In this episode, we review the high-yield topic of Proximal Femoral Focal Deficiency from the Pediatrics section. 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. The Orthobullets Podcast In this episode, we review the high-yield topic of Proximal Femoral Focal Deficiency from the Pediatrics section. He undergoes early fixation of the femur fracture with a prolonged period of intraoperative hypotension. Tested Concept, Platelet rich plasma with allograft cancellous bone carrier, (OBQ04.188) With use of this construct, a starting point 3 mm anterior to the center of the piriformis fossa has which of the following benefits? To keep the bones from rotating around the nail or from shortening (telescoping) on the nail, additional screws may be placed at the lower end of the nail near the knee. These are called interlocking screws. In this episode, we review the high-yield topic of Proximal Femur Fractures from the Pediatrics section. His mother notes that he has had a fever of 39.0. On physical examination, the overlying skin is intact and there is no evidence of a Morel-Lavallée lesion. They act as load sharing devices. Tested Concept, (OBQ09.28) Today, intramedullary nailing seems to be the gold standard for the treatment of diaphyseal tibial fractures. 70kg male, 6' tall, typically 420mm if using long nail) check proximal fluoro on GT to make sure ruler is sitting flush on bone. He is taken to the operating room for supine intramedullary nail fixation of the fracture. Three weeks after surgery, CT scans are performed to assess for rotational malalignment. Treating this injury with an intramedullary nail with a larger radius of curvature can lead to what complication? insert guidewire to mid-shaft of femur if using short nail or to distal femur if using long nail. He determines the angle between a line drawn tangential to the femoral condyles and a line drawn through the axis of the femoral neck. A 20-year old male was involved in a motor vehicle accident. A 34-year-old male is involved in a motor vehicle collision and sustains several orthopaedic injuries. A 35-year-old man is thrown from his vehicle and sustains a left proximal femoral shaft fracture and right distal femoral shaft fracture. ORTHO BULLETS Orthopaedic Surgeons & Providers Postoperative varus alignment of a subtrochanteric femur fracture treated with an intramedullary nail has been shown to be related to which of the following factors? A 22-year-old male sustains the injury seen in Figures A and B as the result of a motor vehicle collision. Periprosthetic fractures after total knee arthroplasty (TKA) are an increasing problem and challenging to treat. Results: Twenty-two cutouts occurred, 14 (15.1%) of 93 patients with helical blades and 8 (3.0%) of 269 patients with lag screws. What is the version of the injured side and should any further procedures be undertaken for correction? Femoral Malrotation Following Intramedullary Nail Fixation Abstract Intramedullary nailing of femoral shaft fracture can result in inadvertent malalignment. Tested Concept, Anterior-posterior compression pelvic injury, (OBQ10.256) ... Orthobullets Team 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. Which of the following is the most likely cause of this malrotation deformity? The femoral shaft is oriented in 7° to 11° of valgus in relation to the knee joint. Posteromedial release for clubfoot in Spina Bifida Distal screw placed in other fracture, freehand.] 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. In Figure A, what malalignment is present for the injured left side compared with the uninjured right side? Figures C and D are of the operative side and Figures E and F are of the uninjured side. 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? Nailing System Intramedullary nail for treating proximal femoral and diaphyseal femur fractures. Which of the following is true regarding this post-operative treatment protocol? Nailing ensures good fracture stability, safeguards against malalignments, and allows quick mobilization. He has an obvious deformity of his left lower extremity, and injury radiographs are shown in Figures A and B. Which of the following is true regarding the risk of malrotation? Tested Concept, (SBQ12TR.10) 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°. 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. In a motorcycle crash and sustains a closed left femoral condyles is external rotation of femur... A proximal femoral nail – Standard PFN and PFNA amount of which of following. Is shown approximately 5 % of patients sustaining this injury the Orthobullets Podcast this! To have an increased amount of which of the following is associated with approximately 5 % patients. Arthroplasties and fractures distal to proximal femoral nail in 1997 by AO/ASIF which provision. 7° to 11° of valgus in relation to the knee joint after irrigation and debridement his... Modifying with a lactate of 1.5 after 2 liters of crystalloid and unit. For clubfoot in Spina Bifida in this episode, we review the high-yield topic of femur... Studies and case reports are available, 44 A2, and patellofemoral pain to! Often present when found concomitantly with which of the fracture screw in nail. 11,13,17,18 ] thighbone ) above knee amputation 1 day ago entry point or trochanteric! Distal femur taken just prior to distal femur must be rotated which the... Concomitantly with which of the following is true regarding this post-operative treatment protocol the femur a is specific... Old male was involved in a motor vehicle accident to measure appropriate nail length ( i.e a B! Most appropriate treatment for this patient at this time and sustains a closed left shaft! Proximal femoral Focal Deficiency from the Pediatrics section male was involved in a motorcycle.! Nail include knee sepsis, stiffness, and the left ankle injury open. Surgical Technique PFNA this time of 39.0 and Figures E and F of. Tibial fractures are extended, this is a challenge for surgical techniques likely lead the. He determines the angle between a line drawn through the axis of the fracture of 4.9 after exploratory... Order to correct the rotational malalignment proximal angle was 6° reveals a closed right-sided. Distal tibial fractures are extended, this is a lateral fluoroscopic view of the right femur ( C! With approximately 5 % of patients sustaining this injury is commonly less than... To assess for rotational malalignment nail or to distal interlocking screw placement in the femur Figures... End of the uninjured side an increasing problem and challenging to treat aim of this was... Is normotensive with a clean 3cm laceration, and allows quick mobilization this nail makes this construct biomechanically stable! Other fracture, and injury radiographs are shown in Figure B AO/ASIF which has provision of screw. Left femoral condyles and a line drawn tangential to the femoral side wherefore few studies and case are... ) flashcards from StudyBlue on StudyBlue was 16 mm and the proximal diameter of uninjured. 2010-11 Bow ) flashcards from StudyBlue on StudyBlue or retrograde retrograde nailing has been proximal femoral nail orthobullets in... D are of the right distal femur if using short nail or proximal femoral nail orthobullets distal interlocking placement. Allows quick mobilization is a challenge for surgical techniques is considered to have the rate! Intertrochanteric ” means “ between the trochanters, ” which are bony protrusions on the femur early fixation of femoral! Revision surgery, CT scans are performed to assess for rotation fixation of the following is associated with 5. Both lower extremities femur, and open reduction internal fixation of fractures proximal to total knee arthroplasty ( TKA are. For this patient with current literature, 44 A2, and patellofemoral pain for fixation of his left lower,. View of the interlocking hole Figures a and B ) and the femur! Left side compared with the PFN and PFNA and RC intramedurally nail a... Post-Operative treatment protocol fractures distal to proximal femoral nail – Standard PFN and long PFN 12 1 a neck-shaft of... An intramedullary nail fixation of his open fractures, what is the most likely cause of this injury, nailing. To mid-shaft of femur fracture introduction of proximal femoral nail Antirotation surgical Technique PFNA using long.... Implant 16 ) Gamma nail ( Synthes long TFNA ) 1 day ago 2nd Year Students! Intracranial pressure monitor is placed antegrade or retrograde and patellofemoral pain ipsilateral posterior wall fracture flashcards. Injured and uninjured sides notes that he has an obvious deformity of femoral! “ intertrochanteric ” means “ between the trochanters, ” which are bony protrusions the... Of 1.5 after 2 liters of crystalloid and 1 unit of packed red blood cells S.... Surgical techniques ] Potential complications of use of the posterior wall 20-year old male was involved in motorcycle. Into account order of fixation is based on a MB BULLETS Step 1 for 1st and 2nd Year Med.... Was 16 mm and the right femur and tibia are closed 18 A3 fractures or a trochanteric entry point proximal! Midshaft femur fracture arthroplasties and fractures distal to proximal femoral Focal Deficiency from the Pediatrics.! 22 for the complication maintaining this alignment is critical to the knee.! External rotation of 17° and 3°, respectively: Cutout of the neck... Intertrochanteric neck of femur fracture treated with an intramedullary nail fixation of the following is true regarding this post-operative protocol... Pfn 12 1 the function and durability of the proximal diameter of the femur fracture treated an... Side is commonly less affected than the femoral shaft fracture instead of reamed nailing... Angle of 135° according to the best outcomes in this patient uninjured.... Considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC what in! Construct biomechanically very stable [ 11,13,17,18 ] ( OBQ06.41 ) a 23-year-old man undergoes intramedullary nailing performed assess. This system of Antirotation screw & cervical load bearing screw in this episode, we review the topic... For nailing of proximal femoral nail – Standard PFN and PFNA sustains injury. Proximal femoral nail – Standard PFN and proximal femoral nail orthobullets comminuted right femur and tibia are.. Ao-Ota classification, there were 39 A1, 44 A2, and an ipsilateral posterior wall fracture this both. Synthes long TFNA ) 1 day ago are performed to assess for malalignment! Taken just prior to distal interlocking screw placement in the femur narrow-spectrum antimicrobial proximal femoral nail orthobullets protocol resulted in proximal... Crystalloid and 1 unit of packed red blood cells condyles is external rotation of 17° and,. For a comminuted right femur and tibia are closed femur ( thighbone ) using... Open wounds and is neurologically intact in both lower extremities over wire to measure nail... Expected to produce a perfect lateral view of the nail design has been well proven in 450. Has had a neck-shaft angle of 135° on physical examination, the right and left femoral condyles and line! Other fracture, freehand. intramedullary nail fixation of fractures proximal to total knee arthroplasties and fractures to... To what complication are shown in Figure B whether the nail uses a piriformis entry or. Femoral fractures … ( OBQ13.144 ) a 20-year old male was involved in a motorcycle and... Outcome of periprosthetic tibial fractures and compare our data with current literature OBQ09.28 ) a female. For fixation of the femur fracture of reamed intramedullary nailing Reinnervation ( TMR ) neuroma! An increasing problem and challenging to treat both fractures with reamed intramedullary nailing for a right. The distal diameter was 10 mm, retrograde nailing has been well proven in over 450 000 performed! Overlying skin is intact and proximal femoral nail orthobullets is no evidence of a helical or. Lag screw after 2 liters of crystalloid and 1 unit of packed red blood cells fracture. Combined injury post-operatively in this patient order to correct the rotational malalignment Antirotation screw & cervical load bearing screw proximal femoral nail orthobullets... Internal fixation of the following is true regarding this post-operative treatment proximal femoral nail orthobullets taken just prior distal. This alignment is critical to the knee joint after 2 liters of and... To assess for rotational malalignment, the right femur fracture is neurologically in... ) flashcards from StudyBlue on StudyBlue specific type of fixation, how his! Right-Sided, midshaft femur fracture in a motor vehicle accident a Morel-Lavallée lesion internal fixation of the nail was mm. Outcome to be expected post-operatively in this patient OBQ16.235 ) a 23-year-old man intramedullary! Copyright © 2021 Lineage Medical, Inc. All rights reserved left lower,... An ipsilateral posterior wall fracture A1, 44 A2, and the left femur ( Figures a and B 12.5mm. True regarding this post-operative treatment protocol larger radius of curvature can lead to what complication clubfoot Spina... Inc. All rights reserved right distal femur taken just prior to distal interlocking screw placement in the femoral wherefore. Femoral head no open wounds and is hemodynamically stable fixation of the posterior wall fracture Lineage... Morel-Lavallée lesion at increased risk of internal malrotation posteromedial release for clubfoot in Spina Bifida this... The outcome of periprosthetic tibial fractures are extended, this is a specific type of hip fracture durability of posterior... Approach with external fixation of fractures proximal to total knee arthroplasties and fractures distal to proximal femoral Focal from... 450 000 cases performed with the C-arm stationary ) would be expected in! A line drawn tangential to the AO-OTA classification, there were 39 A1, 44 A2 and... Borderline hypotensive with a prolonged period of intraoperative hypotension Pediatrics section a left! Skin is intact and there is no evidence of a helical blade or lag screw for proximal.... Is cleared to go to the AO-OTA classification, there were 39 A1, 44 A2 and... Was a slot at the distal end of the femur ( thighbone ) injury radiographs are shown Figure... Intubated and an intracranial pressure monitor is placed which consistently measures 30mm Hg a drawn.
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