- Discussion:
- may be indicated for:
-
combined fractures of the femoral neck and shaft and for
distal femoral fractures;
- multi-trauma patient (procedure can be performed in supine position on regular flouro table);
- obese patients (starting hole is not a problem);
-
advantages:
- avoids damage to the
blood supply to the femoral head (ie avoids
AVN);
-
disadvantages:
- in the case of open fractures, retrograde nailing thru the knee may provdie a conduit for infection to
reach the knee joint;
- possible articular damage and injury to the PCL insertion;
- nail must be seated deeply below the level of the articular cartilage inorder to prevent impingement on
the patella during flexion;
- Intra-articular Nail Insertion:
- indicated for extra-articular
supracondylar fractures,
distal femur frxs, obese patients, or
patients who have sustained multi-trauma;
- Extra-articular Nail Insertion: (from Sanders et al 1993)
- most indicated for femoral frx at the isthmus;
- inserts nail thru the extra-articular portion of the medial femoral condyle;
- best performed w/
Synthes Tibial IM Nail (11-13 mm diameter);
- contra-indicated w/ supracondylar frx (insertion of tibial nail may result in procurvatum deformity);
- absence of tibial bow may tend to straighten out the femur;
-
entry site:
- a point 2 cm medial to the junction of the distal femoral articular cartilage and medial metaphyseal flare;
- obviously, the entry position needs to be made in line with the shaft of the femur on the lateral view;
-
reduction:
- consider use of the
universal femoral distractor;
- bicortical pin is placed proximally and distally a pin is inserted just proximal to the articular surface;
-
reaming:
- over reaming by 0.5 to 1.0 cm is usually required;
-
nail passage:
- initially keep the angled portion of the nail pointed upwards until the nail passes
the isthmus, at which time the angled portion is rotated 45 deg posteriorly;
Retrograde nailing of femoral shaft fractures.
Retrograde reamed femoral nailing.
Retrograde intramedullary nailing, without reaming, of fractures of the femoral shaft in multiply injured patients.
Retrograde Reamed Femoral Nailing.
R. Sanders, K.J. Koval, T. DiPasquale, D.L. Helfet, and M. Frankle. J. Orthop. Trauma. 1993. Vol 7. No 4. p 293-302.
