Date: Wed, 1 May 2002 21:05:29 EDT
Subject: Lateral position for femoral nailing
I would like to change from using a fracture table to lateral position for femoral nailing.
Are there any pearls for this technique?
Date: Thu, 02 May 2002 07:37:18 -0400
From: Kevin Pugh
I have used a fracture table for femoral shaft fractures less than 5 times since 1994. I use the semi-supine poisition (lateral is also easy) so that multiple extremities can be prepped, multiple teams can be used, you can avoid fracture table set-up, and have easier access to the starting point on antegrage nails. The fracture table is essential to most reconstructive cases. Two good references re: this technique follow. One details use of a distractor, one without. Once you try it, you won't go back.
Kevin J. Pugh, MD
Chief, Division of Trauma
Department of Orthopaedics
The Ohio State University
Columbus, OH 43210
Date: Thu, 02 May 2002 07:22:33 -0500
From: Steven Rabin
First, well pad every bony prominence especially with an axillary roll.
Second, be sure the down hip/leg is out of the way of x-rays, so use a fully radiolucent table, and usually extend the down hip, as the up hip (the broken one) often needs to be flexed and adducted to get the reamers and rod in. (When you adduct the up leg, it becomes easier to find the pyriformis entry portal)... The hip has a tendency to internally rotate, so be aware of that when determining fracture alignement and rotation. The fracture also tends to sag with the force of gravity (i.e. go into valgus - so watch that also when reaming)... With distal locking, try to keep the leg straight, so that the c-arm can be perpendicular to the leg and the ground. In big patients there may be limited room and it is sometimes difficult to get the drill properly positioned, so be sure that there is enough room as the arc of the c-arm needs to get around not only the broken leg, but the table, the down leg, the drill, and the drill bit.
Why do you want to make the change? While it is easier to find the entry point, it is harder to hold the alignment, and if there are other injuries, especially of the opposite leg or back, those injuries may be more difficult to treat. Also if there is pulmonary injury, the anesthesiologist may have more trouble ventilating. If there is cardiac risk, it may be safer to have the patient supine. If your goal is to get rid of the fracture table, you can still do a supine rodding without a fracture table (on a radiolucent table with possibly a femoral distractor) and still have access to other injuries.
Date: Thu, 02 May 2002 07:05:36 -0700
From: Chip Routt
Visit a surgeon that knows how to do a variety of techniques well, discuss their indications, advantages, and details. Then observe/assist that surgeon using the various techniques.
M.L. Chip Routt, Jr.,M.D.
Harborview Medical Center
Seattle, WA 98104-2499
Date: Fri, 3 May 2002 11:58:39 +0600
From: Alexander Chelnokov
Mac> I would like to change from using a fracture table to lateral position for femoral nailing.
We started closed femoral nailing since Feb 2001 and all our first 50 cases have been performed without a fracture table using a distractor (assembled from parts of the Ilizarov set), with flexed-adducted limb. It works fine for obese and multiple injured also. I don't know whether it is essential for your settings but our sterile team usually includes only 2 people - a surgeon and a nurse.
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia