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Repair of Femoral

Shaft Fracture

with AO Titanium Femoral Nail System

Quinn Herrick

  • Largest bone in the body

  • Head attaches to the hip

  • Greater Trochanter is the point of insertion for the Gluteus Medius and Gluteus Minimus

  • Lateral and Medial Condyles articulate with the Proximal Condyles of the Tibia

  • The Femoral Condyles are separated by the Patellofemoral Groove forming the articulating surface for the Patella

Anatomy and Physiology

Medial condyle

Pathophysiology

&

Diagnostics

Osteomalacia

Trauma

Osteonecrosis

Pathophysiology

Osteoporosis

Trochanteric and Condylar fractures often occur in conjunction with Femoral Shaft fractures

Title

Surgeon determines the length of the nail by placing a nail on the lateral side of the leg as an X-ray is taken

Anteroposterior and lateral X-rays

Diagnostics

  • Fracture table
  • Nitrogen tanks
  • Power drill and drill bits
  • C-arm
  • Basic Ortho Set
  • AO system and nails
  • ESU, Grounding Pad, Suction
  • Tourniquet, Esmarch, Laps, Skin sutures, hypo & syringe, Dressing

Supplies, Equipment, and Instruments

  • Anesthesia general
  • Position: Supine on a fracture table
  • Prep: Begin at the hip, go up to mid chest, laterally from mid-line to as close to the table as possible, and the entire operative leg down to the ankle
  • Draping: The surgeon may use a custom hip fracture drape, which is a large sheet that hangs from an over-head rod and has Ioband in the center: or they will use two split sheets

Patient

Prep

Special

Considerations

  • The X-rays need to be in the OR
  • Check nitrogen tank levels
  • Make sure power tool batteries are charged
  • Test power equipment before use
  • The C-arm will be used during the surgery, make sure there is room for it and that it is draped before use
  • Confirm that the AO instrument set and nails are sterile and ready
  • Remember/record the types, sizes, and number of implants used to inform the circulator
  • The surgeon may have the people that draped changed gloves after draping

Basic Orthopedic Instrument Set-

Get out:

  • Knife handles
  • Suture Scissors
  • Adson w/teeth
  • Needle Holders
  • Mallet
  • Small retractors(army/Navy or self retaining) may be used
  • Pliers

Basics-

  • Sponges
  • Sutures
  • Needles
  • Syringe
  • Local
  • Saline
  • Asepto
  • Needle counter
  • Blades
  • Light Handles
  • Prep
  • Drapes
  • Blue towels

Back table

Drill bit box

AO System & Nails

Get Out:

  • Tissue Protector
  • Insertion Instrument
  • Driving cap
  • Guidewire
  • Reamer
  • Triple Trocar Assembly
  • Aiming Arm

Mallet

Aiming Arm

Triple Trocar Assembly

Guidewire bent with pliers

Reamer

Guidewire

Mayo Stand

Blade & Local

Drill

Tissue Protector

Insertion Instrument

2

3

5

1

Using the power drilll, a guide wire is placed into the medullary canal (A), using the C-arm to ensure placement

4

An initiator drill bit with a tissue protector (B) is placed over the guide wire to enlarge the opening. The medullary cavity is reamed out.

The surgeon then inserts the nail, by hand, as far as possible. Then the surgeon then uses a mallet to drive the nail the rest of the way through the femur, and the guide wire is removed.

An incision is made proximal to the greater trochanter

The surgical technologist assembles the insertion instrument with a driving cap (Striking point for mallet) used to place the nail

A

*Initial count of softs is done before the incision

B

Reamer

7

Procedure

6

8

9

Two locking bolts are placed proximal using a hand-held screwdriver, with help of a standard aiming arm attached to the insertion handle with a triple trocar assembly inserted to the bone (Protection sleeve, drill sleeve, and a trocar)

Insertion instruments are removed.

An end cap is screwed onto the proximal end of the nail.

Fluoroscopy is used to create a stab wound over the distal hole in the femoral nail, a depth gauge obtains the bolt length then the bolt is placed using a holding sleeve and screwdriver

*Final count of all softs

The incisions are sutured close.

Dressing: Incisions are covered with 4X4's and wrapped with wrapped with Ace/Coban. The surgeon may use a stent.

Full Procedure

Video: https://www.orthobullets.com/trauma/12079/femoral-shaft-fracture-antegrade-intramedullary-nailing

  • No specimen
  • Complications:
  • SSI
  • Delayed union
  • Mal-union
  • Non-union
  • Bone marrow fat embolization
  • Mal-rotation of femur
  • Shortening of femur
  • Implant failure or break

Post-Op

  • Surgical Technology For The Surgical Technologist A Positive Care Approach: Fifth Edition
  • https://www.orthobullets.com/trauma/12079/femoral-shaft-fracture-antegrade-intramedullary-nailing

References

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