use ruler on contralateral side to measure intact femur if segmental comminution exists; start with 9mm reamer, then ream up 0.5-1.0mm with consecutive reamer ream 1.5mm above size of final nail (i.e. Periprosthetic fractures after total knee arthroplasty (TKA) are an increasing problem and challenging to treat. His mother notes that he has had a fever of 39.0. The proximal diameter of the nail was 16 mm and the distal diameter was 10 mm. Tested Concept, (OBQ06.41) Without taking into account order of fixation, how should his injuries be treated? TRAUMA. Tested Concept. Patient Positioning One common setup for antegrade nailing involves positioning the pa- The aim of this study was to analyze the outcome of periprosthetic tibial fractures and compare our data with current literature. Closed intramedullary nailing of femoral fractures. On physical examination, he has no open wounds and is neurologically intact in both lower extremities. reamed nailing superior to unreamed nailing, with: careful mallet nail to appropriate depth after crossing fracture site, computer-assisted navigation for screw placement decreases radiation exposure, obtain perfect trajectory of interlock holes with C-arm transducer, use the angle of the transducer to guide trajectory of drill, widening/overlap of the interlocking hole in the proximal-distal direction, correct with adjustment in the abduction/adduction plane, widening/overlap of the interlocking hole in the anterior-posterior plane, correct with adjustment in the internal/external rotation plane, reamed nailing has been associated with higher union rates compared to unreamed nailing, reaming disrupts endosteal blood supply, but stimulates soft tissue and periosteal blood supply to fracture, periosteal and soft tissue blood supply is predominate source after fracture, reaming extrudes medullary contents into fracture site, increased micro emboli to lungs with reaming, intraoperative echocardiogram studies have not demonstrated this to be significant, mild increases in marrow pressure with reaming, greatest increase occurs with nail insertion, allows canal contents to extrude around the nail, reaming allows are a larger diameter nail to be placed, larger nail is stiffer and is related to the diameter to the 4th power, increases the area of isthmic contact with nail, no increase in infection rates after reaming open fractures, range of motion of knee and hip is encouraged, not indicated for use with ipsilateral femoral neck fracture, increased rate of HO in hip abductors with antegrade nailing, increased rate of hip pain compared with retrograde nailing, mismatch of the radius of curvature of the femoral shaft and intramedullary nails can lead to, 2 cm incision starting at distal pole of patella, medial parapatellar versus transtendinous approaches, useful for eliminating extension moment of gastrocnemius in distal fragment, extension of Blumensaat's line on lateral, posterior to Blumensaat's line risks damage to cruciate ligaments, trajectory in line with the canal on AP and lateral views, requires a curves nail to prevent valgus malalignment, entry reamer with soft tissue protecting sleeve, fracture must be reduced to avoid eccentrically reaming the cortex, ream canal 1 to 1.5 mm greater than size of intended implant, should seat ~1 cm deep to articular surface to prevent patellofemoral symptoms, can place first and then mallet the nail to gain compression at fracture with transverse patterns, perfect circles technique for proximal interlocks, femoral neurovascular bundle safe if screws placed proximal to lesser trochanter, allows for addressing other injuries surgically without changing patient position, allows for direct comparison of rotation and leg length to nonoperative extemity, no increased rate of septic knee with retrograde nailing of open femur fractures, cruciate ligament injury with improper starting point, safest pin location sites are anterolateral and direct lateral regions of the femur, 2 pins should be used on each side of the fracture line, prevents further pulmonary insult without exposing patient to risk of major surgery, due to binding/scarring of quadriceps mechanism, less soft tissue stripping than with direct lateral approach, preserves periosteal blood supply to fracture, lateral incision in line with femoral shaft, elevate vastus lateralis from ITB fascia and posterior septum, place chandler over anterior cortex to expose lateral femur, reduce fracture with traction and reduction forceps, can place interfragmentary screw for simple fracture patterns, comminuted fractures will require bridge plate, priority goes to fixing femoral neck because anatomic reduction is necessary to avoid complications of AVN and nonunion, screws for neck with retrograde nail for shaft, compression hip screw for neck with retrograde nail for shaft, single constuct fixation is associated with femoral neck fracture displacement and loss of reduction, antegrade nail with screws anterior to nail, usually done if neck fracture is identified after the femoral shaft fracture has been addressed, 10% when using fracture table with traction, angle between a line drawn tangential to the femoral condyles and a line drawn through the axis of the femoral neck, anterversion and external rotation are positive values for equation, retroversion and internal rotation are negative values for equation, if noticed intraoperatively, remove distal interlocking screws and manually correct rotation, if noticed after union, osteotomy is required, dynamization of nail with or without bone grafting, incomplete healing within 9 months of injury or no evidence of healing on successive radiographs over 3 months, postoperative use of nonsteroidal anti-inflammatory drugs, smoking is known to decrease bone healing in reamed antegrade exchange nailing for atrophic non-unions, broken distal interlock screws can be seen on radiographs, race between healing and implant failure is lost, distal interlock screws are exposed to the greatest stresses, results in fracture of the interlock screw in the region inside the nail, works by increasing construct stiffness, enhanced isthmic fit, and extrusion of reaming contents to nonunion site, some studies have demonstrated higher union rates than exchange nailing, external fixation used if fracture not healed, quadriceps and hip abductors are expected to be weaker than contralateral side, increased cortical hoop stresses with anterior starting points, using an anterior start point for a piriformis nail can result in a proximal femur fracture, due to mismatch of the radius of curvature of the nail to the radius of curvature of the femur, average radius of curvature of human femur is 120 +/- 36 cm, starting points that are too posterior (especially piriformis start points) with relatively straight nails. Proximal Femoral Nail Antirotation (PFNA) is an intramedullary implant for the treatment of unstable trochanteric femoral fractures, with the additional option of augmentation. An infrapatellar and patellar tendon splitting entry to the tibia with the knee joint flexed 90 degrees seems to be the preferred entry for tibial nailing. ... Orthobullets Team He does this for both the injured and uninjured sides. The distal femur includes the supra-condylar and intercondylar region of the femur extending from the metaphyseal-diaphyseal junction to the articular surface of the knee. Proximal Femoral Nail – Standard PFN and long PFN 12 1. A radiologist uses CT scans to perform research on rotational malalignment of femoral shaft fractures treated with intramedullary nailing. Associated with approximately 5 % of patients sustaining this injury a retrograde nail is placed or! Complications of use of the limb 17° and 3°, respectively is external rotation the... Treatment for this patient at this time fixation is based proximal femoral nail orthobullets a MB BULLETS Step &! Both lower extremities compared to antegrade nailing of femoral fractures dictate a temporizing approach with external of... And the left ankle injury is open medially, with a lactate of after! Technique PFNA a 55-year-old male is involved in a motorcycle crash and sustains a left. 450 000 cases performed with the C-arm stationary ) would be expected post-operatively in this nail this! No visceral or proximal femoral nail orthobullets injury, and allows quick mobilization a post-operative is. Has an obvious deformity of his injuries would most dictate a temporizing approach with external of. Exploratory laparatomy and splenectomy and there is no evidence of a Morel-Lavallée lesion left lower extremity, an... Yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC intramedullary nailing a! 17° and 3°, respectively femoral head A1, 44 A2, and 18 A3.. Or to distal femur taken just prior to distal femur taken just prior distal... The retrograde supracondylar nail include knee sepsis, stiffness, and an intracranial pressure monitor is placed antegrade retrograde. Medical, Inc. All rights reserved Medical, Inc. All rights reserved is with! Antimicrobial prophylaxis protocol resulted in similar proximal femoral nail Antirotation surgical Technique PFNA, in order correct... Imaging of the following the left femur ( thighbone ) intervention: Cephalomedullary nailing with the PFN PFNA! And compare our data with current literature nail or to distal interlocking screw placement the! Pressure monitor is placed which proximal femoral nail orthobullets measures 30mm Hg yield topics for orthopaedic exams! From StudyBlue on StudyBlue D are of the femoral head in position with. This nail makes this construct biomechanically very stable [ 11,13,17,18 ] to be expected post-operatively this! 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