Universal Large Distractor

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- Discussion:
    - length & alignment are restored by use of femoral distractor in saggital plane,
            w/o need for fracture table;
    - this permits hip and knee to be flexed on the table during nailing;
    - the distractor may be particularly suited to poly trauma patients;
    - disadvantage is that image intensification control is difficult to
            obtain in the lateral view;

- Proximal Schanz Screw:
    - note that the proximal position of the pin must allow meduallary reaming
          and subsequent nailing to be carried out w/o interference;
    - horizontal approach:
          - 5 mm half pin is placed laterally into the lesser trochanter, w/ the half pin
                  directed slightly upward (20 deg) from a posterior to anterior direction;
          - pin is directed 90 deg to long axis of femur;
    - vertical approach:
          - proximal screw will pierce the rectus femoris muscle and often will also
                  pierce the lateral edge of the sartorius;
          - the femoral nerve, artery, and vein all lie medial to the screw;
                  - the femoral nerve is closest to the pin, lying 2.5 cm medial;
          - the half pin should be inserted only after the nail is driven into the
                  proximal fragment;
                  - the target is the proximal femur, just medial (and sl distal to)
                        the lesser trochanter;

- Distal Schanz Screw:
    - inserted just proximal to the condylar area in the anterior 1/3 of the femur;
    - distally the Schanz screw must be removed before final Nail insertion;
    - pin is directed 90 deg to long axis of femur;

- Femoral Shaft Frx:
    - pressure on the proximal fragment is exerted by the assistant to over-
            come tendency to extend w/ knee flexion;
    - some manual support of frx is usually needed to control angulation;
    - once the two Schanz screws are in place, the distractor is attached
            securely, and is threaded length adjustment is used to apply
            traction across the fracture site;
    - typically mild apex anterior angulation of the fracture is controlled
            with manual pressure during reduction and nail insertion;
    - alternatively, some surgeons will apply traction to the distractor only in cases
            in which the reduction cannot be accomplished w/ manual traction alone;



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Technique of Using the AO Femoral Distractor for Femoral IM Nailing;
    F. Baumgaertel, C Dahlen, R. stiletto, and L. Gotzen.
    J. Orthop. Trauma. Vol 8. No 4. p 315-321.

Intramedullary Nailing of Acute Femoral Shaft Fractures Without a Fracture
    Table: Technique of Using a Femoral Distractor.
    M.A. McFerran and KD. Johnson
    Journal of Orthop. Trauma. Vol 6. No 3. pp 271-278. 1992.