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Femur Fractures:Case-based solutions to common

problems with intramedullary nailingG Bl i d ll MDGreg Blaisdell, MD

New Hampshire Orthopaedic Center

I have no disclosures

ObjectivesReview common problems in femur fracture care

Pre-operative decision making

Case-based examples to help avoid complications with:

Subtrochanteric fractures

Femoral shaft fractures

Distal femur fractures

Subtrochanteric femur fractures

Don’t let these be your x-rays!

Subtrochanteric femur fractures

Flexion and external rotation of proximal fragment

Need more information pre-poperatively typically

Does it extend into the intertrochanteric zone?

-Has affect on nail choice

Subtrochanteric femur fractures

Traction Views are HELPFUL

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Positioning supine on fracture table

Good reduction! Quick Case!

Right?

Get a lateral or Prep and Drape?p

Options:

Supine vs. Lateral

Fracture table/Free leg

WRONG

Proximal guidewireposition CRITICAL

R d ti idReduction aids:

Percutaneous elevators, bone hooks, unicortical schanz pins, external manipulation, leg elevator

Reaming while in a malreduced position cannot be overcome by the nail

Opening reamer dictates nail pathway

Trochanteric start nails: Guidewire on medial slope of tip.

Fight the soft tissues!

Piriformis Greater Troch

Starting point: Does it matter?

Piriformis vs. trochanteric start point: No significant difference (Starr, JOT 2006)

Trochanteric entry on medial edge of trochanteric tip

Subtrochanteric femur fractures Clamp reduction +/- Cable for spiral fractures

Fracture table – Will this reduce?

Cables – Excellent reduction aid for spiral fractures

-Afsari et al, JBJS-A 2009

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Re-create the tube

Don’t crimp until nail is seated and proximal screw(s) are in

Femoral shaft fracturesAntegrade vs. Retrograde

Fracture table vs. Free-leg

Antegrade:

Piriformis vs. trochanteric

How many locking screws

Reamed vs. Unreamed

Gold Standard: Antegrade nailing,

statically locked, REAMED

Shaft fracturesAvoiding Malrotation

Bråten et al. Acta Orthop Scand 1992

Normal variation in anteversion exists between sides

2 standard deviations is 11-13°

J t l J O th T 2004Jaarsma et al. J Orthop Trauma 2004

Clinical judgment alone is poor

Supine: 42% > 20° malrotation

Prone: 25% > 20° malrotation Not good!

Shaft fracturesAvoiding Malrotation

Tornetta et al. J Trauma 1995

Lateral only technique

Perfect lateral of uninjured hip

Perfect lateral of uninjured knee

Measure difference to get anteversion

Correct fractured limb

12 patients, avg 5° (0-8°)

Shaft fracturesAvoiding Malrotation

Deshmukh et al. Injury 1998

Lesser trochanteric Profile

Start with perfect lateral knee

Rotate flouro 90 get AP hipRotate flouro 90, get AP hip

Compare lesser trochanter profiles

5 patients, all <10° variation

Occasionally not much of a profile!

Shaft fracturesAvoiding Malrotation

MOST IMPORTANT

GET PRE-OPERATIVE IMAGES OF UNINJURED LEG

BASE ALL PROFILE IMAGING OFF OF PERFECT LATERAL OF KNEE

AP KNEE AND AP HIP SHOULD BE 90° FROM PERFECT KNEE LATERAL

NOT SURE? GET A CT

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Shaft fracturesDealing with Malrotation

Lindsey and Krieg, JAAOS 2011

If unsure of rotation at index nailing procedure:

Consider single interlocking screw above and below fracture

Shaft fracturesAvoiding leg length inequality

Measure! Radiolucent ruler

Clinical check before extubation

CTCT scanogram

Discuss pre-operatively (Winquist 3 and 4 especially)

Shaft fracturesAvoiding leg length inequality

Vaiyda et al. Injury 2012

28 patients Winquist 3 or 4

Only 64% had <10 mm LLDy

16% LLD 10-15mm11% LLD 15-20mm11% LLD >20mm

5 patients underwent correction

What’s the cut-off?

Femoral shaft fracturesWinquist classification associated with malalignment

Malalignment:

Proximal/distal fractures worse than mid-diaphyseal

More likely when antegrade nailing distal fractures

More likely when retrograde nailing proximal fractures

Ricci JOT 2001

Blocking screws/wires

Krettek et al. JBJS-Br 1999

Success in preventing/treating malalignment in tibia fractures

Unreamed nailing technique

Diaphyseal blocking screw less successful in reamed nailing

Concave side of deformity

Extrapolated to femoral shaft fractures proximal/distal to diaphysis

Krettek et al., Injury 1999

Blocking screws/wires

Ostrum and Maurer JOT 2009

Blocking screw use in retrograde IMN distal 1/3 femur

No angular deformityNo angular deformity

Small group (5 patients)

Shahulhameed et al Injury 2011

Technical recommendation of Steinmann pins to effect blocking of nail malposition

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Blocking screws/wiresTechnical Example

Blocking screws/wiresTechnical Example

Blocking screws/wiresTechnical Example

Starting point and guidewire direction are ESSENTIAL

Blocking screws/wiresTechnical Example

Re-establish posterior cortex Concave side of deformity

The Set-Up

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Anterior-posterior Steinmann pin leaves a mild deformityUse reduction tool to hold guidewire out of way for second Steinmann

Small adjustment of pin

Be careful inserting rod (can create new comminution)

Distal femur fractures:Combining ORIF with IMN

Thomson et al Orthopedics 2008Lower malunion, secondary bone grafting, nonunion compared to ORIF

Garnavos et al. Injury 2012Prospectively followed 17 patientsNo malunions or nonunionNo malunions or nonunionPartial weight-bearing by 6 weeks

Limitations:Extensive intra-articular comminutionInability to gain purchase with interlocks

Combining ORIF with IMNPerfect guidewire alignment

to avoid nail-induced malreduction

Lag screws recreate distal block

Keep lags out of nail path

Open reduction of joint, parapatellar vs. lateral

Choose a nail with multi-planar locking

Avoid short nails

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Reduction tool -Find proximal fragment easier-Better control of distal fragment than with external manipulationp

Can guide position of blocking screws if needed

Every company makes one – If it isn’t in the set in your hospital, it can be

Conclusions• Advanced femoral nailing techniques have provided

major advancements in femur fracture care

• Must respect limitations and overlooked problems with nailing

• Cannot treat all femoral nail cases like a mid-diaphyseal nailing of a simple fracture

• Use available techniques to make fractures straighter, better aligned, without rotational or length abnormalities

Thank You

Greg Blaisdell, MD

603-883-0091 work603 883 0091 work