Closed Cephalomedullary Nailing of a Diaphyseal Femur Fracture on a Fracture Table
2. Positioning on Fracture Table
3. Marking and Incision
4. Insert Nail
- Obtain Starting Point for Guidewire
- Drill Guidewire
- Open Canal
- Pass Wire Through Reduced Fracture
- Measure and Ream
- Insert Nail While Checking Placement
5. Proximal Locking
- Drill Guidewire for Locking Bolt
- Puncture Iliotibial Band
- Ream Across Femoral Neck
- Place Locking Bolt
- Engage Locking Mechanism
- Check Reduction and Nail Placement
6. Distal Locking
- Drill for 1st Distal Locking Screw
- Insert Screw
- Drill and Insert 2nd Screw
- Final X-ray Check
TranscriptionsPlease note that, unless otherwise stated, these transcriptions have been auto generated and therefore we can not guarantee their complete accuracy.
I'm Mike Weaver. I'm one of the orthopedic trauma surgeons here at the Brigham and Women's Hospital. Today this case is a 76-year old woman. She has a history of osteoporosis and she's been on bisphosphonates for a long time, over 5 years and she has an atypical femoral fracture, which occurred that just ambulating it's kind of got the classic features it's fairly transverse to slightly oblique and you can see on the AP there's a slight beat to the fracture which is a common finding. The thing that makes it slightly unusual as it's a little bit more more distal than most of the atypical femoral fractures that we see. Most of them are in the subtrochanteric region or mid-shaft. This is getting into the junction between the middle and distal third so it's a little bit unusual like that. She's had a previous knee that's been well-functioning.
So today with the plan is to fix this with intramedullary fixation. That’s a standard treatment for this you could treat this with a retrograde retrograde nail, however in someone with osteoporosis I like to treat this like a pathologic fracture so I use this cephalomedullary device. Today we’re using the diffuse synthes trochanteric fixation nail but any cephalomedullary nail would work fine for this. For this kind of case I use the fracture table I can get my reduction and makes things a little bit easier for cases where I need to do an open reduction so that's more often the proximal fractures I'm going to use a radiolucent table and do it in the lateral position, because I find it working in an open environment works a little bit easier there, but here the fracture table should bring us out to lengthen a lower energy fracture should come together nicely.
So setting up the fracture tables a critical part of this case. Number one for patient safety you know if the patient falls off the table it's a very narrow bed that can be a disaster and then secondly, the fraction tables really your tool to make this case easy. So there’s a few things that are important.
Number one, that’s a peritoneal post, that's the first thing that goes on as soon as the patient’s on the table and that's the last thing to come off because that’s really going to be the security blanket to make sure they stay on. There are two ways of positioning the well leg, you can have it hung down like this, which is the why I prefer, the legs padded down here with a lot of foam and then secured to the post here. The other way is to use a well leg holder. Either one’s okay. Even with a well leg holder you have to be very careful. There are incidences of compartmental syndrome, peroneal palsy and even a femoral fracture if you stress the position of the leg. The foot needs to be securely attached to the the boot and I like to over wrap this with some kind of elastic bandage like coban to really make sure you have a good purchase of it. Particularly in a case like this for a femur fracture you’re going to be pulling really hard and if the foot becomes loose during the case that can be a big problem.
And then finally you want the bed as high as it can possibly be so it's comfortable to put the nail in and you want the foot and the leg to be low so the trajectory of the nail is in line with the bed and the femur. If you have the hip flex you're going to run into the table with the nail when you're trying to put it. So those are kind of the key things. I like to start with the knee in a fairly neutral position and then you can always adjust and if you find you’re really internally or externally rotating the knee, you’re probably doing something wrong and misaligning the fracture.
So first thing I like to do is take a marker and I'll mark out the excess of the femur and that's so when you're putting in your rod you're thinking of the access to the femur. You're not coming out the front or out the back. The one thing I think we probably needed was adduct a little bit. Cheryl would you mind adducting the lights for us? Not going to make it too big, we’ll make it like that, please. Just be careful, we don’t want to scythe the skin. You’re standing above the patient so you can kind of, cutting down there a little bit. You just want to be above, straight across. Like that. Good.
You know it's all radiographic, there's no way to feel and some of that has any real amount of soft tissue the troc, so I just it all, radiographically. Remember, you got to drop that hand so you’re in line with this. X-ray. X-ray. Good. So you're right there.
So the important thing with the starting point is even though it’s trochanteric or lateral entry, you really want to be on the most medially aspect of the trough. So I would say that’s even a bit slightly too lateral. You’re pretty close. So just small movement there. The other thing that's reassuring is you’re right on the tip there so that's a sign that you're probably okay on the anterior posterior plane, you know if you're too anterior or too posterior, the tip of the wire will actually be appear sunken into the bottom. X-ray. Good. So I like that better, I think that’s really set, but we just I like that better I think that's a really nice to get the angle right.X-ray.One more time I think. X-ray.Good. X-ray there. Oh, it slid. X-ray. You know I think we might be off the troc. X-ray. I think you’re too anterior. X-ray. Okay that’s better. X-ray. X-ray there. Okay so I’d call that ideal.
And then what we’ll do is we’ll bite it with the mallet. X-ray. So just give it a couple taps. Not to drive it in but more so it doesn’t slide. Good. X-ray there. X-ray. Drive it in another 2 inches, you’re not going to adjust it so there's no way you can do it. So just put it in. Good. X-ray please. Go to a lateral. So I like our starting point we're just aiming a little bit too posterior so let's come back up to the AP so this is when we're going to back it up but not all the way out of the bone and leave it in just a little bit and then we can correct it at both points so we know that we have to drop our hand a little bit more and bring it again and this is why I want that foot down as low as you can to see you’re fighting the table already particularly in someone that's a little bigger it’s tough. Remember use your eyes, your your x-ray. X-ray please. Make sure it’s still in the bone. Back it up a little more. X-ray. X-ray. There you go. Stop.
So now you can adjust it. You can drop and then in the movement through ,do you have a lady finger for me or one by one. Push here this is going to bend the wire a little bit. X-ray. Yea that’s going to need to be changed. You didn’t try it. You want to take a shot at it or back out of-Do it. Go to a lateral, shot please. Back up to an AP.
So one of the things I try to do is separate the different movements so I got the sense that you were trying to back it up and change it at the same time so the first thing I do is I'm just going to back it up. X-ray. So I'm not trying to change his direction at all. X-ray. X-ray. I'm still in the bone but I'm in it now I can change it. X-ray. That's not going to change it much there. X-ray. X-ray. Yea.
She is definitely bigger than she looks. X-ray. X-ray there. X ray. Will you take the mallet? I’m going to try a different trick here. X-ray. X-ray. Here go ahead. It's like not working you know like it seems like a real big delay. X-ray. Keep going. X-ray. Keep going.X-ray. I don’t like this one. I don’t either. X-ray. Real struggle. You have a different wire? X-ray. X-ray. X-ray. Mallet. X-ray. X-ray. What is this? X-ray. X-ray. It’s gonna be way over here. X-ray. X-ray. Tap tap tap. X-ray. Go ahead. Tap tap. Really get it down there. Really get it down. Good. x-ray. Let me see that. X-ray. X-ray. Will you come south to center up the femur please. Okay good. Save that and come do a lateral. So by tapping it, it hits that cortex and then drives it off, particularly someone with a soft amount of tissue that’s in your way. That way it will kind of correct the angle and the top of the shaft. We’ll leave the soft tissue protector for sure. I try not to rotate it too much because it can saw. Now just give that a few blows. Remember that’s your angle so give that a few blows with your hand. It’s like as-hard-as-you-can blows. There you go. Good. Shot.
Good so now you’re down and the key is I’m going to push you this way to medialize that femur. High speed light touch. X-ray. You don't need a picture you can just start. This you want high speed but go in slow. X-ray. Good. So I really like that starting point. X-ray. Keep going. X-ray. X-ray. There it is. It’s perfect.All the way in and then out. Just pull it right out. Just pull it out. And this is the same thing right? If you just put it in straight like this or you missed the hole you can, if you bend it back like this it changes where the tip is so you can use that trick here to find that hole inside. Because again it’s going to be really hard for someone like this to feel the entry point with your finger because it’s so deep. X-ray. Good. Come down to the fracture please. which is distal third. X-ray there. X-ray. Can you come further south to the fracture, please. Good. X-ray there. So go ahead and drive it across. X-ray. You feel like you're in bone? No, it feels like it’s soft. No I don’t think so, right? So leave it right because do you know? No, so how do you check? You do a lateral. Right so come do a lateral, please. Shot. So it’s out the front.
So a lot of times it sags the other way so we know that we got to back us out so if you just reach around and pull that back a little bit. Just until it's in the fragment. X-ray there. Push it down a little bit. X-ray. Good so now I’m here. X-ray.X-ray. Very stiff today. X-ray there. X-ray. Shot. shot. Shot. okay. Mallet. X-ray. Go ahead and advance that. That feels like bone. Get all the way down. X-ray. Good. x-ray there and you can tell it’s maintaining the reduction. Even that little wire will maintain the reduction roughly if you’re okay. Come up to an AP. And that looks nice there. You can see the cortices it’s all the little nooks and crannies lining up well. Shot there. Good.
So that’s probably the ideal height. You want it right at the top of the patella. Which is probably about there. You know down but here it’s the distal third fracture, so we want to be is distal as we can, safely. Can you come up to the hip, please? Good, so you’re right where you want to be. So there’s a three forty-five, three sixty or three forty. So three forty? Yep, I agree with that. Eleven by three forty. We’ll start with a 12 reamer. So I just pass the 12 reamer you know I use 11 mm nail for standard intertroch or femoral shaft in an elderly person. If you get a lot of chatter and resistance then it stopped and reamed up, but most people there fairly capacious and it just slides right down. She measured about a twelve. We don't need to worry about holding the reduction because it was reduced on both views without doing anything. You know if it wasn't then try to hold it reduced as you ream. And it’s okay to stop if you're not advancing it. So like-stop. Really get to end point there. Good. You won’t need that anymore.
And this is one where you're you're right to be careful you know if you pull that guidewire above the fracture you know this one wasn't too hard to get the reduction and then here you just don’t want to hurt the soft tissues. You want this nail to go in like this because that's the curve to enter the troc and then as you insert it and you’re hammering it and you want to bring the sample down. X-ray. So we got to get it in first. There you go. So now as it goes in, rotate it in, kind of like a corkscrew there. Good. Nice. And then, tap tap. X-ray there.
Let's come down to the fracture site and see how things are there. You know in general when I’m nailing a diaphyseal fracture I want to watch the nail cross the fracture site because that's where you can get in trouble it was something really funny. So here it cross the fracture site without too much hitting so that's a good sign. Good. X-ray there. A little bit more. Good. X-ray. A little bit more. Now this this is kind of an interesting thing to notice, right. Our guidewire was lateral in the shaft right? But now you can see it’s even bending and the mail is more central, okay? You know what why’s that happen? Because the nail will contact the isthmus whereas the wire wouldn’t? Right, so the isthmus is forcing, the guidewire is flexible. So the isthmus has got to be absolutely right there.
Okay so come up to the hip. So what I’ll do here is I’ll say alright, we’ve got two or three centimeters before we get to the top of the prosthesis and so here. You know, it looks like we're good you know because now I just have a rough idea like, oh I'm safe you know if it looked like it was a centimeter away and I was looking here I'd be like maybe we need to check a lateral or something but I think we’re in good shape. Here the arrow is always being too high. A little more. Obviously if it feels really hard there’s lot of resistance so always check the knee, maybe somethings going on. X-ray.
So let’s come down to the knee one last time I'd say that's probably say that’s just a shade high. And now let's go to a lateral just this to make sure everything's not funny. Okay good. Nice. So the reduction looks good. You can see you know when it's oblique but we're not hugging that anterior cortex. We’re not hitting that flange of the prosthesis and that's the one I would worry about if it was a mismatch between the shape of the femur and the nail. A lot of these nails are too straight. If it came out a front and you start hitting on that prosthesis hard you could loosen it. That's probably about the end of the anteversion we want. Good. Come up to the hip please.
Good if you just hold that. It's pretty good I think. Good. Make a little bigger than that it's going to be a fairly decent size hole to get this thing up. I wouldn't worry too much about that. There's no real way of planning that hole. Shot. So I don't worry about getting that thing right down on bone yet but with any of these systems that has to be perfectly on bone before you put your blade in.
Alright so shot there. So I like that that looks nice so let's go to a lateral so that's how we're going to aim for the head. So here you can see we're aiming a little too anteverted so if I go like this. X-ray. Can you raise the machine a little bit? So if you look at that raise it a tiny bit more this is a really cool thing. You can see the neck on both sides? Yea you can see, the neck is on both sides. X-ray. And you’ve got head, aiming arm, and nail all on a line. So when you put your guidewire on here it's going to go, it's going to keep going and then radiographically it's going to be right at the tip there. So by holding it like this you can aim for the center of the head, but you have to have this lateral view which isn't really a lateral of the femur, it’s a lateral the femoral head and neck because it takes the inversion into account. Shot there. X-ray there. X-ray there. Stop. So I like that.
So to use this trick you have to be pretty confident about your AP depth, but I think we're pretty good there. Just drive it in that whole depth before you take a picture. Because you know it's going to be about 80. Good. Shot. Keep going a little further X-ray. A little more. X-ray. So there you go. It comes right out at the tip there. X-ray. And that's right where we want it. Yea. Maybe a few millimeters anteriorly but really close to the tip. So that’s good. Or if we look close to the apex, excuse me.
Come up to an AP. And then we're right where we want to be there. first I would drive that wire in a tiny bit more so I like the wire to touch the subchondral bone. Not that you're going to put your final implant there but so you can measure off it. X-ray. X-ray, perfect. This is this is pretty tight, right? Because you’ve got the iliotibial band there so what I want you to do is take your opening reamer and we're not going to do the final reaming into the head now, but punch a hole through that iliotibial band. X-ray. A little more. And now try turning that. X-ray. X-ray. I'm going to run it just a little bit more. X-ray. Almost. X-ray.
Just making sure that wire stays where it belongs now we're going to measure it and set our screwdriver, or drill. Measures 98 with subchondral bone and not quite so put in a ninety-ish. Yea I agree with a ninety on this. You know with a cephalomedullary implant, so particularly a helical blade, you probably want your tip apex to be slightly longer than for a DHS but still you know less than 25. X-ray. You know here I'm not worried about slider cut out you know because it's a femoral shaft fracture. X-ray. Good that looks nice. X-ray.
The important thing to recognize is the blade is actually would be a little bit deeper than the draw. This’ll help us fine tune our reduction now too. Because now we really have control of the proximal fragment. So if we have control of the proximal fragment once you have your blade and with this handle and then you can, you know, rotate the distal piece to really make sure it's keyed in. I really like that starting point. You come lateral and for an intertroch it'll mal reduce it. Right so if you’re starting points for an intertroch, it will mal reduce the fracture. It'll kick in into reverse but for a femoral shaft fracture it’ll break the femur because if you start too lateral your nail engages, it tries to kick over and you're trying to put a, you know, it just won't go. You know if you make a small mistake early it magnifies by the ends, so. X-ray. Looks good. X-ray. Almost there. X-ray. Probably just a few more blows. X-ray. See if I can get a little bit more. X-ray. Good.
And I'm not really getting it down for the tip apex system so I was happy before it's more just so it's not prominent on the lateral side. It doesn’t seem like it's down there. Mallet. Shot. You can give it a couple whacks. X-ray. Gonna go down. X-ray. Can we adduct the leg a little bit more, Cheryl? Yep. That’s as far as it will go. X-ray. Give that a few taps so see if we can engage it. Just gentle. There it goes. That’s going to be squeaky tight. Good. So before we actually take off the handle I do want to check a lateral and that's because the handle is your access to get the thing out so if there's a problem you want to know before, before you take off the handle attached to the nail. X-ray there.
That's great so if anything were ever so slightly below the apex but if I'm going to err one way I'd rather err that way and then come to a lateral. X-ray there. X-ray there. Good save that. And that's nice. maybe a few degrees anterior the Apex there but but right where we want to be. Alright so let’s come down to the fracture. If you hold this. I can try twisting. X-ray. X-ray. That looks pretty good. You can see that stress fracture now nicely because it’s anatomic on the medial side but you know you can just see where the beak is there. Let's come to a lateral. Shot there. That looks really nice. so we got a nice reduction. And our implant is right where you want it. Let’s whack south you can see we've got the leg adducted. Good. Shot there. Good so save that. So I really like our nail position. You know we couldn't have been 20 longer. X-ray there. A little bit further. X-ray there. Good, so I really like that. That's a nice reduction.
One thing I notice is a lot of people make that incision too small. Like, it doesn't have to be giant but you know give yourself a little bit of room to work. X-ray. X-ray. X-ray.So it's perfectly centered you want the tip right in the center of the hole. That’s nice. X-ray. Bull’s eye. Mallet please. X-ray there please. So you gotta think you got to be in that same angle as this so if you look here you're probably missing the nail behind it. See if you look back here this is the, this is it here. Shot. Nope, nope, you’re good. So put in that, a forty-six. Yea, put in a forty-six.
So know when you think you're down what we do is jump right to see if we really don't. So it’s starting to feel like it’s pretty close. Yeah so then you just want to hop off and then back on. And that way you'll know. Is your head right on or is it-? It feels like it’s a couple of millimeters off. That little trick gives you a little security to know you're there though you know what I mean? In the end I’d much rather have to drive in in a few more millimeters on the AP than strip them out. Yea, it feels like it’s down there. Oh yea, it’s down. You’re good. Good. Shot. Alright, I think we’re done. Can you come off mag please. Actually you know what, let’s, go back on mag, we’ll do two screws, you know it’s a pretty distal fracture. X-ray, please. Nice! Bullseye.
So the lesson there is osteoporotic bone it’s probably not going to have a good feel so like I said I'd much rather leave it proud and then come up to an AP and say oh we’re a centimeter off I got to drive it in and then strip it. X-ray. The important thing is it doesn't really matter if this is a little bit, if a purchase isn't great because just for axial stability and even that, or rotational stability the pullout strength doesn't matter because we have an anatomic reduction so it’s length stable you know, load sharing situations. There you go. X-ray. Good. Can you pull back towards you just about an inch. X-ray there. Save that. Come up the leg just a little bit. Shot there. Push in please. Shot there. Save that. Now you'll need to come at the angle view to get the head please. Shot there. Make that straight up and down so again I like our starting point.
You know if i was getting real critical it would be a tiny bit low in the head but you know, pretty close and I'd rather it be low than high and it's not prominent on the troc so that's nice. Alright let’s come to a lateral. X-ray. X-ray. Save that. So that’s nice, we’re centered in the neck, maybe a bit anterior in the head. Good. Shot there. Make that straight across. save that and then just come proximal about 6 inches and we’ll take one of the fraction and then we’re done. Good. Shot there. Nice. Save that.
In this case we were very lucky with our reduction. You know just with a little bit of traction and then manual manipulation in the femur we were able to get the guidewire done. Because this was a diaphyseal fracture the nail did the reduction for us. So if you have a diaphyseal fracture it’s a hollow tube. When you ream that up and put a nail bed in it, it’s going to make that straight. For fractures that have a metaphyses of a bone, that’s different. You need to make sure the reduction is as perfect as you are reaming it in and putting your nail down. So that was a bit different in respect. And because the fracture had some little interstasies to it it was able to line up nicely so that worked well. And then finally perfect circles in interlocking that’s something a lot of people struggle with. You just have to take your time and then make sure everything's right. You have to have a perfect circle x-ray centered in the CRB. If it’s off to one side then parallel access will make it harder and then you know, make sure you measure your screw in carefully.
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