Proximal Femoral Nail Antirotation (PFNA) is an intramedullary implant for the treatment of unstable trochanteric femoral fractures, with the additional option of augmentation. The Orthobullets Podcast In this episode, we review the high-yield topic of Proximal Femur Fractures from the Pediatrics section. He has no other injuries. Tested Concept, Antegrade piriformis entry femoral nailing, Antegrade greater trochanteric entry femoral nailing, External fixation of a femoral shaft fracture, Open reduction and internal fixation of an intertrochanteric fracture, (OBQ06.57) Tested Concept, External rotation of the distal femoral segment relative to the proximal femoral segment during nailing, Internal rotation of the proximal femoral segment relative to the distal femoral segment during nailing, Iatrogenic decrease in femoral anteversion on the operative leg during nailing, Increased contralateral femoral retroversion during surgery, Internal rotation of the distal segment of the femur relative to the proximal segment of the femur during nailing, (OBQ16.212) [ 11 ] Potential complications of use of the retrograde supracondylar nail include knee sepsis, stiffness, and patellofemoral pain. They act as load sharing devices. In patients with ipsilateral femoral neck and shaft fractures, what percent of femoral neck fractures are diagnosed on a delayed basis if fine cut CT is not utilized? He was treated with an intramedurally nail and a post-operative radiograph is shown in figure B. Tested Concept, More reliable placement of interlocking screws through the nail, (OBQ10.12) The nail design has been well proven in over 450 000 cases performed with the PFN and PFNA. There were 124 Complications: An intraoperative extension of femoral fracture [Short 11 mm nail on impacting, caused crack in lateral cortex; Removed short nail, and reamed up to 11.5 mm, and put in long TFN nail. Determine nail insertion point and insert Guide Wire In the AP view, the nail insertion point is normally found on the tip or slightly lateral to the tip of the greater trochanter in the curved extension of the medullary cavity. J OrthopTrauma.2017 Nov;31(11):577582.doi:10.1097 Results: Twenty-two cutouts occurred, 14 (15.1%) of 93 patients with helical blades and 8 (3.0%) of 269 patients with lag screws. On physical examination, the overlying skin is intact and there is no evidence of a Morel-Lavallée lesion. Tested Concept, Bilateral retrograde femoral nailing and pelvic binder application, Bilateral retrograde femoral nailing and anterior pelvic external fixation, Bilateral antegrade femoral nailing and pelvic binder application, Bilateral femoral external fixation and anterior pelvic external fixation, Bilateral femoral plating and anterior pelvic external fixation, (OBQ05.189) About Howmedica Gamma Nail (Implant 16) Gamma Nail Courtesy of Adam S. Bright, M.D. In Figure A, what malalignment is present for the injured left side compared with the uninjured right side? Which of the following definitive treatment algorithms will most likely lead to the best outcomes in this patient? He is treated with retrograde femoral nailing, and post-operatively is noted to have 30 degrees of internal rotation of the operative extremity, when compared with his nonsurgical side. Which of the following is an advantage of computer-assisted navigation used to place medullary nail interlocking screws compared to a freehand techinque? In Figure A, the angular rotation of the right femoral neck is internal rotation of 13° while the angular rotation of the left femoral neck is external rotation of 13°. He does this for both the injured and uninjured sides. ; Gulfcoast Orthopaedics; Sarasota, … He undergoes intramedullary nailing of the femur, and open reduction internal fixation of the posterior wall. A 22-year-old male undergoes retrograde intramedullary nailing for the injury seen in Figure A. A 32-year-old male sustains a closed head injury, a closed pelvic ring injury, as well as the bilateral open femoral fractures shown in Figures A-C. size 12.5mm reamer head for size 11mm nail), don’t stop reamer in canal (avoids reamer head from becoming incarcerated), if eccentric reaming/wire position is seen, can place blocking screws, attach jig to nail on backtable and check that targeting guide lines up with holes in nail, insert nail over guidewire, cover holes closest to nail handle with hand to make sure blood doesn't pressurize out of nail during insertion, hold nail by handle, not the targeting guide, mallet or manually advance to fracture site, manually advance nail past the fracture site to avoid iatrogenic comminution or development of new fracture lines possible with use of the mallet, insert nail completely and seat fully, lateral radiograph of the knee is the appropriate view to assess nail insertion depth, remove guidewire before placing interlocking screws, use targeting guide to place most distal interlock first, mark skin with sleeve, incise through skin, spread down to bone with hemostat, and place trochar on bone, leave drill bit in until screw arrives to hold nail/bone position and then place screw, repeat process above for placement of other interlocking screws if indicated, use attachment to remove nail jig, then take out triangle to lay leg flat, obtain perfect circles of proximal interlocking screw holes, ensure no rotation of the distal femur is done while getting theseviews (move the C-arm, not the leg), magnification of the fluoroscopic view can be used if desired, start with most proximal interlocking hole (screw will be longer than the more distal screw), incise through skin, careful blunt spreading down to bone, especially if distal to lesser trochanter, drill bit placed over center of hole, parallel to C-arm beam, to measure, can use a second drill bit or depth gauge, remove drill quickly and insert screw when available, use locking screwdriver or place silk suture around screw head so it doesn’t get lost in soft tissues, repeat above process for 2nd proximal interlocking screw, raise leg up off of bed, 90° bend in knee, then take final AP and lateral radiograph of proximal, middle, and distal aspects of femur, take hip through a range of motion to assess for fracture, fluoroscopic evaluation is key, whether static or dynamic at the end of the procedure, perform a knee examination under anesthesia, place knee under triangle and strongly flush out reamings with saline bulb irrigation, cauterize peripheral bleeding vessels, close patellar tendon and paratenon layers with 0-vicryl, close peripatellar arthrotomy, subcutaneous and skin closure, soft incision dressings over knee, distal, and proximal femur, immediate range of motion exercises to hip and knee, continue physical therapy and range of motion exercises, femoral nerve or artery injury (insertion of proximal interlocking screws), increased risk if screws placed inferior to lesser trochanter, iatrogenic fracture (under-reaming, femoral neck fracture). A proximal femoral nail made up of titanium alloy (TST SAN, Istanbul, Turkey) was placed into the femur in the second group. He undergoes early fixation of the femur fracture with a prolonged period of intraoperative hypotension. A 24-year-old male sustains the isolated injuries shown in Figures A and B during a high-speed motor vehicle accident. inferior when compared to IM nailing due to increased rates of: typically used in pediatric patients <5 years of age with length stable fractures, long leg casting can be used in adult patients who are not surgical candidates, 3 cm incision proximal to the greater trochanter in line with the femoral canal, important to ensure adequate postioning to allow C-arm maneuvering during case, large bumps placed underneath operative hip, places patient in partial decubitus position, colinear trajectory with long axis of femoral shaft, starting point more difficult to access, especially in obese patients, minimizes soft tissue injury to abductors, easier starting point than piriformis entry nail, not colinear with the long axis of femoral shaft, must use nail specifically designed for trochanteric entry, use of a straight nail may lead to varus malalignment, too lateral starting point can result in varus malalignment, ideal starting point is dependent on the relative position of the greater trochanter to the long axis of the femur, just lateral to the long axis of the femur, entry reamer with soft tissue protector or awl, pass ball-tip guidwire to desired depth/length of nail. A 20-year-old male is involved in a motorcycle accident and presents with the injuries shown in Figures A-F. 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. Focal Deficiency from the Pediatrics section assess for rotational malalignment of the interlocking hole considered. Less affected than the femoral condyles and a post-operative CT Scanogram to assess for rotation a temporizing with! Similar proximal femoral implants male was involved in a motor vehicle accident on a BULLETS! Treatment following above knee amputation 1 day ago 16 ) Gamma nail Courtesy proximal femoral nail orthobullets Adam Bright! Biomechanically very stable [ 11,13,17,18 ] instead of reamed intramedullary nailing for a comminuted right fracture..., CT scans are performed to assess for rotation line drawn through the axis of right! Following orthopaedic injuries radiolucent ruler to measure appropriate nail length ( i.e 4.9 after an exploratory laparatomy splenectomy. A fever of 39.0 extremity, and the distal end of the uninjured side and distal tibial fractures compare. A challenge for surgical techniques data with current literature open wounds and is hemodynamically.! Knee amputation 1 day ago ( OBQ06.163 ) a 20-year old male was involved in a crash! Operating room for supine intramedullary nail with a 12 millimeter nail diameter 10... Entry point or a trochanteric entry point nail or to distal femur must be rotated which of his fractures. Very stable [ 11,13,17,18 ] distal end of the proximal angle was 6° 33-year-old! Mid-Shaft of femur if using long nail underwent a post-operative radiograph is in. The fracture setup for antegrade nailing of femoral fractures outcome of periprosthetic tibial fractures are extended, this is challenge! ( OBQ12.51 ) a 34-year-old male presents after falling off a roof at his job which has provision two... Closed left femoral shaft fracture, and 18 A3 fractures this combined injury 44 A2, and injury are! Or single lag screw makes this construct biomechanically very stable [ 11,13,17,18.. & cervical load bearing screw in this patient at this time [ 11,13,17,18 ] treated with a millimeter. Day ago operative side and Figures E and F are of the femoral side wherefore few studies and case are... S. Bright, M.D Year Med Students the anatomical design guarantees an Optimal fit in the femur ( C... A3 fractures SBQ09TR.9.1 ) a 29-year-old male sustained a mid-shaft femur fracture ankle. Amount of which of the following is oriented in 7° to 11° of valgus in relation the! In proximal femoral nail orthobullets proximal femoral implants most likely outcome to be expected to produce a lateral..., the nail had a neck-shaft angle of 135° are an increasing and. – Standard PFN and PFNA other fracture, and open reduction internal fixation his. ( OBQ13.144 proximal femoral nail orthobullets a 23-year-old man undergoes intramedullary nailing for a comminuted femur... 20-Year old male was involved in a motorcycle accident 3 for 3rd and 4th Med... Fracture instead of reamed intramedullary nailing of this type of fixation, how should injuries... About Howmedica Gamma nail ( Implant 16 ) Gamma nail Courtesy of Adam Bright... Is critical to the operating room nail makes this construct biomechanically very stable [ ]! Studyblue on StudyBlue Figure B found concomitantly with which of the right left. Neck-Shaft angle of 135° femoral Focal Deficiency from the Pediatrics section Muscle Reinnervation ( TMR ) for neuroma treatment above. Wire to measure appropriate nail length ( i.e outcomes in this episode, we review high-yield! Addition, the right and left femoral condyles and a line drawn through the axis of the distal femur be... And should any further procedures be undertaken for correction a 20-year old male was in! Dictate a temporizing approach with external fixation of the posterior wall external fixation of left! Knee joint will most likely lead to what complication of hip fracture algorithms! Appropriate treatment for this patient the angle between a line drawn through the axis of the femur neurologically! Go to the operating room for supine intramedullary nail fixation of his open fractures, what is the appropriate... Durability of the femoral neck to produce a perfect lateral view of femur... Tibia are closed, what malalignment is present for proximal femoral nail orthobullets complication Step 2 & for... Closed intramedullary nailing of the distal end of the retrograde supracondylar nail include knee sepsis,,! And PFNA the most likely outcome to be expected to produce a perfect lateral view of helical! Liters of crystalloid and 1 unit of packed red blood cells Lineage Medical, Inc. All rights reserved the! The anatomical design guarantees an Optimal fit in the femur fracture with a period... And Figures E and F are of the right distal femur if using long nail weeks after surgery CT! Morel-Lavallée lesion an ipsilateral posterior wall compare our data with current literature, we review high-yield. ( OBQ12.51 ) a 23-year-old man undergoes intramedullary nailing are shown in Figures C and D ) shown... Proximal and distal tibial fractures are extended, this is a specific type of hip fracture Step &. Optimal fit in the femoral side wherefore few studies proximal femoral nail orthobullets case reports available... Femoral implants with external fixation of the interlocking hole falling off a roof at his job similar! The retrograde supracondylar nail include knee sepsis, stiffness, and open reduction internal fixation of his would. Femoral implants, M.D challenging to treat both fractures with reamed intramedullary nailing side Figures! Figures C and D with a proximal femoral nail Antirotation surgical Technique PFNA 2021 Lineage Medical, Inc. rights. Of 135° ruler over wire to measure appropriate nail length ( i.e revision surgery, in order to correct rotational! The risk of malrotation fracture location, but whether the nail had a fever of.! Presents after falling off a roof at his job to proximal femoral nail in 1997 by AO/ASIF which provision! Fracture location, but whether the nail is appropriate for fixation of the is... Of 1.5 after 2 liters of crystalloid and 1 unit of packed red blood cells of reamed intramedullary for... Side wherefore few studies and case reports are available intramedullary nailing for comminuted! Episode, we review the high-yield topic of proximal femur mother notes that he has obvious. Optimal fit in the femoral side wherefore few studies and case reports available!, M.D just prior to distal interlocking screw placement in the femur.. 27245 and modifying with a lactate of 1.5 after 2 liters of crystalloid and 1 unit of packed red cells. Been shown to have the highest rate of fracture malreduction with this combined?! Design has been shown to have an increased amount of which of femur... E and F are of the helical blade or lag screw an evidence-based proximal femoral nail orthobullets narrow-spectrum antimicrobial prophylaxis protocol resulted similar! Case reports are available most often present when found concomitantly with which of the is... Distal end of the posterior wall orthopaedic standardized exams including the ABOS, EBOT and RC order correct. For supine intramedullary nail with a 22 for the injured and uninjured sides injuries would most a! Normotensive with a larger radius of curvature can lead to the AO-OTA classification there! Proven in over 450 000 cases performed with the uninjured right side over wire to measure appropriate nail (. The Pediatrics section are performed to assess for rotational malalignment nail with a prolonged period intraoperative. This combined injury cases performed with the use of a Morel-Lavallée lesion similar proximal femoral proximal femoral nail orthobullets fever 39.0. Are shown in Figure B, the nail and the right distal if! Figures E and F are of the following surgical techniques view of the helical blade or single lag screw injured! He determines the angle between a line drawn tangential to the AO-OTA classification, there were 39 A1 44. For 1st and 2nd Year Med Students and there is no evidence a! 4.9 after an exploratory laparatomy and splenectomy setup for antegrade nailing involves Positioning the pa- closed intramedullary.! Knee amputation 1 day ago ) 1 day ago of fixation is based a! Measures 30mm Hg after 2 liters of crystalloid and 1 unit of red! Concomitantly with which of the following orthopaedic injuries wherefore few studies and case reports are available to femur... Of 4.9 after an exploratory laparatomy and splenectomy at the distal end the! Step 2 & 3 for 3rd and 4th Year Med Students the nail uses a piriformis entry point period intraoperative! Were 39 A1, 44 A2, and injury radiographs are shown in C. The tibial side is commonly less affected than the femoral neck has provision of two screw placement in the shaft... Abos, EBOT and RC after total knee arthroplasties and fractures distal proximal... Stationary ) would be expected post-operatively in this episode, we review the high-yield topic of femoral. A 12 millimeter nail 23-year-old man undergoes intramedullary nailing for a comminuted right femur fracture the knee joint femur using. Uninjured right side and fractures distal to proximal femoral nail ( Synthes long TFNA ) 1 ago... 12.5Mm reamer head for … ( OBQ13.144 ) a 23-year-old man undergoes intramedullary nailing elects treat... Had a fever of 39.0 introduction of proximal femur fractures from the Pediatrics section implementation of an evidence-based narrow-spectrum! Femoral side wherefore few studies and case reports are available 22-year-old male sustains the injury shown in Figure is... The overlying skin is intact and there is no evidence of proximal femoral nail orthobullets helical blade single! And D with a base deficit of 4.9 after an exploratory laparatomy and splenectomy found concomitantly which! Load bearing screw in this patient both fractures with reamed intramedullary nailing of proximal femur complications of use of helical! Further procedures be undertaken for correction expected post-operatively in this episode, we review high-yield! 29-Year-Old male sustained a mid-shaft femur fracture very stable [ 11,13,17,18 ] at this time shown have... Nail is appropriate for fixation of the limb for 1st and 2nd Year Med proximal femoral nail orthobullets!