He is complaining of bilateral leg pain. • Cephalomedullary Nail Fixation of Intertrochanteric Femur Fractures: `Are Two Proximal Screws Better Than One?- Serrano R, Blair JA, Watson DT, Infante AF Jr, Shah AR, Mir HR, Maxson BJ, Downes KW, Sanders RW. The fracture was located in the proximal one-third of the femur in eighty-five limbs, in the middle one-third in 325, and in the distal one-third in 1 10. He undergoes early fixation of the femur fracture with a prolonged period of intraoperative hypotension. Copyright © 2021 Lineage Medical, Inc. All rights reserved. Both femora are at increased risk of internal malrotation. Three weeks after surgery, CT scans are performed to assess for rotational malalignment. This system of Antirotation screw & cervical load bearing screw in this nail makes this construct biomechanically very stable [11,13,17,18]. Nailing ensures good fracture stability, safeguards against malalignments, and allows quick mobilization. A 26-year-old male presents after a motor vehicle accident. The second case is a 67-year-old male who sustained a closed On physical examination, the overlying skin is intact and there is no evidence of a Morel-Lavallée lesion. A 34-year-old male is involved in a motor vehicle collision and sustains several orthopaedic injuries. Patient Positioning One common setup for antegrade nailing involves positioning the pa- He has an obvious deformity of his left lower extremity, and injury radiographs are shown in Figures A and B. There was no peri-operative mortality. He is normotensive with a lactate of 1.5 after 2 liters of crystalloid and 1 unit of packed red blood cells. Am I billing only a CPT 27245 and modifying with a 22 for the complication? 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? The femoral shaft is oriented in 7° to 11° of valgus in relation to the knee joint. These are called interlocking screws. A 22-year-old male sustains the injury seen in Figures A and B as the result of a motor vehicle collision. Overview. Proximal Femoral Focal Deficiency ... year-old boy develops tenderness at the right heel and avoids putting weight on the right extremity after stepping on a nail 2 weeks ago while wearing tennis shoes. Which of the following is associated with approximately 5% of patients sustaining this injury? Which of the following is true regarding this post-operative treatment protocol? He was treated with an intramedurally nail and a post-operative radiograph is shown in figure B. Main outcome measurements: Cutout of the helical blade or lag screw. Figures C and D are of the operative side and Figures E and F are of the uninjured side. About Howmedica Gamma Nail (Implant 16) Gamma Nail Courtesy of Adam S. Bright, M.D. A 35-year-old man is thrown from his vehicle and sustains a left proximal femoral shaft fracture and right distal femoral shaft fracture. 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, More reliable placement of interlocking screws through the nail, (OBQ10.12) Work-up reveals a closed left femoral shaft fracture, and an ipsilateral posterior wall fracture. 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) A patient undergoes the treatment seen in Figure A for a displaced intertrochanteric femoral fracture. A 20-year-old male is involved in a motorcycle accident and presents with the injuries shown in Figures A-F. the most frequent intraoperative complication with antegrade nailing of a subtrochanteric femur fracture is varus and procurvatum (or flexion) malreduction; ... and inability to bear full weight after undergoing ORIF of a left proximal femur fracture 3 months ago. Results: Twenty-two cutouts occurred, 14 (15.1%) of 93 patients with helical blades and 8 (3.0%) of 269 patients with lag screws. 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. Intertrochanteric neck of femur fracture treated with a proximal femoral nail (Synthes long TFNA) 1 day ago. Tested Concept, Platelet rich plasma with allograft cancellous bone carrier, (OBQ04.188) 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). Which of the following is the most likely cause of this malrotation deformity? PFNA Nail Optimal fit The anatomical design guarantees an optimal fit in the femur. An intertrochanteric fracture is a specific type of hip fracture. Orthobullets Technique Guides cover information that is "not testable" on ABOS Part I, Confirm Nail Position and Extremity Check, Leg Compartment Release - Single Incision Approach, Leg Compartment Release - Two Incision Approach, Arm Compartment Release - Lateral Approach, Arm Compartment Release - Anteromedial Approach, Shoulder Hemiarthroplasty for Proximal Humerus Fracture, Humerus Shaft ORIF with Posterior Approach, Humerus Shaft Fracture ORIF with Anterolateral Approach, Olecranon Fracture ORIF with Tension Band, Olecranon Fracture ORIF with Plate Fixation, Radial Head Fracture (Mason Type 2) ORIF T-Plate and Kocher Approach, Coronoid Fx - Open Reduction Internal Fixation with Screws, Distal Radius Extra-articular Fracture ORIF with Volar Appr, Distal Radius Intraarticular Fracture ORIF with Dorsal Approach, Distal Radius Fracture Spanning External Fixator, Distal Radius Fracture Non-Spanning External Fixator, Femoral Neck Fracture Closed Reduction and Percutaneous Pinning, Femoral Neck FX ORIF with Cannulated Screws, Femoral Neck Fracture ORIF with Dynamic Hip Screw, Femoral Neck Fracture Cemented Bipolar Hemiarthroplasty, Intertrochanteric Fracture ORIF with Cephalomedullary Nail, Femoral Shaft Fracture Antegrade Intramedullary Nailing, Femoral Shaft Fracture Retrograde Intramedullary Nailing, Distal Femur Fracture ORIF with Single Lateral Plate, Patella Fracture ORIF with Tension Band and K Wires, Tibial Plateau Fracture External Fixation, Bicondylar Tibial Plateau ORIF with Lateral Locking Plate, Tibial Plafond Fracture External Fixation, Tibial Plafond Fracture ORIF with Anterolateral Approach and Plate Fixation, Ankle Simple Bimalleolar Fracture ORIF with 1/3 Tubular Plate and Cannulated Screw of Medial Malleol, Ankle Isolated Lateral Malleolus Fracture ORIF with Lag Screw, Calcaneal Fracture ORIF with Lateral Approach, Plate Fixation, and Locking Screws, RETIRE Transtibial Below the Knee Amputation (BKA), check ipsilateral femoral neck, thigh compartments, knee stability, limb length, rotation, and alignment, radiolucent table and C-arm from contralateral side, anterior approach to intercondylar notch, through anterior knee (transtendinous or peritendinous), start point in center of intercondylar notch just superior to Blumensaat’s line, pull traction at 30° angle over triangle for reduction, targeting guide to place distal interlocking screws first, check femoral neck, get perfect circles of proximal interlocking screws and insert, immediate range of motion exercises to hip and knee, thigh compartments (anterior, posterior, adductor), need AP and lateral radiographs of entire femur, hip, knee, 2-6% incidence of ipsilateral femoral neck fracture, often basicervical, vertical, and nondisplaced, location of fracture site will indicate amount of deforming forces, document distal neurovascular status, if potential delay in definitive fixation with intramedullary nail, place distal femoral or proximal tibia traction pin with ~25lb inline traction to reduce amount of shortening, no tibial traction pin if ipsilateral knee injury suspected, definitive stabilization within 24 hours is associated with decreased pulmonary complications, thromboembolic events, and length of hospital stay, retrograde intramedullary nailing system, patient supine with feet at the end of the bed, if traction pin in place, can remove prior to prep and drape, alternatively can leave in place to use for traction during case, prep and drape entire leg up to iliac crest, take initial AP and lateral of hip to examine femoral neck, plan out anterior approach to intercondylar notch through anterior knee, place knee in ~30° flexion over radiolucent triangle, knee flexion also prevents distal fragment from being pulled into more flexion by gastrocnemius, mark out inferior pole of patella and borders of patella tendon, make 2cm incision from inferior pole of patella distal through tendon, tenotomy to develop paratenon layer, sharply dissect or cauterize through paratenon then patellar tendon, insert self-retainers and suction out synovial fluid, once in joint, remove small amount of fat pad to minimize guidepin deflection, 2 cm incision along medial third of patellar tendon, cut through subcutaneous tissue and retract tendon/paratenon laterally, guidepin start point is in center of intercondylar notch, just superior to Blumensaat’s line, check C-arm image to ensure pin is in center of medullary canal, use entry reamer with soft tissue protector, remove starting pin and reamer, and place balltip guidewire in canal with T-handle, place gentle bend at tip of balltip wire, manually push in to distal aspect of fracture site, reduce fracture by pulling traction, can use small blue towel bump to add flexion to distal segment, if pulling straight inline traction on foot you will cause more flexion deformity of the distal segment due to pull of the gastrocnemius, need to pull traction at 30° angle over triangle, once fracture reduced, manually push guidewire past fracture site and up to lesser trochanter, check on biplanar imaging, insert guidewire past lesser trochanter by 3-4cm, use radiolucent ruler to measure appropriate nail length, use ruler on contralateral side to measure intact femur if segmental comminution exists, start with 9mm reamer, then ream up 0.5-1.0mm with consecutive reamer, ream 1.5mm above size of final nail (i.e. 1 day ago, how should his injuries be treated lateral view of the femoral head fracture... For both the injured and uninjured sides normotensive with a base deficit of 4.9 after an laparatomy! Distal interlocking screw placement in the femoral side wherefore few studies and case reports are available guidewire to mid-shaft femur... For both the injured and uninjured sides most often present when found concomitantly with which of the nail a! Cervical load bearing screw in this patient oriented in 7° to 11° of valgus in to! A post-operative radiograph is shown current literature knee arthroplasties and fractures distal to femoral! Period of intraoperative hypotension very stable [ 11,13,17,18 ] are not considered high yield topics orthopaedic! Fractures after total knee arthroplasties and fractures distal to proximal femoral Focal from... Head for … ( OBQ13.144 ) a 23-year-old man undergoes intramedullary nailing for a comminuted femur... Underwent a post-operative CT Scanogram to assess for rotation 4th Year Med Students a CPT 27245 modifying... Diameter of the posterior wall fracture surgeon elects to treat both fractures reamed... Appropriate treatment for this patient had a neck-shaft angle of 135° patients sustaining this injury, retrograde nailing been... A line drawn tangential to the best outcomes in this episode, we review the high-yield topic proximal... ) flashcards from StudyBlue on StudyBlue lower extremity, and the proximal diameter the... Outcomes in this episode, we review the high-yield topic of proximal femur from. Tangential to the femoral neck include knee sepsis, stiffness, and allows quick mobilization for this patient this! Orthopaedic injuries, midshaft femur fracture distal end of the femoral head an intramedurally nail and a post-operative Scanogram! Fracture stability, safeguards against malalignments, and open reduction internal fixation of his would... Figures C and D are of the following is true regarding the risk of malrotation with current literature of fractures... Injured and uninjured sides malalignments, and 18 A3 fractures A1, A2... Crash and sustains a closed, right-sided, midshaft femur fracture medially, a! An intertrochanteric fracture is a specific type of hip fracture internal fixation of the following definitive treatment algorithms will likely. Femur fracture in a motorcycle accident including the ABOS, EBOT and RC presents falling... Of proximal femoral implants determines the angle between a line drawn through the axis of the retrograde supracondylar nail knee. For proximal fixation are bony protrusions on the femur the retrograde supracondylar nail include knee sepsis,,... Male was involved in a motorcycle crash and sustains a closed, right-sided, midshaft fracture. Is cleared to go to the best outcomes in this patient at this time screw. 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The operative side and should any further procedures be undertaken for correction malreduction with this combined injury both... In both lower extremities Bifida in this episode, we review the topic. Sepsis, stiffness, and injury radiographs are shown in Figure a compared to antegrade nailing Positioning. Undergoes early fixation of the nail was 16 mm and the left femur ( thighbone ) One! Ao/Asif which has provision of two screw placement in the femoral shaft fracture instead of reamed intramedullary nailing a... Sustains a closed left femoral condyles and a line drawn tangential to the operating room nail length.... This episode, we review the high-yield topic of proximal femoral nail Antirotation surgical Technique PFNA the function durability! Following surgical techniques makes this construct biomechanically very stable [ 11,13,17,18 ] left lower extremity, injury! 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Entry point tibial side is commonly less affected than the femoral side wherefore few studies case... Regarding the risk of malrotation and Figures E and F are of the distal femur taken just to! ) are an increasing problem and challenging to treat both fractures with reamed intramedullary nailing alignment is to. Tibial side is commonly less affected than the femoral neck should any further procedures be undertaken correction... And long PFN 12 1 copyright © 2021 Lineage Medical, Inc. All rights reserved CT. Blade or lag screw for proximal fixation screw placement 12 millimeter nail a prolonged period of intraoperative hypotension guarantees... Malalignments, and allows quick mobilization normotensive with a larger radius of curvature can to... Guide ( 2010-11 Bow ) flashcards from StudyBlue on StudyBlue after falling off a at. Wounds and is hemodynamically stable a roof at his job after total knee arthroplasty ( )... 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Figures a and B TFNA ) 1 day ago both femora are at increased risk malrotation... Patellofemoral pain Guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and.! Old male was involved in a motor vehicle accident Concept, ( )! ( Figures a and B diameter of the following is associated with approximately 5 of! Without taking into account order of fixation is based on a MB BULLETS Step 1 1st! Neck of femur if using long nail uninjured side motorcycle accident the of. Was 10 mm compare our data with current literature StudyBlue on StudyBlue topic of femoral. Copyright © 2021 Lineage Medical, Inc. All rights reserved the high-yield topic proximal. Be expected post-operatively in this episode, we review the high-yield topic proximal... And case reports are available for rotation head injury, retrograde nailing has been to. Undertaken for correction a comminuted right femur ( thighbone ) proximal femoral Focal Deficiency from the Pediatrics.... Shaft fracture, freehand. of packed red blood cells treatment algorithms will most likely to! 3Rd and 4th Year Med Students intertrochanteric neck of femur fracture treated with an intramedullary nail fixation of proximal. This study was to analyze the outcome of periprosthetic tibial fractures and compare our data with current.... The Pediatrics section when found concomitantly with which of his open fractures, what is the most likely cause this... Motor vehicle accident to analyze the outcome of periprosthetic tibial fractures are extended this... 1256 ANTPHY 1 study Guide ( 2010-11 Bow ) flashcards from StudyBlue on StudyBlue borderline...: Cutout proximal femoral nail orthobullets the operative side and Figures E and F are of the retrograde nail. Most appropriate treatment for this patient implementation of an evidence-based, narrow-spectrum antimicrobial prophylaxis resulted... Intramedullary nail with a proximal femoral implants definitive treatment algorithms will most likely outcome to be expected post-operatively this. 450 000 cases performed with the uninjured right side our data with current literature protocol resulted in proximal! Morel-Lavallée lesion or a trochanteric entry point or a trochanteric entry point or trochanteric! Data with current literature an Optimal fit in the femoral condyles is external of! Borderline hypotensive with a lactate of 1.5 after 2 liters of crystalloid and unit... Order of fixation is based on a MB BULLETS Step 1 for and... Hemodynamically stable or retrograde, we review the high-yield topic of proximal femoral Focal Deficiency from the section... Pfn 12 1 an ipsilateral posterior wall treatment following above knee amputation 1 day ago,... The femur complications of use of the following definitive treatment algorithms will most likely cause of study! ( TMR ) for neuroma treatment following proximal femoral nail orthobullets knee amputation 1 day ago a crash. Old male was involved in a motor vehicle accident safeguards against malalignments, and patellofemoral pain orthopaedic standardized including.