These images demonstrate a distal femoral shaft fracture

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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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1cm
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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1cm
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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The reamer introduced through the stab incision
and the soft-tissue protector used to protect the
musculature.
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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 the level 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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Portable AP x-ray of the hip, which should be
taken in the operating room to rule out
iatrogenic femoral neck fracture.