Closed Cephalomedullary Nailing of Subtrochanteric Hip Fracture
In this case, Dr. Michael Weaver performs an intramedullary fixation of a reverse oblique trochanteric femoral fracture in a lateral position. Neutralizing the deforming forces on the proximal femur, this positioning allows the soft tissue to fall away and makes a direct reduction a bit easier, but taking x-rays in the lateral position is more challenging.
Main Text Coming Soon...
1. Exposure and Reduction
- Lateral Incision Over Trochanter
- Provisional Wire Fixation
2. Proximal Fixation
- Insert Guidewire for Drill
- Drill Through Proximal Cortex
- Ream Medullary Canal
- Insert Nail
- Attach Aiming Arm
- Insert Lateral Guidewire for Drill
- Drill Through Lateral Cortex
- Insert Spiral Blade
- Engage Locking Mechanism
- Adjust as Needed
3. Distal Fixation
- Align Drill with Distal Nail
- Drill Through Cortex
- Insert Distal Screw
- Repeat for 2nd Screw
TranscriptionsPlease note that, unless otherwise stated, these transcriptions have been auto generated and therefore we can not guarantee their complete accuracy.
Get right through the iliotibial band. Good, right through there. Cut. Good, do you see that band? Yeah. So you’ve got to go just a little bit more proximal. Do you have a weedy? Yes, sir. Good. Actually, do you have a Gelpi? Thank you. Alright so the iliotibial band is open, and there’s vastus lateralis right? Do you have your schnip? So you’re right on that piece of bone, and what I want you to do now is to get behind it and spread it open. So you’re kind of behind vastus lateralis. Okay? Back there, yep. Yep. Good. Good. Alright. I think you’re, yep you’re right on it so that’s perfect. And there’s the distal piece there.
Alright so now get your wire, get your wire. X-ray there. X-ray. Usually it’s internal rotation. X-ray. So that’ll be good. So the way this works -- so this is above? Yeah. So you just kind of put that together. Put that together and then flip it apart? You go in, and then that way. X-ray. So you’re only around. Only around that? Well, you’ve got to get around the other way. So you’re doing this, you’ve just got to -- X-ray. Yeah, so now we’re around there. So now, take this one. Get over the top? And you’re just going to loop it that way. X-ray. Good, that’ll do it.
Okay, so now pop that. Good. And now take off that. Leave this one, take that one out. Now with the wires, I kind of do this. I kind of treat it like a screw, and so I go clock-wise. So that way I can always go back to it and tighten it if I want. So give that a pretty good pull up. Pull up? X-ray. Good, as you tighten it, pull. Come south just a little bit? X-ray. X-ray. We may have to adjust a little bit, but I think that’s a pretty good start. We need to have a better reduction when we’re done, but this is a pretty good start. Often times the nail will kind of finish it for you.
Alright, guidewire. No that looks fine. X-ray. That’s fine. There you go, yep. Drive that in, please. Good. X-ray. Good, now try tapping that in with a mallet just a little bit. That’s when I use the mallet, is once it’s down. Yep, exactly. X-ray. Yeah, and now you can tell you’re down because it is staying inside the canal. Yep, good. X-ray there. Good, and you already saw the other views so you know that’s good. Good. Dropping your hand aims lateral and that’s the last place you want to be with this, okay? There I got it. Good. You’ve got to be real careful about going lateral, alright? Because if it goes lateral, that’s the soft bone, it’s going to want to go lateral and then it’ll tip you into veras because your blade will push you over. Or sorry, your nail will push you over. X-ray.
That’s good, keep going. Good. Are you all the way in? Hub it, hub it. Hub it. And out. Good. Is that down the pipe? Come down to the knee please? X-ray there. Always measure before you ream. There you go. X-ray. What does that measure? That measures exactly 360 and this is your x-ray on the right. What do you want? 8-5? X-ray. Alright. Good. 12 please. That’s it, you’re good. 12 in it? Yep, 12’s it. 12 and then the nail. Because there’s no chatter, it’s a wide capacious canal, no need to ream up. But I always like to pass that 12, the final reamer, just to make sure. Now if you hit a lot of chatter here, I’d say let’s back up and starting reaming it up but you’re not going to hit any chatter.
Alright ready for the nail. You can see as the reamer and the guidewire have gone down, it helps with your reduction. It just kind of goes in like a corkscrew. And just remember we’re lateral so this is going to start in the front, and then corkscrew it in that way. There you go. Yep. Good. X-ray. Mallet. X-ray. Alright why don’t you come down to the knee to make sure that’s okay. Good. X-ray there. Yep that’s perfect. Good, come back up to the top. A little less like that, probably. Good, X-ray there. That looks pretty good there. X-ray. Alright.
Just keep your eyes on those wires, okay? What’s that? Be careful of those wires. So if you go like this, see it just keeps pulling it back. If you go the other way, then it tightens up. After it locks? Yep. Yep. X-ray there. That’s good. X-ray. Stop there. So next time, I want you to be really careful. That’s most likely in the hip joint. Next time, before you drive it beyond half way, you really need to check your lateral. Come up to a lateral. X-ray there. Alright so, that’s right in the joint. So back that out. X-ray. X-ray. X-ray. Okay. X-ray. Keep driving it forward. X-ray. X-ray there. X-ray there. Drive it forward just a tiny bit more. Good. X-ray. Let’s swing around to an A-P. So that looks pretty good. So go ahead and drive that in a little bit more. X-ray. X-ray. So you want to go a little bit more than that. So you can back out when you drill. X-ray. Okay. Save that. Can you swing up to an A-P? X-ray there. X-ray there. Can I have the wide driver? So that’s just a tiny tiny bit posterior. X-ray. X-ray. X-ray. That looks pretty centered to me.
Alright swing around to an A-P. X-ray there. See if you can tighten that wire just a little bit more. I get the sense that we keep losing our reduction ever so slightly. I think we’ll probably take that wire out at the end. You know, often times I’ll leave it if it’s a really nice reduction. You know, in this case, we couldn’t capture that piece so I don’t think it’s worth keeping it. But it’s helping us hold it. Are you pulling? I’m pulling. Good. X-ray. X-ray. Okay, alright. Let’s go do the blade.
So before you measure, you’ve got to get this thing down, okay? See how it’s not on the bone yet? It’s off the bone there. Because the blade is stopped by this cannula. So if you’re not on the bone, the blade is going to stick out the side of the femur and it’s just really prominent and can bother people. Good X-ray there. So even that’s not down. Do you have a tommy bar? Yeah I agree it’s hitting on the wire a little bit. Can you suck?
Do you have a chubby please? Bone tamp and a mallet? So often, you can just kind of tap that wire around in a circle, even when it’s tight it’ll move that way. X-ray. Now that’s down. X-ray. Yeah that’s pretty good. X-ray. X-ray. X-ray. Yeah that looks good. Okay. Yep. I’ll take the wire driver first, please? Now if you measure to 90 and put in a 90 there, you’re not going to be able to keep that guidewire in because it’s just going to come right out. So I always put it in before, but then we changed it, but I’d like to put it in further so it’s got fresh bite in the head. So you drive it in just to touch? Normally, I have it touch the subcondylar bone because then you’re actually measuring the tip apex distance, right? And the tip apex distance is probably the second most important thing. X-ray. As far as keeping it from losing its reduction. X-ray. So now, you know, you can double check, but yeah so I think 90 is fine. That measures 97 or something like that, so tip apex would be about 15. So what do you want? 90. 90. X-ray. You’ve got to check X-rays to make sure you don’t drive the pin into the head. X-ray. X-ray. Don’t trust your stop. Okay. X-ray. Still got 1. X-ray. Yeah, a little bit more. X-ray. That’s down.
So it’s important to know that this blade is longer than the drill. You can’t hold there, it’s rifled. If you hold this, it won’t go in, you have to hold it here. Because it’s rifled so it’s grabbing in the barrel. X-ray. X-ray. Down. Let me see. Good. Flexible? Alright.
Alright. Wire driver? Thank you. Alright. X-ray there. X-ray. Huh. X-ray. Back out for a second. Do you have a wire cutter for me? So at some point we lost our reduction there. It was like really good until our blade went in. We have got to take this wire out. X-ray. X-ray. X-ray. Alright. I’m going to take this out. I need the flexible screwdriver. Sorry. Can you get me the extractor handle for the blade? I don’t know what went wrong there. We had a really nice reduction with the wire and then when we put the blade it, somehow it displaced. Back to the shaft, like that. X-ray. Okay.
X-ray there. Now we’ve got that posterior piece that’s a part of it. X-ray. Come south for me a little bit? Give it a really good pull and slight internal rotation. X-ray there. Okay can you pull hard? Like real hard. X-ray. Alright. Time to make the magic happen. There we go. X-ray. This is going to be a herculean pull okay? X-ray. And then internal, or external maybe? Pull away. X-ray. There we go it’s starting to go in. X-ray. Now internal. X-ray. X-ray. Watch out for a second I just want to see what happens when I pull. X-ray. X-ray. X-ray. X-ray. X-ray. Just hold that there. I think that piece is rotated still. Can I see the nail please? X-ray. X-ray. Mallet.
X-ray. So sometimes when you get it close, the nail will kind of help fill the canal. So now we have that reduction a lot better, it’s not perfect yet, but we’re much better. I think we’re even better than when we were at the beginning because unless there’s a free piece, but now that other piece is -- X-ray. Alright so that’s good there. Alright Gelpi? Now I’m back to happy, like I think that’s an acceptable reduction. It’d be nice if we could key that in a little bit more. Do you have the 1x1? X-ray. Now release it. X-ray. Just a little bit more. X-ray. You can see that wire, if it was a tiny bit more distal, would probably be helping us a little bit better. I definitely don’t want to put a third wire, you know, I think we’ve got plenty.
Okay. Guide. And guidewire stuff. I’ll take the wire freehand. Mallet, please? Yep. X-ray there. X-ray. Wire driver? X-ray. X-ray. That looks pretty centered. X-ray. Alright let’s come up to an A-P. Yep. X-ray there. Power. X-ray. I think that’s the same hole, that didn’t feel like a lot of anything. Looks like we’re going to stick with a 90. I’m going to use the one I said I wouldn’t use now. Same thing. X-ray. X-ray. X-ray. Blade. So this turns, and once it locks in, you just push it. If you hold here, it just stops it from turning, so it can’t go in. X-ray. X-ray. X-ray. Lock that down for me? Glad we changed it though, anytime you see it like kind of fall apart, it’s like eehhh. Yeah it came all the way apart.
But, you know, the tip apex distance is what’s written about as being the most important thing, but I think that’s secondary to reduction. You have a good reduction, you’re not going to fail. X-ray. Okay, and acorn.
Good, let’s come up to an A-P now please? And then tilt a little bit more. X-ray there. Knife please? Knife please. X-ray. How do you want to spread? I’m going to spread with the drill. X-ray. X-ray. Bullseye. Depth gauge? 50. X-ray. X-ray. If you had done this lateral, would you still have opened? For this one, probably. It would have been harder. It would have been harder to get a good reduction. I think we would have -- supine you mean -- yes. X-ray. I think we wouldn’t have ended up quite as good. Watch your hand. Thank you. X-ray. X-ray. X-ray. X-ray. X-ray. X-ray. So that’s like ideal, when it falls right through. 46. 46. X-ray. X-ray. Do you want one to close off? Yeah, definitely. Yes, please. Can you square up for me, nice and straight. X-ray. Save that. Come up proximal. Drop your machine as far as it’ll go. Table up please? You got it. X-ray there. X-ray there. You can see that piece is folded around the back, that was what I was trying to undo. X-ray. Save that. Come up proximal just a little bit more. X-ray there. Save that.
Swing around to an A-P please? X-ray. Save that. Come down to the knee please? X-ray. Save that. These screws are aiming slightly posterior to anterior which is kind of what you want. That means your version is about right. That’s another check for version, alright? Thank you.
So that was challenging but things came out nicely in the end. So we performed an intramedullary fixation of a reverse obliquity in the lateral position. This positioning is useful because it allows the soft tissue to fall away and makes a direct reduction a little bit easier than if you were on a fracture table. And also it neutralizes the deforming forces of the proximal femur when you’re in that lateral position. But the X-rays are a little bit more challenging and it’s something you have to get used to, but it works out pretty well. I think when you need them, cerclage wires around the proximal femur are pretty useful but you have got to make sure you’ve got a good reduction. If you leave a large fracture gap, you’re going to have trouble with healing and you want to be careful not to make too many passes because that can lead to the stripping of the bone fragments which can lead to a non-union.
To maintain access: please let your librarian know you would like a subscription or send us an email at firstname.lastname@example.org and we will forward your feedback to your librarian.