AP view of the pelvis of a multiple trauma patient, demonstrating

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AP view of the pelvis of a multiple trauma
patient, demonstrating the subtrochanteric
fracture of the right hip as well as fracture
dislocation of the left hip.
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AP view of the hip and femur on the affected side.
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Positioning for the long gamma nail. The patient
is supine on the fracture table, with the
affected leg in skeletal traction and the
hip slightly flexed.
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The contralateral leg is in slight extension,
allowing for good lateral radiographs. The arm
on the affected side is draped over the body.
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FLEXION
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FLEXION
AP and lateral radiographs of the femoral
fracture, demonstrating A good reduction on the
AP and the typical flexion deformity of the
proximal fragment.
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Cartoon drawing on the outside of the leg of the
flexed position of the proximal fragment.
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A 2cm incision is made slightly proximal to the
trochanter, attempting to be in an area that is
between the anterior third and posterior two
thirds of the greater trochanter. The muscle
fascia is split, allowing access to the greater
trochanter.
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A curved awl is introduced to the tip of the
greater trochanter and driven in gently in line
with the femoral shaft of the proximal fragment.
An alternative technique is the use of a starter
reamer over a guidewire.
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AP view
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Lateral view
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A guidewire is introduced in line with the
proximal fragment.
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AP view
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Lateral view
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To correct the flexion deformity, many methods
have been devised. In this case, a clamp is
placed through a percutaneous incision onto
the anterior aspect of the femur, and used to
lever the proximal fragment posteriorly to gain
alignment with the distal fragment.
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The AP radiographs before and after the reduction
maneuvers using the clamp and a laterally applied
force on the shaft
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The proximal and distal fragments are lined up
using the clamp as a lever.
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AP and lateral views with the fracture aligned,
the guide wire is passed down the shaft.
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With the reduction being held, reamers are passed
in 1mm increments to size 12-1/2 for the shaft
and size 18 or 18 1/2 for the proximal segment to
accommodate the size 17 nail proximally.
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After appropriate reaming, the nail is passed.
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Passing the nail will maintain the correction in
the lateral radiograph.
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The nail is passed until the proximal locking
screw hole allows for placement of the screw in
the inferior to central portion of the neck.
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• Once the nail is at its proper depth, a perfect
  lateral radiograph
• must be obtained using the following sequence
• Rotate the x-ray machine until the nail is in the
  center of the
• head and neck.
• Rotate the jig until the jig is centered about
  the nail, which is
• centered within the head and neck.
• This figure is depicted here.
• With the nail centered within the jig and both
  centered within
• the head and neck), the screw must be in the
  center of the head
• when placed. This rotation must be maintained
  while the guidewire
• is advanced.

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The perfect lateral radiograph demonstrating the
nail centered within the jig and both centered
within the neck and head. This will direct the
screw into the center of the head on the lateral
view.
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The perfect lateral radiograph demonstrating the
nail centered within the jig and both centered
within the neck and head. This will direct the
screw into the center of the head on the lateral
view.
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The guidewire is advanced into subchondral bone.
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Appropriate length reaming is performed.
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Appropriate length screw is placed into the head.
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Semilateral view demonstrating the screw within
the head.
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A freehand perfect circle technique is used to
distally lock. Usually only one locking screw in
the proximal hole, as depicted here, is necessary.
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AP view of the fracture of the nailing.
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AP view of the pelvis.
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AP view of the femur after appropriate nailing.