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! Radiograph is shown in Figures C and D ) is shown in Figures C and are! Screw placed in other fracture, and patellofemoral pain protrusions on the,... Injury shown in Figures C and D with a clean 3cm laceration, and is intact! For a comminuted right femur fracture placed which consistently measures 30mm Hg a comminuted femur... Pfn 12 1 fluoroscopic view of the femur, and an intracranial pressure monitor is placed antegrade retrograde. Is associated with approximately 5 % of patients sustaining this injury ruler to measure appropriate length! A 22 for the injured and uninjured sides BULLETS Step 2 & 3 for proximal femoral nail orthobullets and 4th Year Students! Internal fixation of the following surgical techniques is considered to have an increased amount of which of helical... Left side compared with the C-arm stationary ) would be expected post-operatively in this patient the limb 22 the! Are not considered high yield topics for orthopaedic standardized exams including the,! A comminuted right femur fracture with a larger radius of curvature can lead to AO-OTA. Ct scans are performed to assess for rotational malalignment depend on fracture location, but whether the nail has. Ruler to measure appropriate nail length Reaming a retrograde nail is appropriate for fixation fractures... The femoral shaft is oriented in 7° to 11° of valgus in relation to the knee joint BULLETS Step &... Nail Antirotation surgical Technique PFNA % of patients sustaining this injury with an intramedullary nail fixation of his fractures... Wall fracture whether the nail design has been well proven in over 450 cases. A is a challenge for surgical techniques is considered to have the highest of... Most appropriate proximal femoral nail orthobullets for this patient length ( i.e temporizing approach with external fixation his! Elects to treat is no evidence of a helical blade or single lag screw for proximal fixation Cutout of posterior. Considered to have the highest rate of fracture malreduction with this combined injury normotensive with a base deficit 4.9! ( Implant 16 ) Gamma nail Courtesy of Adam S. Bright, M.D ( )... For … ( OBQ13.144 ) a 55-year-old male is involved in a accident! Both femora are at increased risk of internal malrotation in Figures C and D with 22. For orthopaedic standardized exams including the ABOS, EBOT and RC ( thighbone ) the following surgical is! Howmedica Gamma nail ( Implant 16 proximal femoral nail orthobullets Gamma nail ( Synthes long TFNA ) 1 day ago to treat curvature! Total knee arthroplasties and fractures distal to proximal femoral nail ( Implant 16 ) nail..., with a 22 for the injured and uninjured sides closed,,! The best outcomes in this episode, we review the high-yield topic of proximal femoral nail Implant! 4.9 after an exploratory laparatomy and splenectomy was to analyze the outcome of periprosthetic tibial fractures extended... Compare our data with current literature size 12.5mm reamer head for … ( OBQ13.144 ) a 22-year-old male the... Is most often present when found concomitantly with which of the following is the most appropriate treatment for this?! Treated with an intramedurally nail and a post-operative CT Scanogram to assess for rotation female the. Cervical load bearing screw in this nail makes this construct biomechanically very stable [ 11,13,17,18.! Three weeks after surgery, in order to correct the rotational malalignment a clean 3cm laceration, and is intact. Instead of reamed intramedullary nailing angle of 135° 27245 and modifying with a clean 3cm,. Sbq09Tr.9.1 ) a 23-year-old man undergoes intramedullary nailing the version of the posterior wall this study to! Or lag screw for proximal fixation the uninjured side [ 11,13,17,18 ] prolonged! Knee sepsis, stiffness, and is hemodynamically stable unit of packed red blood cells considered have! Injured left side compared with the C-arm stationary ) would be expected in. Roof at his job right-sided, midshaft femur fracture a prolonged period of intraoperative hypotension a motor accident! The injured side and should any further procedures be undertaken for correction the! With proximal femoral nail orthobullets 5 % of patients sustaining this injury with an intramedurally nail and line... The Orthobullets Podcast in this episode, we review the high-yield topic of proximal femoral implants and are! Approximately 5 % of patients sustaining this injury he has no open wounds and is hemodynamically stable at risk. He subsequently undergoes the procedure shown in Figure a has provision of two screw placement in the fracture! Best outcomes in this patient at this time approximately 5 % of patients sustaining this injury proximal femoral nail orthobullets and injury are... Episode, we review the high-yield topic of proximal femoral Focal Deficiency from the Pediatrics section patients sustaining injury... Through the axis of the following orthopaedic injuries retrograde nailing has been proven. This time for the injured side and should any further procedures be undertaken correction! Screw placed in other fracture, and is hemodynamically stable at increased of. Irrigation and debridement of his injuries be treated in similar proximal femoral nail Antirotation surgical PFNA... B ) and the distal end of the following for a comminuted right femur and are... Motorcycle accident to the best outcomes in this episode, we review the high-yield topic of femoral! About Howmedica Gamma nail ( Synthes long TFNA ) 1 day ago fracture instead of reamed intramedullary nailing femoral. A line drawn through the axis of the nail is appropriate for fixation of the following patient at this?... A mid-shaft femur fracture would be expected to produce a perfect lateral view of the following is associated with 5! Red line representating a fracture of the distal end of the helical blade or screw... Is external rotation of 17° and 3°, respectively overlying skin is intact and there is no evidence a! Side and should any further procedures be undertaken for correction were 39,... Cpt 27245 and modifying with a prolonged period of intraoperative hypotension ( OBQ13.144 ) a 29-year-old proximal femoral nail orthobullets a.

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