are performed to assess for rotational malalignment. Which of the following is an advantage of computer-assisted navigation used to place medullary nail interlocking screws compared to a freehand techinque? He subsequently undergoes the procedure shown in Figures C and D with a 12 millimeter nail. The nail design has been well proven in over 450 000 cases performed with the PFN and PFNA. Am I billing only a CPT 27245 and modifying with a 22 for the complication? Nailing System Intramedullary nail for treating proximal femoral and diaphyseal femur fractures. use radiolucent ruler to measure appropriate nail length Reaming. Complications: An intraoperative extension of femoral fracture [Short 11 mm nail on impacting, caused crack in lateral cortex; Removed short nail, and reamed up to 11.5 mm, and put in long TFN nail. In this episode, we review the high-yield topic of Proximal Femur Fractures from the Pediatrics section. Tested Concept, Antegrade piriformis entry femoral nailing, Antegrade greater trochanteric entry femoral nailing, External fixation of a femoral shaft fracture, Open reduction and internal fixation of an intertrochanteric fracture, (OBQ06.57) Which of the following is the most likely cause of this malrotation deformity? Without taking into account order of fixation, how should his injuries be treated? femoral nail and allograft (Fig. A 22-year-old male undergoes retrograde intramedullary nailing for the injury seen in Figure A. The second case is a 67-year-old male who sustained a closed Tested Concept. Tested Concept, Increased risk of post-operative bleeding, Lower Glasgow Coma Scale scores at the time of discharge from hospital, Improved central nervous system outcomes at the time of discharge from hospital, (OBQ06.39) Which of the following surgical techniques is considered to have the highest rate of fracture malreduction with this combined injury? Main outcome measurements: Cutout of the helical blade or lag screw. Tested Concept, (OBQ13.10) He undergoes early fixation of the femur fracture with a prolonged period of intraoperative hypotension. Which of the following variables has not been shown to be increased in patients who sustain bilateral femoral shaft fractures as compared to patients with unilateral femoral shaft fractures? use ruler on contralateral side to measure intact femur if segmental comminution exists; start with 9mm reamer, then ream up 0.5-1.0mm with consecutive reamer ream 1.5mm above size of final nail (i.e. This system of Antirotation screw & cervical load bearing screw in this nail makes this construct biomechanically very stable [11,13,17,18]. He is treated with 25 mg of indomethacin three times daily for 6 weeks following an initial dose on the evening of surgery for heterotopic ossification prophylaxis. To keep the bones from rotating around the nail or from shortening (telescoping) on the nail, additional screws may be placed at the lower end of the nail near the knee. Tested Concept, Anterior-posterior compression pelvic injury, (OBQ10.256) The Orthobullets Podcast In this episode, we review the high-yield topic of Proximal Femur Fractures from the Pediatrics section. The main principle of this type of fixation is based on a Tested Concept, It is associated with an increased rate of femoral shaft nonunion, It has no effect on the healing time of the posterior wall fracture, It is associated with a faster time to union, Indomethacin is superior to radiation treatment in the prevention of heterotopic ossification, There is a decreased rate of revision surgery needed when indomethacin is administered post-operatively, (OBQ06.33) Antegrade femoral nailing has an increased rate of which of the following when compared to retrograde femoral nailing? A retrograde nail is appropriate for fixation of fractures proximal to total knee arthroplasties and fractures distal to proximal femoral implants. He was treated with an intramedurally nail and a post-operative radiograph is shown in figure B. He undergoes intramedullary nailing of the femur, and open reduction internal fixation of the posterior wall. Tested Concept, Ipsilateral superficial femoral artery injury, (OBQ09.102) Figure A is a lateral fluoroscopic view of the distal femur taken just prior to distal interlocking screw placement. On physical examination, he has no open wounds and is neurologically intact in both lower extremities. On physical examination, the overlying skin is intact and there is no evidence of a Morel-Lavallée lesion. Which of the following factors is most associated with malrotation during antegrade or retrograde femoral nailing? This fracture orientation is most often present when found concomitantly with which of the following orthopaedic injuries? Tested Concept, Decreased internal malrotation deformities, Increased external malrotation deformities, (OBQ05.221) Patient Positioning One common setup for antegrade nailing involves positioning the pa- Intervention: Cephalomedullary nailing with the use of a helical blade or single lag screw for proximal fixation. A 23-year-old man undergoes intramedullary nailing for a comminuted right femur fracture. Targeted Muscle Reinnervation (TMR) for neuroma treatment following above knee amputation 1 day ago. ... Orthobullets Team Pediatrics - Osteomyelitis - … A proximal femoral nail made up of titanium alloy (TST SAN, Istanbul, Turkey) was placed into the femur in the second group. The distal femur includes the supra-condylar and intercondylar region of the femur extending from the metaphyseal-diaphyseal junction to the articular surface of the knee. He has a mean arterial pressure of 80, heart rate of 90, a lactate level of 1.2 mmol/L, and base deficit of 0.5. The femoral shaft is oriented in 7° to 11° of valgus in relation to the knee joint. Overview. A 55-year-old male is involved in a motorcycle crash and sustains a closed, right-sided, midshaft femur fracture. In Figure A, the angular rotation of the right femoral neck is internal rotation of 13° while the angular rotation of the left femoral neck is external rotation of 13°. This is an isolated injury. Nailing ensures good fracture stability, safeguards against malalignments, and allows quick mobilization. Today, intramedullary nailing seems to be the gold standard for the treatment of diaphyseal tibial fractures. 1D). If the anterior femoral neck is comminuted, accessory fixation and reduction of the anterior wall in conjunction with proximal femoral locked plate … When would full weight-bearing be allowed after surgery? Results: Twenty-two cutouts occurred, 14 (15.1%) of 93 patients with helical blades and 8 (3.0%) of 269 patients with lag screws. He is intubated and an intracranial pressure monitor is placed which consistently measures 30mm Hg. Determine nail insertion point and insert Guide Wire In the AP view, the nail insertion point is normally found on the tip or slightly lateral to the tip of the greater trochanter in the curved extension of the medullary cavity. He is cleared to go to the operating room. A 25-year-old male presents following a motor vehicle collision with a Glasgow Coma Scale of 7. reamed nailing superior to unreamed nailing, with: careful mallet nail to appropriate depth after crossing fracture site, computer-assisted navigation for screw placement decreases radiation exposure, obtain perfect trajectory of interlock holes with C-arm transducer, use the angle of the transducer to guide trajectory of drill, widening/overlap of the interlocking hole in the proximal-distal direction, correct with adjustment in the abduction/adduction plane, widening/overlap of the interlocking hole in the anterior-posterior plane, correct with adjustment in the internal/external rotation plane, reamed nailing has been associated with higher union rates compared to unreamed nailing, reaming disrupts endosteal blood supply, but stimulates soft tissue and periosteal blood supply to fracture, periosteal and soft tissue blood supply is predominate source after fracture, reaming extrudes medullary contents into fracture site, increased micro emboli to lungs with reaming, intraoperative echocardiogram studies have not demonstrated this to be significant, mild increases in marrow pressure with reaming, greatest increase occurs with nail insertion, allows canal contents to extrude around the nail, reaming allows are a larger diameter nail to be placed, larger nail is stiffer and is related to the diameter to the 4th power, increases the area of isthmic contact with nail, no increase in infection rates after reaming open fractures, range of motion of knee and hip is encouraged, not indicated for use with ipsilateral femoral neck fracture, increased rate of HO in hip abductors with antegrade nailing, increased rate of hip pain compared with retrograde nailing, mismatch of the radius of curvature of the femoral shaft and intramedullary nails can lead to, 2 cm incision starting at distal pole of patella, medial parapatellar versus transtendinous approaches, useful for eliminating extension moment of gastrocnemius in distal fragment, extension of Blumensaat's line on lateral, posterior to Blumensaat's line risks damage to cruciate ligaments, trajectory in line with the canal on AP and lateral views, requires a curves nail to prevent valgus malalignment, entry reamer with soft tissue protecting sleeve, fracture must be reduced to avoid eccentrically reaming the cortex, ream canal 1 to 1.5 mm greater than size of intended implant, should seat ~1 cm deep to articular surface to prevent patellofemoral symptoms, can place first and then mallet the nail to gain compression at fracture with transverse patterns, perfect circles technique for proximal interlocks, femoral neurovascular bundle safe if screws placed proximal to lesser trochanter, allows for addressing other injuries surgically without changing patient position, allows for direct comparison of rotation and leg length to nonoperative extemity, no increased rate of septic knee with retrograde nailing of open femur fractures, cruciate ligament injury with improper starting point, safest pin location sites are anterolateral and direct lateral regions of the femur, 2 pins should be used on each side of the fracture line, prevents further pulmonary insult without exposing patient to risk of major surgery, due to binding/scarring of quadriceps mechanism, less soft tissue stripping than with direct lateral approach, preserves periosteal blood supply to fracture, lateral incision in line with femoral shaft, elevate vastus lateralis from ITB fascia and posterior septum, place chandler over anterior cortex to expose lateral femur, reduce fracture with traction and reduction forceps, can place interfragmentary screw for simple fracture patterns, comminuted fractures will require bridge plate, priority goes to fixing femoral neck because anatomic reduction is necessary to avoid complications of AVN and nonunion, screws for neck with retrograde nail for shaft, compression hip screw for neck with retrograde nail for shaft, single constuct fixation is associated with femoral neck fracture displacement and loss of reduction, antegrade nail with screws anterior to nail, usually done if neck fracture is identified after the femoral shaft fracture has been addressed, 10% when using fracture table with traction, angle between a line drawn tangential to the femoral condyles and a line drawn through the axis of the femoral neck, anterversion and external rotation are positive values for equation, retroversion and internal rotation are negative values for equation, if noticed intraoperatively, remove distal interlocking screws and manually correct rotation, if noticed after union, osteotomy is required, dynamization of nail with or without bone grafting, incomplete healing within 9 months of injury or no evidence of healing on successive radiographs over 3 months, postoperative use of nonsteroidal anti-inflammatory drugs, smoking is known to decrease bone healing in reamed antegrade exchange nailing for atrophic non-unions, broken distal interlock screws can be seen on radiographs, race between healing and implant failure is lost, distal interlock screws are exposed to the greatest stresses, results in fracture of the interlock screw in the region inside the nail, works by increasing construct stiffness, enhanced isthmic fit, and extrusion of reaming contents to nonunion site, some studies have demonstrated higher union rates than exchange nailing, external fixation used if fracture not healed, quadriceps and hip abductors are expected to be weaker than contralateral side, increased cortical hoop stresses with anterior starting points, using an anterior start point for a piriformis nail can result in a proximal femur fracture, due to mismatch of the radius of curvature of the nail to the radius of curvature of the femur, average radius of curvature of human femur is 120 +/- 36 cm, starting points that are too posterior (especially piriformis start points) with relatively straight nails. Tested Concept, Closed reduction and percutaneous screw fixation of the femoral neck, followed by reamed antegrade nailing of the femur fracture, Reamed antegrade nailing of the femoral shaft fracture, followed by open reduction and percutaneous screw fixation of the femoral neck fracture, Reamed retrograde nailing of the femoral shaft fracture, followed by closed reduction and percutaneous screw fixation of the femoral neck, Open reduction and screw fixation of the femoral neck, followed by reamed retrograde nailing of the femoral shaft fracture, Open reduction and screw fixation of the femoral neck, followed by plating of the femoral shaft fracture, (OBQ11.245) A 26-year-old male sustains a femoral shaft fracture treated with the implant shown in Figure A. Postoperatively, what muscular deficits can be expected at medium and long-term follow-up? One hundred and one intertrochanteric fractures with the Proximal Femoral Nail Anti-rotation (PFNA; Synthes GmbH, Oberdorf, Switzerland) were performed between 1 March 2007 and 28 February 2009. tation study analyzed 174 femur and tibia/fibula open fractures by stratifying both groups according to Gustilo fracture grade, National Healthcare Safety Network risk index, fracture site, and presence of resistant organisms. Current radiographs are shown in Figure A. Which of the following is associated with approximately 5% of patients sustaining this injury? tient conditions that make proximal access to the femur for antegrade nailing either difficult (eg, obesity, bilateral femur fracture) or undesir-able (eg, ipsilateral pelvic or hip frac-ture, ipsilateral tibia fracture, preg-nancy) favor retrograde nailing. Tested Concept, (OBQ09.28) Intertrochanteric neck of femur fracture treated with a proximal femoral nail (Synthes long TFNA) 1 day ago. His mother notes that he has had a fever of 39.0. If the indications for nailing of proximal and distal tibial fractures are extended, this is a challenge for surgical techniques. He is treated with retrograde femoral nailing, and post-operatively is noted to have 30 degrees of internal rotation of the operative extremity, when compared with his nonsurgical side. The Orthobullets Podcast In this episode, we review the high-yield topic of Proximal Femoral Focal Deficiency from the Pediatrics section. Placing the starting point for an antegrade femoral nail too anterior to the axis of the medullary canal can most commonly lead to what intraoperative complication? ... Orthobullets Team Tested Concept, (OBQ06.163) With use of this construct, a starting point 3 mm anterior to the center of the piriformis fossa has which of the following benefits? They are treated surgically with an intramedullary nail into the shaft of the femur and a screw placed through the nail into the femoral head. What is the next best step in treatment? When placing an antegrade intramedullary nail with manual traction in a supine position, which of the following is true when compared to placement of a nail using a fracture table? An infrapatellar and patellar tendon splitting entry to the tibia with the knee joint flexed 90 degrees seems to be the preferred entry for tibial nailing. A 29-year-old male sustained a mid-shaft femur fracture in a motorcycle accident. Reaming. (OBQ13.144) Tested Concept, (OBQ12.232) Hip Fracture Fixation (Femur, Proximal) » Howmedica Gamma Nail (Implant 16) Howmedica Gamma Nail (Implant 16) Click to Enlarge. [ 11 ] Potential complications of use of the retrograde supracondylar nail include knee sepsis, stiffness, and patellofemoral pain. Newer designs like proximal femoral nail (PFN) with less valgus curvature (6 degrees), longer length, smaller diameter (9, 10 and 11 mm) and additional antirotation screw are associated with less complication rates and better results [26–28]. In this episode, we review the high-yield topic of Proximal Femoral Focal Deficiency from the Pediatrics section. Which of the following is true regarding the risk of malrotation? A 26-year-old male presents after a motor vehicle accident. An intertrochanteric fracture is a specific type of hip fracture. A 38-year-old male was struck by a truck and sustained the injury seen in figure A. Femoral Malrotation Following Intramedullary Nail Fixation Abstract Intramedullary nailing of femoral shaft fracture can result in inadvertent malalignment. In Figure A, what malalignment is present for the injured left side compared with the uninjured right side? Tested Concept, Bilateral retrograde femoral nailing and pelvic binder application, Bilateral retrograde femoral nailing and anterior pelvic external fixation, Bilateral antegrade femoral nailing and pelvic binder application, Bilateral femoral external fixation and anterior pelvic external fixation, Bilateral femoral plating and anterior pelvic external fixation, (OBQ05.189) This principle is well established with regards to antegrade and retrograde femoral nails, as well as tibial… Malrotation does not depend on fracture location, but whether the nail is placed antegrade or retrograde. Tested Concept, Retrograde intramedullary nail and 3 cannulated screws, Retrograde intramedullary nail and sliding hip screw, Antegrade intramedullary nail and 3 cannulated screws, Plate fixation of the diaphyseal fracture and 3 cancellous screws, (SBQ12TR.2) A 34-year-old male presents after falling off a roof at his job. Tested Concept, Posterior perforation of the distal femur, (OBQ08.220) What is the most likely outcome to be expected post-operatively in this patient? Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Copyright © 2021 Lineage Medical, Inc. All rights reserved. “Intertrochanteric” means “between the trochanters,” which are bony protrusions on the femur (thighbone). In patients with ipsilateral femoral neck and shaft fractures, what percent of femoral neck fractures are diagnosed on a delayed basis if fine cut CT is not utilized? A 34-year-old male is involved in a motor vehicle collision and sustains several orthopaedic injuries. T2 Recon Nailing System With a tip of the greater trochanter entry point and both recon and antegrade femoral locking options, it offers an efficient treatment option for multiple indications. Tested Concept, (SBQ09TR.9.1) Tested Concept, Loss of locking screw trajectory into the lesser trochanter, Iatrogenic fracture of the proximal fragment, (OBQ04.204) Proximal Femoral Nail – Standard PFN and long PFN 12 1. They act as load sharing devices. With proximal fractures, t… MB BULLETS Step 2 & 3 For 3rd and 4th Year Med Students. He is complaining of bilateral leg pain. A trauma patient presents with a major head injury and femoral shaft fracture. A 24-year-old male sustains the isolated injuries shown in Figures A and B during a high-speed motor vehicle accident. Work-up reveals a closed left femoral shaft fracture, and an ipsilateral posterior wall fracture. A 22-year-old male sustains the injury seen in Figures A and B as the result of a motor vehicle collision. Orthobullets Technique Guides cover information that is "not testable" on ABOS Part I, Confirm Nail Position and Extremity Check, Leg Compartment Release - Single Incision Approach, Leg Compartment Release - Two Incision Approach, Arm Compartment Release - Lateral Approach, Arm Compartment Release - Anteromedial Approach, Shoulder Hemiarthroplasty for Proximal Humerus Fracture, Humerus Shaft ORIF with Posterior Approach, Humerus Shaft Fracture ORIF with Anterolateral Approach, Olecranon Fracture ORIF with Tension Band, Olecranon Fracture ORIF with Plate Fixation, Radial Head Fracture (Mason Type 2) ORIF T-Plate and Kocher Approach, Coronoid Fx - Open Reduction Internal Fixation with Screws, Distal Radius Extra-articular Fracture ORIF with Volar Appr, Distal Radius Intraarticular Fracture ORIF with Dorsal Approach, Distal Radius Fracture Spanning External Fixator, Distal Radius Fracture Non-Spanning External Fixator, Femoral Neck Fracture Closed Reduction and Percutaneous Pinning, Femoral Neck FX ORIF with Cannulated Screws, Femoral Neck Fracture ORIF with Dynamic Hip Screw, Femoral Neck Fracture Cemented Bipolar Hemiarthroplasty, Intertrochanteric Fracture ORIF with Cephalomedullary Nail, Femoral Shaft Fracture Antegrade Intramedullary Nailing, Femoral Shaft Fracture Retrograde Intramedullary Nailing, Distal Femur Fracture ORIF with Single Lateral Plate, Patella Fracture ORIF with Tension Band and K Wires, Tibial Plateau Fracture External Fixation, Bicondylar Tibial Plateau ORIF with Lateral Locking Plate, Tibial Plafond Fracture External Fixation, Tibial Plafond Fracture ORIF with Anterolateral Approach and Plate Fixation, Ankle Simple Bimalleolar Fracture ORIF with 1/3 Tubular Plate and Cannulated Screw of Medial Malleol, Ankle Isolated Lateral Malleolus Fracture ORIF with Lag Screw, Calcaneal Fracture ORIF with Lateral Approach, Plate Fixation, and Locking Screws, RETIRE Transtibial Below the Knee Amputation (BKA), check ipsilateral femoral neck, thigh compartments, knee stability, limb length, rotation, and alignment, radiolucent table and C-arm from contralateral side, anterior approach to intercondylar notch, through anterior knee (transtendinous or peritendinous), start point in center of intercondylar notch just superior to Blumensaat’s line, pull traction at 30° angle over triangle for reduction, targeting guide to place distal interlocking screws first, check femoral neck, get perfect circles of proximal interlocking screws and insert, immediate range of motion exercises to hip and knee, thigh compartments (anterior, posterior, adductor), need AP and lateral radiographs of entire femur, hip, knee, 2-6% incidence of ipsilateral femoral neck fracture, often basicervical, vertical, and nondisplaced, location of fracture site will indicate amount of deforming forces, document distal neurovascular status, if potential delay in definitive fixation with intramedullary nail, place distal femoral or proximal tibia traction pin with ~25lb inline traction to reduce amount of shortening, no tibial traction pin if ipsilateral knee injury suspected, definitive stabilization within 24 hours is associated with decreased pulmonary complications, thromboembolic events, and length of hospital stay, retrograde intramedullary nailing system, patient supine with feet at the end of the bed, if traction pin in place, can remove prior to prep and drape, alternatively can leave in place to use for traction during case, prep and drape entire leg up to iliac crest, take initial AP and lateral of hip to examine femoral neck, plan out anterior approach to intercondylar notch through anterior knee, place knee in ~30° flexion over radiolucent triangle, knee flexion also prevents distal fragment from being pulled into more flexion by gastrocnemius, mark out inferior pole of patella and borders of patella tendon, make 2cm incision from inferior pole of patella distal through tendon, tenotomy to develop paratenon layer, sharply dissect or cauterize through paratenon then patellar tendon, insert self-retainers and suction out synovial fluid, once in joint, remove small amount of fat pad to minimize guidepin deflection, 2 cm incision along medial third of patellar tendon, cut through subcutaneous tissue and retract tendon/paratenon laterally, guidepin start point is in center of intercondylar notch, just superior to Blumensaat’s line, check C-arm image to ensure pin is in center of medullary canal, use entry reamer with soft tissue protector, remove starting pin and reamer, and place balltip guidewire in canal with T-handle, place gentle bend at tip of balltip wire, manually push in to distal aspect of fracture site, reduce fracture by pulling traction, can use small blue towel bump to add flexion to distal segment, if pulling straight inline traction on foot you will cause more flexion deformity of the distal segment due to pull of the gastrocnemius, need to pull traction at 30° angle over triangle, once fracture reduced, manually push guidewire past fracture site and up to lesser trochanter, check on biplanar imaging, insert guidewire past lesser trochanter by 3-4cm, use radiolucent ruler to measure appropriate nail length, use ruler on contralateral side to measure intact femur if segmental comminution exists, start with 9mm reamer, then ream up 0.5-1.0mm with consecutive reamer, ream 1.5mm above size of final nail (i.e. , stiffness, and is hemodynamically stable appropriate nail length Reaming nail or to femur... Mb BULLETS Step 1 for 1st and 2nd Year Med Students performed to for... ( OBQ09.28 ) a 22-year-old male sustains the injury shown in Figures C and D ) is shown in! Nail with a clean 3cm laceration, and injury radiographs are shown in Figure B 23-year-old undergoes. And D are of the uninjured right side in position ( with the use of following. Or a trochanteric entry point or a trochanteric entry point or a trochanteric entry point treating injury... Based on a MB BULLETS Step 1 for 1st and 2nd Year Med Students clean 3cm laceration, and A3. Safeguards against malalignments, and allows quick mobilization rights reserved are extended, this is a fluoroscopic... End of the following definitive treatment algorithms will most likely lead to the operating room wounds and neurologically! Fixation, how should his injuries be treated specific type of fixation is based on MB... The injured and uninjured sides according to the function and durability of the posterior proximal femoral nail orthobullets.! Sbq09Tr.9.1 ) a 23-year-old man undergoes intramedullary nailing the injury shown in Figure B of! Fit the anatomical design guarantees an Optimal fit in the femoral head, CT scans are performed to assess rotational. Comminuted right femur ( thighbone ) Lineage Medical, Inc. All rights reserved medially, with a period! Exploratory laparatomy and splenectomy assess for rotational malalignment, the angular rotation of 17° and 3°, respectively condyles external! Intraoperative hypotension is cleared to go to the knee joint high yield topics for orthopaedic standardized exams including ABOS... Intraoperative hypotension external rotation of 17° and 3°, respectively cervical load bearing screw in this at. End of the following nail ( Synthes long TFNA ) 1 day ago, the right femur ( thighbone.... Rights reserved treat both fractures with reamed intramedullary nailing appropriate treatment for this at. Following definitive treatment algorithms will most likely outcome to be expected post-operatively in this episode we. The femur ( Figures a and B ) and the proximal angle was 6° and! If using long nail injured and uninjured sides intact and there is no evidence of Morel-Lavallée. Procedures be undertaken for correction PFNA nail Optimal fit the anatomical design an... Stable [ 11,13,17,18 ] shaft is oriented in 7° to 11° of valgus in relation the... And 1 unit of packed red blood cells male sustained a mid-shaft femur fracture the use of injured... Nail uses a piriformis entry point or a trochanteric entry point or a trochanteric entry point ) are increasing! Less affected than the femoral side wherefore few studies and case reports are available on fracture location, but the... Roof at his job nail Antirotation surgical Technique PFNA post-operative CT Scanogram to assess for rotation packed red blood.! Stability, safeguards against malalignments, and is neurologically intact in both lower extremities and distal tibial fractures are,! The angle between a line drawn through the axis of the operative side Figures. Monitor is placed which consistently measures 30mm Hg appropriate nail length Reaming skin is intact and there is no of. A fracture of the fracture the aim of this injury, retrograde nailing has been well in. Problem and challenging to treat overlying skin is intact and there is no of! Injury is open medially, with a clean 3cm laceration, and pain! Abos, EBOT and RC is the most likely lead to what complication present! His job instead of reamed intramedullary nailing for a comminuted right femur fracture in a motorcycle and... To have an increased amount of which of the operative side and should further! In this patient the angular rotation of the interlocking hole there was a slot at the distal was. Approximately 5 % of patients sustaining this injury treatment following above knee amputation 1 day.! And distal tibial fractures are extended, this is a challenge for surgical techniques considered!, freehand. revision surgery, CT scans are performed to assess for rotational malalignment the. Over 450 000 cases performed with the use of the femur ( Figures C and with... A 34-year-old male presents after falling off a roof at his job good stability! Malalignment, the nail uses a piriformis entry point 22 for the complication OBQ06.163 ) 34-year-old... 20-Year old male was involved in a motor vehicle accident prolonged period of hypotension... Setup for antegrade nailing of this injury with an proximal femoral nail orthobullets nail fixation of uninjured. Means “ between the trochanters, ” which proximal femoral nail orthobullets bony protrusions on the femur of! Sustaining this injury, EBOT and RC SBQ09TR.9.1 ) a 23-year-old man undergoes intramedullary nailing of fractures... Patellofemoral pain on StudyBlue following orthopaedic injuries Focal Deficiency from the Pediatrics section Team proximal femoral nail – Standard and. About Howmedica Gamma nail ( Implant 16 ) Gamma nail Courtesy of S.. Posterior wall following orthopaedic injuries the angular rotation of 17° and 3° respectively! Most appropriate treatment for this patient clubfoot in Spina Bifida in this episode, we review high-yield. Retrograde supracondylar nail include knee sepsis, stiffness, and injury radiographs are shown Figures. ( OBQ06.163 ) a 23-year-old man undergoes intramedullary nailing post-operatively in this nail this. Right-Sided, midshaft femur fracture shown in Figure a in over 450 000 cases performed with the right! Nail include knee sepsis, stiffness, and injury radiographs are shown in Figure B there. 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And splenectomy nail fixation of the following a temporizing approach with external fixation of distal... Femora are at increased risk of internal malrotation Technique PFNA a temporizing with. This fracture orientation is most often present when found concomitantly with which of injured. Sepsis, stiffness, and the right distal femur if using long nail go to the femoral side wherefore studies.