^DEFINITION

^{A femoral shaft fracture is any fracture of the femoral diaphysis from 5 cm below the lesser trochanter to within 6 to 8 cm of the distal femoral articular surface.}

^{Some fracture lines extend proximal or distal to the shaft and are therefore not considered shaft fractures.}

^{This description is mostly semantic, as the more important aspect of definition is understanding the “personality” of the fracture.}

^{Fractures whose essential fracture element is diaphyseal with an extension into the outer regions are different from fractures whose essential fracture element is subtrochanteric or supracondylar with extension into the diaphysis.}

^{In some circumstances, proximal and/or distal femur involvement may warrant a different treatment (ie, plating, cephalomedullary nail, etc.) than intramedullary nailing.}

^{For the purposes of this chapter, we will focus on fractures that are amenable to antegrade nailing.30}

^{The Abbreviated Injury Scale (AIS) score for an isolated femoral shaft fracture is three, thus making the Injury Severity Score for an isolated femoral shaft fracture a nine.}

^{Open fractures are usually graded according to the Gustilo-Anderson classification, but this classification system was designed for the tibia—a subcutaneous bone. Thus, if absorbed energy is considered, significantly more energy would be required to fracture a femur because there is more soft tissue envelope around a femur than around a tibia. Nonetheless, this system is widely employed in the femur for descriptive purposes.}

^{The fracture classification system previously used most commonly was the Winquist classification, but it has been modified and standardized with the AO Orthopaedic Trauma Association (AO/OTA) classification, which is the recommended system.22, 40 In the AO classification, the femur is number 32 and further}

^{subdivided in simple, wedge, and complex fractures as shown ( FIG 1).}

 

^ANATOMY

 

^{The femur is the longest bone in the body. It is subject to very high stresses in the proximal region because of the need to transition the forces of body weight via a lever arm (femoral neck) into more axial forces distally. As}

^{such, the subtrochanteric area is subject to very high stresses.19}

 

 

^{The femur is flat on the anterior and lateral surfaces. On the posterior femur surface, there is a taper that is confluent with the linea aspera.}

 

^{The linea aspera is a very thick fascial structure and frequently remains in continuity but separates from the femur.}

 

^{Entrapment of the linea aspera between the fracture ends may impede closed fracture reduction, especially}

^{with simple fracture patterns. The bone ends may need to be “unwound” to effect a reduction.}

 

^{The linea aspera protects many perforating periosteal vessels and may help explain the high healing rate of femoral shaft fractures (about 95%).}

 

^{There are three thigh compartments: anterior, posterior, and medial.}

 

 

^{Thigh compartment syndrome may occur and generally involves the anterior compartment. Frequently, release of the anterior compartment will relieve pressure.}

 

 

 

^{FIG 1 • AO/OTA classification of femoral shaft fractures.}

 

 

^P.450

 

^{The proximity of the gluteal compartment places it at risk as well. It should also be considered with compartment syndromes.}

 

^{The femur has an anterior bow and is not a circular bone.}

 

 

^{Both anterior and lateral bowing is important to recognize, especially if abnormal (eg, metabolic bone}

^disease).

 

 

^{The anterior bow has an average radius of curvature of about 120 cm. If there is excessive bowing, good preoperative planning is needed.}

 

^{Surgical options for such abnormal bowing include plate fixation or a controlled osteotomy to allow nail placement.22}

 

^{The endosteal diameter is important to recognize, especially with young or sclerotic bone.}

 

 

^{Normal aging and osteoporosis results in a biomechanical adaptation of enlarged inner diameter. Thus, elderly individuals may have a larger diameter femoral shaft with a thinner cortex. As in other cylindrical tubes, the bending rigidity of the femur is roughly proportional to the radius to the fourth power.}

 

^{The vascular supply to the femur is a nutrient artery off the second perforating branch of the profunda femoris, entering posteriorly along the linea aspera.}

 

 

^{Normally, periosteal arterial branches supply the outer one-quarter to one-third of the cortex; the direction of blood flow is directed centrifugally from the high-pressure medullary arterial system to the low-pressure}

^{periosteal system.27}

 

^{Once fracture occurs, a reversal of blood flow occurs with blood flowing centripetally from periosteal vessels directed radially inward (because the higher pressure intramedullary system is disrupted).26}

^PATHOGENESIS

 

^{Femoral shaft fractures are high-energy injuries in the young; in the elderly, simple falls from ground level are sufficient to fracture the femur.}

 

^{Fracture patterns give clues to the mechanism.}

 

 

^{For example, a simple transverse fracture with a butterfly fragment is due to a bending force (eg, T-bone vehicle crash).}

 

^{Spiral fracture patterns are usually due to torsional forces.}

 

^{Indirect high-energy mechanisms, such as a fall from a height or motor vehicle crashes, will usually incur a significant initial deformity during the fracture process.}

 

 

^{The active and passive recoil of the muscle soft tissue envelope will decrease the initial displacement. Thus, the extent of soft tissue injury can be difficult to appreciate.}

 

^{Open fractures in this setting are usually “inside-out” injuries.}

 

^{Direct mechanism fractures are from ballistic injuries, crush injuries, or other weapons (eg, chainsaw, axe).}

 

 

^{With these injuries, there may be less initial displacement of the fracture and soft tissues, but the amount of soft tissue injury can still be extensive.}

 

^{In ballistic injuries, the shock and cavitation can result in extensive tissue necrosis.}

 

^{In both direct and indirect mechanisms, it is important to recognize that the zone of tissue injury may extend well beyond the fracture site.}

 

^{NATURAL HISTORY}

 

^{1500s: The earliest record of intramedullary splinting is from the Spanish and Aztecs who used wooden sticks to}

^{treat pseudarthroses.}

 

^{1800s: Germans used ivory pegs with interlocking holes. In 1890, Gluck used the first interlocking ivory nail with interlocking pegs.}

 

^{Early 1900s: In the early 20th century, the natural history of femur fractures was poor.}

 

 

^{The mortality of wartime femur fracture before and during World War I (WWI) was approximately 80%. Serendipitous use of a wheeled splint for transport off the battlefield resulted in a precipitous drop in the mortality rate (the Thomas splint was thus developed). During WWI, Hey Groves used metallic rods for the treatment of gunshot wounds but there was a very high infection rate and it was not universally accepted.}

 

^{Because surgical techniques were primitive in those times, fears about infection and surgical complications resulted in most fractures being treated in traction.}

 

^{The outcome was frequently a shortened, rotated, varus malunion of the femur. Additional problems such as decubiti, venous thromboembolism, and pulmonary infections with prolonged bed rest resulted in high morbidity and mortality.}

 

^{1930-1940s: In 1931, Smith-Petersen reported the first successful use of stainless steel nail for the treatment of femoral neck fractures—the Smith-Petersen nail sparked an interest in the application of intramedullary devices for fracture treatment.}

 

 

^{Gerhardt Küntscher is considered the father of intramedullary nailing and much of his interest in intramedullary devices originated from his use of the Smith-Petersen nail for femoral neck fractures.}

 

^{Küntscher's first nail used (1940) was a V-shaped stainless steel antegrade nail; this V-shaped design had evolved to a cloverleaf design by the late 1940s. Küntscher's original technique was on open nailing (ie, exposing the fracture site). In Western nations, poor surgical technique resulted in high rates of infection and nonunion.}

 

^{1950-1960s: The 1950s saw the advent of intramedullary reamers and interlocking screws with Modny and Bambara introducing the transfixion intramedullary nail in 1953. Intramedullary nailing enthusiasm diminished in the 1960s in favor of compression plating, but by the late 1970s, renewed interest in developing closed nailing}

^{techniques appeared.5, 22}

 

^{1970s: With diminished interest in compression plating and improved reaming methods, closed nailing gained popularity by the late 1970s. The dominant design was the slotted cloverleaf-shaped interlocked nail, the AO, and Gross-Kempf nails.}

 

^{1980s: Küntscher's method was resurrected in the United States by early traumatologists, such as S. Hansen and M. Chapman, who used Küntscher's newer technique of “closed” femoral nailing.}

 

 

^{In the late 1980s, Brumback and colleagues reported the high success rate (98%) of reamed, statically locked intramedullary nails.10, 11}

 

^{The success rate of femoral nailing using closed technique resulted in low morbidity and began a change in practice to what we perform today.}

 

 

^P.451

 

^{Early studies outlined the benefits of early reamed femoral nailing.}

 

 

^{1990s-present: As survival of more traumatized patients increased, a subset of patients who may benefit from “subacute” nailing developed.}

 

 

^{Later studies identified patients at risk (eg, pulmonary injury, incomplete resuscitation, and brain injury) who}

^{benefited from stabilization of life-threatening injuries before fixation.}

 

 

^{This reflects the paradigm shift from early total care (ETC) to damage control orthopaedics (DCO).4, 24, 31}

 

 

^{Although some have advocated plating in such cases, there have been no studies demonstrating the superiority of one method over the other in terms of patient survival.6}

^{PATIENT HISTORY AND PHYSICAL FINDINGS}

 

^{Relevant history includes age, sex, mechanism of injury, associated injuries (ie, chest/head) loss of consciousness, weakness, paralysis, or loss of sensation.}

 

 

^{Metabolic conditions and any musculoskeletal conditions should be elucidated if possible.}

 

^{Patients should be evaluated according to the advanced trauma life support (ATLS) guidelines.}

 

^{Particular attention should be given to hypotension because femoral shaft fractures can be associated with up to 1000 to 1500 mL of blood loss. Although not solely responsible for hypotension, femoral shaft fractures can be a contributory source.}

 

^{Upon evaluation by first responders, the limb should be aligned and placed in a traction device, such as a Sager splint or a Thomas splint.}

 

 

^{These initial splints should be removed and replaced with skeletal or limb traction because of the risk of skin problems in the perineal or ischial and ankle areas. Traction improves patient comfort, restores length, and tightens the surrounding muscles. The taut surrounding musculature decreases potential space for blood loss, provides a tamponade effect to hemorrhage, and serves as a soft tissue stabilizer to the fracture fragments.}

 

^{It is essential to inspect the affected limb for any open wounds, swelling, and ecchymosis (see Exam Table for Pelvis and Lower Extremity Trauma, page 1).}

 

 

^{The extent of the open wound does not always correlate with the degree of soft tissue or fascial stripping due to the fracture.}

 

^{Vascular evaluation should include manual palpation of the popliteal, posterior tibial, and dorsalis pedis pulses.}

 

 

^{It is important to understand that a pulse is a pressure wave and can still be present in the absence of flow; alternatively, the absence of a pulse does not always mean absence of flow. A Doppler ultrasound device should be used in cases where a pulse cannot be palpated.}

 

 

^{Hypotension with peripheral vasoconstriction may accompany such injuries. The limb should be aligned before vascular examination.}

 

^{Asymmetric or absent pulses warrant a measurement of the ankle-brachial index (ABI). An ABI less than 0.9 is abnormal.}

 

^{Arteriography should be considered to rule out vascular injury.}

 

^{Neurologic evaluation includes motor and sensory function of the femoral and sciatic nerve.}

 

 

 

^{The femoral nerve may be difficult to examine secondary to pain associated with the fracture. Sciatic nerve function can be evaluated for both peroneal and tibial branches.}

 

^{The peroneal branch is tested with ankle and toe dorsiflexion and sensation on the top of the foot.}

 

^{Tibial branch function is tested with ankle and toe plantarflexion as well as sensation to the sole of the foot.}

^{IMAGING AND OTHER DIAGNOSTIC STUDIES}

 

^{The tenet of imaging a joint above and a joint below should be followed.}

 

^{Good anteroposterior (AP) and lateral views of the hip, femur, and knee are required.}

 

 

^{Such films can be obtained in the operating room but are essential in planning because the presence of a femoral neck fracture or a fracture about the knee will greatly change the operative tactic.}

 

^{Attempts should be made to get an internal rotation AP view of the femoral neck. However, with current trauma algorithms, the commonality of the pelvic computed tomography (CT) scan allows imaging of the femoral neck. The scan should be viewed before deciding on the surgical tactic.}

 

^{If radiographs are normal but the clinical examination suggests injury (eg, inability to bear weight, pain out of proportion to injury), coronal magnetic resonance imaging (MRI) may elucidate an occult fracture.}

 

 

^{CT scanning in these situations may not be sensitive enough to find such fractures.}

 

^{Occult femoral fractures may be hard to identify with preoperative radiographs.}

 

 

^{Use of CT scans of the abdomen that go to the level of the femoral neck have been found to be sensitive enough to identify such occult femoral neck fractures and should be done for most cases.35}

 

^{DIFFERENTIAL DIAGNOSIS}

^{Other injuries may occur concomitantly with femur fractures, including pelvic fractures, acetabular fractures, femoral neck fractures, and ligamentous injuries to the knee.}

^{If an effusion is present in the knee, the index of suspicion for a knee injury should be elevated.}

^{Distal femur fracture may also occur but may not be radiographically evident, especially in osteoporotic bone.}

^{In the absence of a reasonable mechanism, other causes for fracture such as metabolic bone disease or metastatic (or primary) fracture should be ruled out.}

^{Although rare, compartment syndrome without fracture will also manifest as thigh pain with inability to bear weight. In these cases, the physician should perform serial examinations for compartment syndrome, measure compartment pressures if the clinical examination is equivocal or indeterminate, and have a low threshold for fasciotomy.}

 

 

^{NONOPERATIVE MANAGEMENT}

 

^{Nonoperative management has typically been reserved for patients who are unfit for surgery, patients who are quadriplegic or paraplegic, patients in whom the benefits do not outweigh the risks, or other precluding factors (eg, active infection).}

 

 

^P.452

 

 

^{Truly nondisplaced fractures in a compliant and able patient may also be treated nonoperatively. Infants and young children may also be treated nonoperatively because of their ability to remodel.}

 

^{Nonoperative management consists of bed rest and skeletal traction (either through the distal femur or proximal tibia) with 20 to 30 pounds of weight.}

 

^{Attention should be given to mechanical and pharmacologic venous thromboembolism prophylaxis if this}

^{treatment is considered.}

 

^{SURGICAL MANAGEMENT}

 

^{Isolated femur fractures are not urgent. Appropriate evaluation and medical clearance should be performed to stabilize the patient expeditiously. Definitive treatment should be performed when appropriate resources are available (eg, knowledgeable staff, anesthesia,). It is not necessary to stabilize such fractures during off shifts unless indicated for other reasons (eg, open fracture, polytrauma).}

 

^{In the multiple injured patient (Injury Severity Score of more than 18), with pulmonary compromise or head injury, fracture fixation should be delayed until suitably cleared for surgical intervention, and damage control methods with use of a temporary external fixator should be considered.3, 6, 23, 29}

 

^{Patients with isolated femur fractures should have some method of traction, pain control, and deep vein thrombosis prophylaxis while awaiting surgical intervention.}

 

^{Currently, statically locked femoral nailing with limited reaming is the standard of care.}

 

 

^{The studies by Brumback et al7, 8, 9, 10, 11 determined that statically locked nails do not affect healing and avoid the problems of malrotation and shortening. Unreamed nails were proposed to limit effects of canal fill and the theoretical concern of infection. Neither concern was proven, and, in fact, small unreamed nails had}

^{the same problems as in the tibia: higher rates of nonunion. Currently, the “ream-to-fit” technique is used.38}

 

^{Recently, the reamer-irrigator-aspirator (RIA) has been used to minimize the pressure-induced embolization from the marrow. As studies are ongoing and controversial, this method may reduce the risks in the multiply injured patients.33, 39}

 

^{Open fractures can be safely nailed if a thorough irrigation and débridement is performed.}

 

 

^{Absorbable antibiotic beads (calcium sulfate, not calcium phosphate, mixed with vancomycin or tobramycin) can be used at the time of definitive closure to provide local antibiotic delivery.28}

 

^{In severely contaminated fractures, a staged approach using temporary antibiotic beads (using polymethylmethacrylate mixed with vancomycin or tobramycin) and external fixation, followed by nailing within 2 weeks (with or without use of absorbable beads), can be employed.}

 

 

^{If there is no pin tract infection, conversion from external fixation to intramedullary nailing is best performed within 10 to 14 days after external fixation to minimize infection risk.13}

 

^{In such cases, the risk of infection is increased but acceptable in lieu of prolonged bed rest.}

 

^{Because of deforming forces in proximal femur fractures, the proximal segment tends to flex and externally rotate.}

 

 

^{Care should be taken to ensure that the posterior cortex of the proximal fragment is not inadvertently reamed away.}

 

^{In distal fractures, the distal segment tends to flex at the knee (recurvatum of fracture).}

 

^{With distal fractures, care should be taken to avoid varus or valgus reduction. This can occur because the opening of the medullary canal distally does not have intimate contact with the nail and does not “self-align.”}

 

^{Transverse fractures may contain a segment of intact linea aspera that peels off the posterior aspect and may get entrapped in the fracture.}

 

 

^{It can result in shortening that may be difficult to overcome without either “unwinding” the fracture or opening}

^{the fracture site.}

 

^{In skeletally mature children, intramedullary nailing offers the same benefits as in adults.}

 

 

^{Attention should be paid to adolescents with very valgus neck angles, as some have hypothesized that this can increase the risk of avascular necrosis of the femoral head. However, with newer implants such as trochanteric entry or lateral entry nails, many of these concerns can be alleviated.}

 

^{Skeletally immature children may still be considered for some form of intramedullary treatment after considering remaining growth, type of fracture, and benefits over other methods of treatment.1, 14}

^{Preoperative Planning}

 

^{All films should be reviewed, with particular attention paid to the presence of an ipsilateral femoral neck fracture.}

 

^{The overall condition of the patient and any associated injuries should be contemplated before embarking on a surgical tactic.}

 

^{In the presence of pelvic or acetabular fracture, pregnancy, or obesity, one should consider a more elegant tactic, such as retrograde nailing, as opposed to antegrade nailing.}

 

^{If suitable, antegrade nailing in the supine position can be safely performed with proper positioning and knowledge.}

 

^{Several options have to be considered during preoperative planning. They include the following:}

 

 

 

^{Table: fracture table or radiolucent Position: supine or lateral}

 

^{Entry point: piriformis or trochanteric}

 

 

^{Type of nail: cephalomedullary or standard Use of traction: skeletal, boot, or manual}

 

^{Reduction tools: Crutch, ball spike pushers, 5.0- or 6.0-mm Schanz screws with T-handles, mallet, F tool; in the remote case the surgeon needs to perform an open reduction, conventional reduction clamps such as Weber clamps or Verbrugge-type clamps can be useful.}

 

^{As mentioned before, strong consideration should be given to checking fine-cut CT scans to evaluate the femoral neck. Before the surgeon leaves the operating room, he or she should ensure that femoral intramedullary nail fixation has resulted in satisfactory: (1) length, (2) alignment, (3) rotation, and (4) intact femoral neck (in cases where a piriformis-entry nail was used).}

 

^Positioning

 

^{Fracture table}

 

 

^{Standard fracture tables (eg, those used commonly for hip fractures) can be used for antegrade femoral nailing but are best used for supine position nailing.}

 

 

^{A large and well-padded perineal post should be used. Traction should be used sparingly and only when needed.}

 

^P.453

 

^{The legs should be scissored to facilitate imaging and allow for appropriate countertraction. Placing the opposite leg in lithotomy position can allow rotation of the pelvis when traction is applied.}

 

^{The ability to image all aspects of the femur should be verified before preparing and draping (FIG 2A).}

 

^{Radiolucent tables}

 

 

^{Newer tables allow free image intensifier access to the lower extremity.}

 

^{Some of the tables (Jackson table; Mizuho Osi, Orthopaedic Systems, Inc., Union City, CA) also provide traction assemblies. These types of tables are suitable for multiple limb operations (FIG 2B).}

 

^{Our preferred method uses a radiolucent Jackson table with traction apparatus and lateral positioning (FIG 2C).}

 

^{Supine position}

 

 

^{The supine position may be easier for surgeons to visualize anatomic relationships, although it is potentially more difficult to perform nailing of obese patients in this position.}

 

^{Supine positioning may be preferred in patients with spinal cord injuries or severe chest injuries.}

 

^{If the supine (floppy) positioning on a radiolucent table is chosen, it helps to position the patient at the edge of the bed with a small bolster under the pelvis—with the upper torso slightly adducted. Supine nailing can also be performed on a fracture table to allow traction.}

 

^{If the patient is supine with the leg free, preparing and draping should include the posterior aspect of the glutealarea because crossing the leg over will facilitate access to the piriformis.}

 

 

 

^{FIG 2 • A. Supine positioning on a fracture table with legs scissored. Slight obliquity using a bump under the sacrum helps with hip visualization. B. Supine position without traction on flat-top table. The ipsilateral hip should be close to the edge, and a bump under the sacrum will help with visualization. Standard lateral views of the hip for entry points can be used but so can frog-leg laterals. C. Lateral position with traction. Skeletal traction in the proximal tibia or distal femur can be used. The perineal post is pictured here in the perineum, which is best for proximal fractures. In fact, little traction is usually needed and the post is frequently positioned under the apex of the fracture and used to overcome gravitational sagging. If traction will be needed, we have found that placing a blanket on the “down” leg and securing the contralateral thigh with a sling of tape coursing in a proximal and oblique fashion will resist moderate amounts of traction. D.}

^{Preparation and draping of the leg using a flat-top table without traction should include posterior sections of the buttocks. The leg can be crossed over to gain easier access to the piriformis starting point.}

 

 

^{Even with the newer trochanteric entry technique and implants, the ability to manipulate the leg in adduction may be useful during the procedure (FIG 2D).}

 

^{Lateral position}

 

 

^{The lateral position facilitates gaining an entry point, especially with a piriformis starting point in obese patients, and can be used with/without traction.}

 

^{When using the lateral position, the pelvis is rolled forward about 15 degrees to allow lateral imaging of the proximal femur.}

 

^{Care should be taken during positioning for proper padding and spinal precautions if occult spinal injury may be present.}

 

^Traction

 

 

^{If traction is used, it frees an assistant and the length and rotation can be “set.”}

 

 

^{If manual traction is used, the length and rotation need to be checked before final interlocking. Skeletal traction can be via the proximal tibia or distal femur.}

 

^{The surgeon should be careful if there is any ligamentous instability of the knee, as suggested by a knee effusion or other sign of injury.}

 

^{In such cases, distal femoral traction can be used and it can be prepared and draped into the operative field.}

 

 

^{Use of distal femoral traction can complicate distal interlocking because of the proximity of the traction apparatus with the interlocking site.}

 

 

^P.454

 

^{Boot traction is a very common alternative.}

 

 

^{Unlike tibial or femoral skeletal traction, where the knee is slightly bent, boot traction uses a straight leg (FIG 2A).}

 

^{Care should be taken to avoid nerve traction injury (eg, avoid prolonged and excessive traction).}

 

 

^{Small perineal posts and long durations of traction have been shown to increase the risk of pudendal nerve injury.}

 

^{If traction is used, it should be first applied to determine the “reducibility” of the fracture. Then it should be reduced during prepping and applied as needed.}

 

^{Large and well-padded perineal posts should be used whenever possible.8, 20}

 

 

^{Regardless of patient position, the surgeon should ensure that the patient has complete muscle relaxation to facilitate reduction.}

 

^TECHNIQUES

• ^{Soft Tissue Dissection}

^{Whether using a cephalomedullary nail or piriformis fossa nail, the surgical approach is similar. The surgeon palpates the greater trochanter.}

 

 

^{For trochanteric entry, the skin incision is based about 4 to 10 cm above the trochanter in line with the femur.}

 

^{The tensor fascia is incised, and the abductor musculature is gently separated.}

 

^{The tendinous insertion of the gluteus medius is frequently more distal, and this tendon can be gently spread to identify a bursal area just below the medius and above the minimus.}

 

^{For piriformis entry, the incision is made about a handbreadth along the line between the trochanter and the posterior superior iliac spine.}

 

^{Once the gluteus maximus is gently separated, the access to the piriformis fossa is posterior to the medius.}

 

^{The piriformis fossa can be easily palpated as a “dimpled ledge” behind the trochanter. This anatomic feature is used during the percutaneous approach for proprioceptive feedback during pin placement.}

• ^{Trochanteric and Piriformis Fossa Entry}

 

^{After soft tissue dissection, the tip of the greater trochanter is palpated. The piriformis fossa is palpated medially.}

 

^{The ideal starting point for a piriformis fossa nail is in the fossa along the medial upslope of the greater trochanter because this is most in line with the shaft.}

 

^{This point may vary between patients and should be confirmed with intraoperative fluoroscopy.}

 

^{The surgeon can have an assistant adduct the extremity to aid in exposing this spot (TECH FIG 1A).}

 

^{Once the starting point is identified by palpation and confirmed with fluoroscopy, the cortex is penetrated with either an awl or a threaded Kirschner wire.}

 

^{Every effort should be given in establishing an accurate starting point (ie, one that is in line with the femoral shaft).}

 

^{If this is not possible, as long as the entry site is collinear with the shaft, the pin can be directed anteriorly. In these cases, care should be taken not to perforate the anterior cortex (TECH FIG 1B).}

 

 

 

^{TECH FIG 1 • A. AP image of the correct position of a guide pin for piriformis entry. B. Lateral image of}

^{piriformis starting point. The pin need only start in the piriformis; it will frequently course anterior, and care should be taken not to penetrate the anterior cortex. The rigid reamer need only open the top of the bone for access to medullary canal.}

 

 

^{In supine nailing, especially with obese patients, this can be very difficult. Adduction of the limb may not always be possible because of body habitus and setup and especially with proximal fractures.}

 

^{In these cases, preparing under the buttock and accessing from a more posterior approach may allow access to the fossa.}

 

^{The lateral positioning allows the easiest access, with very few problems. In fact, nailing can be performed percutaneously (described in the following text) with little problem when using the lateral position.}

 

^{Recent literature has demonstrated no significant difference in functional outcome between patients treated with a piriformisentry nail versus a trochanteric-entry nail.32}

 

 

^{The authors would like to emphasize that many later intraoperative complications with intramedullary nailing of the femur originate from a poor starting spot; it is worth investing the time to ensure this portion of the procedure is performed correctly.}

 

^{Percutaneous Method of Nailing}

^P.455

 

 

^{The percutaneous method of nailing42 uses cutaneous landmarks to identify the ideal entry site, which is usually about one full handbreadth (8 cm) from the posterior corner of the trochanter toward the posterior superior iliac spine ( TECH FIG 2A).}

 

^{The incision is a stab wound.}

 

^{A guide pin is advanced to the trochanteric bursa (TECH FIG 2B).}

 

^{The pin is “rolled” off the posterior slope of the trochanter and then advanced distally and anteriorly (TECH FIG 2C,D).}

 

^{A very distinct resistance is felt, as if on a pedestal or ledge of bone. The tip of the pin provides proprioceptive feedback when this occurs, and it can be felt that there are structures anteriorly and medially, which constitute the “walls” of the fossa.}

 

 

 

^{TECH FIG 2 • A. The cutaneous site for percutaneous nailing, situated about midway and slightly posterior to midpoint between tip of trochanter and posterior superior iliac spine. B. Photograph showing pin driven into piriformis via percutaneous wound. C. The pin usually finds the trochanteric bursa. It is then rolled off the back and advanced anterior and distal until a distinct resistance is felt. It should rest on the “ledge” of bone known as the piriformis fossa. D. The pin has a resistance to anterior and distal advancement but can move medial and posterior. (continued)}

 

 

^{At this point, image verification is performed.}

 

^{If the pin is not coaxial with the femur, what is most important is that the tip of the pin is centered.}

 

^{The pin is advanced to engage the cortex, and then a 9- to 12-mm rigid reamer is used to open the proximal femoral cortex (TECH FIG 2E).}

 

^{This reamer need only be advanced enough to open the cortex and provide access to medullary contents. Care should be taken not to ream too deeply and perforate the cortex of the proximal femur anteriorly (see TECH FIG 1).}

 

^{Once this step is accomplished, the remainder of the procedure can be done with standard methods, and instruments are passed via the keyhole skin incision (TECH FIG 2F-H).}

 

^P.456

 

 

 

^{TECH FIG 2 • (continued) E. The rigid reamer advances over the pin to enter the proximal femur. Use of irrigation will help prevent soft tissue catching. F. Insertion of the nail over the guidewire. With use of a bent guidewire and ream-to-fit technique, the likelihood of an incarcerated reamer is very low, and exchange of the guidewire with a chest tube is not needed (unless a ball-tipped guidewire is used). G. Intraoperative photo of final wounds. H. Entry site wounds are usually about 1.5 cm.}

• ^{Trochanteric Entry, Guidewire Placement, and Fracture Reduction}

 

^{After soft tissue dissection (as described previously), the surgeon palpates the tip of the greater trochanter and its AP dimensions.}

 

^{Because of the inherent anatomy of the proximal femur, the ideal starting spot for a trochanteric entry nail is at the tip of the greater trochanter (mediolateral) and the junction of the anterior one-third and posterior two-thirds of the greater trochanter.}

 

^{This spot may vary from person to person, but the correct starting point is one that is in line with the femoral shaft.}

 

^{Once the correct starting spot is identified, the outer cortex is penetrated with either an awl or a pointed guidewire (TECH FIG 3A).}

 

^{In this method, because the abductor mechanism is being split, soft tissue protection is important.}

 

^{After the starting point is identified, a guidewire is placed into the proximal femur and passed down the canal.}

 

^{Forceful and jerking motions can be avoided by firmly twisting the guidewire through the cancellous bone.}

 

^{A gentle J bend at the distal 1 cm of the wire allows the wire to be “bounced” off cortices and to be}

^{“steered” in metaphyseal areas (TECH FIG 3B).}

 

^{The proprioceptive feedback of a wire passing along the medullary canal is similar to the sensation of pushing a stick on a sidewalk.}

 

^{If the fracture is not reduced sufficiently to easily pass the wire across, there are several techniques available to facilitate reduction and wire passing.}

 

^{Some nail systems provide a cannulated rod that is placed over the wire and passed into the proximal femur. This rigid wire holder functions as a wand to manipulate the proximal fragment as the wire approaches the fracture so that it can easily be passed across (TECH FIG 3C).}

 

^{An F or H bar, a crutch, or both can also be useful to manipulate the proximal and distal fragments (TECH FIG 3D).}

 

^{Sometimes, the fracture cannot be perfectly reduced, but enough provisional alignment can be established to pass the guidewire.}

 

^{If the fracture is unstable and difficult to reduce after numerous attempts, a small incision can be made along the lateral thigh over the fracture and the fracture can be digitally reduced and provisionally aligned.}

 

^P.457

 

 

 

^{TECH FIG 3 • A. The entry point for the trochanter is usually at the tip of the trochanter on the AP view and the junction of the anterior 1/3 and posterior 2/3 on the lateral view (not shown). B. Bent straight guidewire. This helps to “steer” the wire in metaphyseal bone and will prevent reamer heads from disengaging (relevant only in modular designs). C. The “wand.” It is available on some sets or can be performed with some extraction rods. It is placed over the guidewire into the proximal segment, down to the level of the lesser trochanter. It can manipulate the proximal fragment to aim it into the distal segment, after which the guidewire is advanced into the distal fragment. This is much more desirable than struggling with manual methods. D. F bar. This can be placed around the thigh to effect the desired translation. In out-of-plane deformities, the bar can find the “ideal” orientation and effect a reduction. E. The joystick method. Small terminally threaded wires can be drilled into the cortex of each segment and used to manipulate the fragments into reduction. Small external fixator pins can also be used and have been previously described. F. Intraoperative image of guidewire passed across fracture. (continued)}

 

 

^P.458

 

 

^{TECH FIG 3 • (continued) G. Illustration demonstrating unicortical placement of external fixation Schanz pins to manipulate the fracture. These pins can be placed laterally or anteriorly and should unicortical so that the guidewire can pass.}

 

 

^{In some cases, the incision can be lengthened to allow placement of “lobster claw”-type clamps.}

 

^{Alternatively, 3-mm threaded guide pins can also be used (TECH FIG 3E). Other methods include the use of unicortical “joystick” half-pins from an external fixator set (usually a 5-mm half-pin) (TECH FIG 3F,G).}

 

^{The guidewire position in the distal segment is confirmed with intraoperative fluoroscopy.}

 

^{The guidewire should be passed down to the distal femur physeal scar and should be center-center on both the AP and lateral views. A bend in the tip of the guidewire can facilitate achieving a satisfactory position in the distal femur.}

• ^{Measurement and Reaming}

   

  ^{Once the guidewire has been placed, the length of the nail is measured either with a measuring device (usually supplied by the intramedullary nail system) or by using a guidewire of the same length.}

   

  ^{Placing the second wire at the entry site and measuring what is not overlapping with the inserted wire provides nail length.}

   

  ^{Before measuring, the surgeon confirms the proximal position of the ruler on the greater trochanter.}

   

  ^{The surgeon should make sure that there is no soft tissue between the ruler and the top of the greater trochanter, as this can artificially increase the length of the nail chosen. After the length is determined at the hip, the surgeon should determine if there is a fracture gap that he or she may backslap to achieve}

  ^{direct cortical contact of the fracture. If this is the case, then a slightly shorter nail should be used to account for the nail's migration proximally.}

   

  ^{Average nail lengths range from 38 to 42 cm.}

   

  ^{Using the radiographs of the femur, the surgeon can estimate the beginning reamer size.}

   

  ^{With “tight” canals, reaming should begin with lower sizes, and sequential reaming can begin starting with the lowest end-cutting reamer size available (usually 8.5 or 9 mm).}

   

  ^{When starting to ream, the surgeon should pay particular attention to keep the reamer medial in the proximal femur to prevent reaming out the posterior or lateral cortex.}

   

  ^{If the reamer does not pass easily, the surgeon should check its position with fluoroscopy because the reamer may be hitting cortical bone (usually anteriorly).}

   

  ^{Reaming can be increased by 1.0-mm increments until distinct “chatter” is encountered, after which it should increase in 0.5-mm increments.}

   

  ^{Once endosteal chatter is encountered, reaming should continue for another 1.0 to 2.0 mm, and a nail diameter of 1.0 to 1.5 mm smaller than the largest diameter reamed should be used.}

   

  ^{With modern nail designs, most male patients can be treated with 11- to 13-mm nails and most females with 10- to 12-mm nails.}

   

  ^{Care should be taken when there is a tendency for a deforming force to allow for “eccentric” reaming (eg, proximal fractures).}

   

  ^{In these cases, without attention, eccentric reaming can remove cortical bone and create defects that result in deformity or a nail outside the bone.}

   

  ^{Intramedullary reaming has a detrimental effect on the endosteal blood supply, but this effect has not translated into a worse clinical outcome. Reaming should be performed at slow driving speeds and high}

  ^{revolutions with sharp reamer heads to minimize intramedullary pressure and heat.28}

   

  ^{Fat embolism syndrome is always a possible concern during intramedullary reaming and is characterized by acute hypoxia (respiratory signs/symptoms), confusion (cerebral signs/symptoms), and a petechial rash. Intravascular fat continues in the circulation of the lungs, kidneys, and brain for 72 hours after reaming.}

   

  ^P.459

• ^{Nail Placement}

   

  ^{If a ball-tipped wire is used, the surgeon should confirm that it can be pulled through the nail or exchanged for a smooth-tip wire.}

   

  ^{After the nail has been inserted, its position is checked distally, at the fracture site, and proximally near its insertion site.}

   

  ^{The surgeon ensures that the nail is not too proud above the greater trochanter or piriformis fossa.}

   

   

  ^{If the fracture site is distracted, traction should be reduced or adjusted to effect a satisfactory reduction. Length and rotation need to be reconfirmed before interlocking. Several methods can be used.17, 18, 36, 37}

   

  ^{Cortical characteristics}

   

  ^{The femur diameter is not symmetric. Variances in cortical thickness can be used to estimate rotation in transverse fracture patterns.}

   

  ^{Fracture lines can also be used to estimate correct rotation.}

   

  ^{Radiographic methods}

   

  ^{One method to determine rotational alignment is to check a lateral view of the contralateral hip and}

  ^{distal femur. These lateral views of the normal hip are then compared to the affected extremity's lateral proximal/distal femur views. The measured difference should be mirrored in the fractured side if}

  ^{rotation is correct. Further discussion on femoral malrotation can be found by Lindsey and Krieg.21}

   

  ^{In cases of comminution or bilateral fractures, another method can be used to determine or set the rotation. A true lateral of the distal femur is obtained, and the intensifier is then moved orthogonal to this position, and the proximal femur is visualized to obtain a profile of the lesser trochanter. The images are saved for reference and mirrored on the fractured side or contralateral side if bilateral.}

   

  ^{Baseline rotation can also be determined clinically. If the patient is positioned supine with the leg draped free, preoperatively, the surgeon should “eyeball” the baseline rotation of the contralateral leg. During or at the end of the case, the surgeon can then compare the affected extremity's rotation and length compared to the contralateral side.}

   

  ^{Surprisingly, rotational deformities appear to be well tolerated, with an average of 28% of patients having a deformity of more than 15 degrees.}

   

  ^{Internal rotation is tolerated better than external rotation.}

   

  ^{In all cases, a clinical examination of rotation of both legs with the pelvis supine and the hip flexed to 90 degrees can be used to estimate symmetry.}

   

  ^{Unless the patient is in extremis or the surgeon is using a compression nail, all nails should be statically locked.}

   

  ^{The order of interlocking should be considered.}

   

  ^{In axially stable cases, the distal segment should be interlocked, and compression is applied to the fracture site by backslapping the nail; some intramedullary nails allow the surgeon to use a compression screw. In these cases, the distal interlocking screw is placed in the static position. The proximal interlocking screw is placed in the dynamic hole. The compression screw is then used and essentially “pulls” the nail, which is fixed to the distal bone fragment via the distal interlocking screw, proximally to abut against the proximal fracture fragment. Again, if this type of nail will be used with a compression screw, a slightly shorter nail should be inserted— because these nails allow up to 10 mm of axial compression.}

   

  ^{The authors find that certain fracture patterns are more amenable to compression than others. Transverse femoral shaft fractures may benefit from axial compression due to their inherent rotational instability. Short oblique fractures, if “keyedin” and reduced, benefit from cortical compression. If the spiral oblique fracture is out to length but not reduced, then compression is not advised as it may shorten the femur—especially if the oblique fracture pattern is prone to shear. These fracture patterns tend to heal due to the large surface area between the fracture fragments. Fracture patterns with butterfly fragments may or may not benefit from compression.}

   

  ^{In unstable cases, traction and alignment should be maintained until interlocking is complete. Usually, distal interlocking precedes proximal interlocking.7, 41}

• ^{Proximal Interlocking Screw Placement}

   

  ^{There are guides with each system that allow placement of proximal screws. In general, at least one screw should be placed.}

   

  ^{The static screw hole should be used, and the hole closest to the fracture is preferred. In stable fracture patterns, one proximal and one distal static interlocking screw is accepted standard of care. If the surgeon is using a compression nail (ie, Stryker T2 nail), and there is a fracture gap, then the surgeon can place the proximal screw in the proximal aspect of the dynamic hole; once he or she then uses the compression}

  ^{screw, the nail will be “pulled” up along with the distal fracture fragment and close the fracture gap.}

• ^{Distal Interlocking Screw Placement}

 

^{Distal screw placement is usually done with a freehand technique, and only one static distal interlocking}

^{screw is necessary.15 This can be one of the most challenging parts of the case for some surgeons and the easiest for others.}

 

^{In general, setup and image positioning can greatly facilitate this part of the procedure.}

 

^{Using the concentric circle concept, the image intensifier or the leg is rotated to obtain a perfect circle.}

 

^{If the image is oval or shaped like an eye, the image intensifier is not perpendicular to the axis of the nail or, in other words, parallel or coaxial with the axis of the screw hole.}

 

^{The goal is to align the axis of the image intensifier/beam source with that of the screw hole. Obtaining perfect circles with fluoroscopy imaging is the first critical step.}

 

^P.460

^{The surgeon will either have to abduct or adduct the extremity or internally/externally rotate the extremity to achieve perfect circles.}

 

^{In TECH FIG 4A, the image intensifier is not aligned in the coronal plane (varus or valgus to the femoral nail).}

 

^{In TECH FIG 4B, the image intensifier is not aligned in the axial-transverse plane (rotationally to the nail).}

 

^{In TECH FIG 4C, both screw holes in the nail line up, giving the “perfect circle” wherein the image intensifier is colinear to the axis of the screw hole in the nail.}

 

^{Next, a drill or scalpel is used to determine the cutaneous location for an incision, which should go through the fascia and to bone.}

 

^{A drill is centered over the hole and held securely (TECH FIG 4D).}

 

^{At this point, there are two options: The drill can be gently tapped to engage the near cortex or it can be drilled.}

 

^{The axis of the drill bit should be aligned with the center of the image intensifier/beam source (which is parallel to that of the hole). Thus, if the drill tip is centered over the hole and aligned with the center of the beam source, it should be coaxial with the axis of the hole.}

 

^{Once the drill tip penetrates the first cortex and advanced slightly, fluoroscopic verification should be obtained again. At this point, subtle changes in the drill bit trajectory can be made by gently malleting the drill bit in the desired direction. For example, if the drill bit appears to be heading posterior to the nail hole, then the surgeon can gently “guide” it anteriorly by redirection with a mallet. This “fine-tuning” step can be very helpful in using a less than ideal starting hole in the bone.}

 

 

 

^{TECH FIG 4 • A. The perfect circle method for freehand interlocking. If the image appears as two circles overlapped, the shape of an 8 will appear. The central area is elliptical and indicates that the image intensifier axis is not collinear with the axis of the screw holes. The appropriate corrective direction is parallel to the short axis of the central ellipse (or perpendicular to the long axis). In this case, the correction would be in the coronal plane (proximal to distal). B. In this situation, the rotation of the image does not match. It will need to be corrected along the path of the C. C. The image of a perfect circle. (continued)}

 

 

^{If the drill bit “kicks” or jerks into a different direction or cannot be advanced, it is likely that it either glanced off the nail (missed the hole anteriorly or posteriorly) or is hitting the nail (proximally or distally) (TECH FIG 4E).}

 

^{After the interlocking hole is drilled, another fluoroscopic image is taken. The interlocking hole should now be “lighter,” or less radiodense, if the drill bit penetrated both cortices at the level of the interlocking hole.}

 

^Measurement

 

^{The drill can be removed and measured with a depth gauge or in many systems read directly from the drill guide.}

 

^{An alternate method, which we have used with surprising accuracy, is to use the known diameter of the nail as a legend.}

 

^{Comparing the width of the femoral canal at the level of the screw hole with that of the nail and estimating the number of nail widths in that segment allows for an estimate of the screw length.}

 

^{With a little practice, this method is fairly reliable, especially considering that many companies provide screws only in 5-mm increments (TECH FIG 4F).}

 

 

^P.461

 

^{TECH FIG 4 • (continued) D. The drill point should be in the middle of the circle. Then the axis of the drill can be made collinear with that of the image intensifier. E. The drill can pass anterior or posterior to the nail and “feel” pretty good. Care should be taken to make sure the drill point does not drift during this motion.}

^{Proprioceptive feedback will frequently indicate when the drill passes through the nail and the contralateral cortex. If the drill kicks in one direction (anterior or posterior), it may have missed the nail. If it is not aligned in the coronal plane, it may hit the nail. It is important to verify all implant positions before leaving the operating room. F. A method of measuring using the nail as a “yardstick.” If the diameter of the nail is known, then the diameter of the bone at the level of the interlocking hole can be estimated by seeing how many multiples of the nail will fit in that segment. With some practice, the accuracy of this technique is impressive: We estimate our accuracy to exceed 90% using this technique.}

 

 

PEARLS AND PITFALLS
	Preoperative ▪ In patients with chest or head injuries, consideration may be given to external fixation; a team-oriented approach with input from general surgery and neurosurgery is warranted. Correct position and traction are chosen based on patient size and assistant availability. Based on patient size and assistant availability Ensure complete muscle relaxation and antibiotic administration before the case begins. Have an external fixation set in the room not only for backup fixation but also for facilitating reduction (ie, joystick maneuver).     Intraoperative ▪ Spend time on (1) obtaining the correct starting spot, (2) ensuring a satisfactory reduction, and (3) satisfactory position of the guidewire center-center in the distal femur if possible; many later complications can be avoided with the correct starting spot.

 

 

 

 

	Postoperative ▪ During nail placement, if it is not advancing down the intramedullary canal, stop. care Check fluoroscopy to ensure the nail is not hitting a cortex. If there is distraction at the fracture site, the surgeon can always use a shorter nail and “sink” it further down the canal—in anticipation of locking distally and backslapping the nail to decrease the fracture gap. If backslapping is performed, two distal interlocking screws may be beneficial in case one screw breaks. For fracture patterns that the surgeon cannot reliably key-in or reduce using fluoroscopy, that is, transverse, ensure the correct rotation by using contralateral views (ie, lesser trochanter, etc.). After nail insertion, the surgeon should always check length, alignment, rotation, and the femoral neck (iatrogenic fracture). After fixation of any long bone fracture, the authors prefer to obtain full-length plane films of the femur to ensure satisfactory alignment. Prescribe satisfactory physical therapy to ensure strengthening of the abductors, quadriceps mechanism, and gait training.

 

 

 

^{POSTOPERATIVE CARE}

^P.462

 

^{Postoperative radiographs should be obtained to check fracture length, alignment, rotation, implant placement, and integrity of the femoral neck.}

 

^{A clinical examination for rotation of the hip and a thorough knee examination are needed to rule out occult knee injury.}

 

^{Most femoral fractures, irrespective of comminution, can be allowed weight bearing as tolerated.}

 

 

^{Care should be taken when fracture lines are within 6 to 8 cm of the interlocking sites. In these cases, higher stresses can result in complications of the nail or delayed healing, and weight bearing can be initiated with radiographic initiation of healing (callus).}

 

^{Patients should be provided with physiotherapy for range of motion of the knee and hip and encouraged to exercise the abductors as well. Specific therapeutic protocols should be developed for these patients to strength}

^{hip abduction, gait training, and quadriceps control.25}

 

^{Deep vein thrombosis prophylaxis should be considered for all patients, unless contraindicated.}

^OUTCOMES

^{The femur can be expected to heal in about 95% of cases, with an infection rate of about 1% (FIGS 3 and}

^4).

^{Knee motion should return to normal about 12 weeks postoperatively but may be limited in head-injured or polytrauma patients owing to heterotopic bone formation or lack of early motion.17}

 

 

 

 

 

^{FIG 3 • Radiograph demonstrating initial damage control measures using external fixation. The one proximal pin was advanced to gain bicortical purchase.}

 

 

 

^{FIG 4 • Final radiographs demonstrating final fixation.}

 

 

^{Although healing rates are good, there is almost always an objective deficit in outcomes, which may or may not be clinically relevant.}

 

^{Objective examination can reveal deficits in endurance and strength; weather-related symptoms; or residual hip, thigh, and knee pain.}

 

^{Much like tibial nailing, the causes of such symptoms have not been well elucidated. A recent study has investigated the use of cephalomedullary nails in select patients after femoral shaft fractures to prevent}

^{“missed” femoral neck fracture and to prophylactically protect the femoral neck.12 This discussion is outside the scope of this chapter but this treatment option warrants consideration in select patients.}

 

^{COMPLICATIONS}

^{Iatrogenic femoral neck fracture}

 

 

^{If the piriformis fossa is used for nail entry, the surgeon should check an AP pelvis with the femur in internal rotation at the end of the case to ensure there is no iatrogenic femoral neck fracture.}

 

^Malunion

 

^{These deformities can occur in very distal rather than proximal femoral shaft fractures, where the intramedullary nail can “toggle” in the medullary space. Malalignment can also occur in highly comminuted femoral shaft fractures in which the surgeon cannot key-in or reduce the fracture.}

^{Varus/valgus deformity (>5 degrees in coronal}

 

^P.463

^{or sagittal planes) can be prevented by ensuring reduction before placement of the guidewire (ie, open reduction, Schanz pins, etc.) and reaming—especially in difficult fracture patterns. Accurate guidewire placement is also important because passage of the nail down an eccentric path can potentially cause fracture displacement in these unstable segments.}

 

^{Whereas varus/valgus malalignment can be visually/radiographically determined to some degree, rotational deformity can be more difficult to assess. As discussed before, rotational deformity can be prevented by paying close attention to cortical thickness because the femur is not perfectly cylindrical and cortical thickness varies. Up to 15 degrees of rotational malalignment can be well tolerated, but greater than 15 degrees should be corrected. External rotation causes more functional limitations than}

^{internal rotation, especially with demanding activities.17, 18}

 

^{The overall rate of malalignment is 7% to 11%, with most angular deformities occurring at the proximal and distal thirds of the femur.22}

 

^Nonunion

 

^{The incidence of femoral shaft nonunion after intramedullary nailing varies based on the literature, but union rates range from 90% to 100%. Although outside the scope of this chapter, treatment entails dynamization, exchange nailing, plate augmentation, or external fixation.}

 

^{Limb length discrepancy}

 

^{Up to 1.5 cm of leg length discrepancy may be well tolerated. Beyond 2 cm, many patients will eventually complain of symptoms of malalignment (eg, back, knee, or ankle pain). Although symptoms should resolve with simple shoe modifications, most patients are not able to maintain compliance.}

 

^{Infection: The risk is less than 1% in closed fractures and is an infrequent but devastating complication. It can be treated by several methods.}

 

^{If the infection is early and fixation is stable, local and systemic antibiotic treatment with nail retention may be considered.}

 

^{If the infection is extensive, a staged procedure should be considered with use of a temporary custom-fabricated, antibiotic-impregnated intramedullary device, possibly an external fixator, and a course of intravenous antibiotics.}

 

^{If the infection is delayed and the fracture is partially healed, one can also consider an exchange nail with reaming and placement of a nail of greater size (usually 2 mm).}

 

^{Deep vein thrombosis}

 

^{Most femur fractures should be considered for a combination of mechanical and pharmacologic prophylaxis against deep vein thrombosis.}

 

^{Fat emboli}

 

^{Symptomatic fat emboli are a rare occurrence after intramedullary nailing. Human studies on the RIA and}

^{its effect on fat emboli syndrome or pulmonary function are few and more conclusive studies are warranted.33, 34}

 

^Pain/limp

 

^{Decreased hip function and muscle weakness of the hip abductors and external rotators, along with trochanteric pain, thigh pain, and limp, may occur Literature has demonstrated that antegrade nailing can affect hip kinematics—specifically with hip abduction, knee extension, and gait abnormalities.2, 16}

 

^{Although hip dysfunction still occurs with even retrograde nailing, the incidence seems to be greater with antegrade nails.}

 

^{As mentioned, functional outcomes seem to be equivalent for both piriformis-entry and trochanteric-entry femoral nails.31}

 

^{Heterotopic ossification}

 

^{Heterotopic ossification may occur in 9% to 60% of patients, with the most commonly associated factor being head injury.}

 

^{Implant failure}

 

^{Failed hardware or refracture usually indicates a nonunion. In some cases, fracture of locking screws serves to “autodynamize” the fracture and healing ensues. There is no need for hardware removal or additional surgery if the fracture heals with minimal deformity.}

 

^{Nerve injury}

 

^{Femoral, sciatic, or pudendal nerve injuries are relatively rare. Stretch injury of the sciatic nerve due to prolonged traction during intramedullary nailing can be avoided with judicious use of traction. Pudendal nerve palsy (if intramedullary nailing is performed on a fracture table) can occur when excessive traction and a small perineal post are used. Most femur fractures can be brought to length easily, and traction should be limited to the time of reduction and nail passage and interlocking. Use of a large well-padded perineal post, judicious traction, or a lateral distractor can avoid this problem. Treatment consists of expectant and supportive treatments.}

 

^{Compartment syndrome}

 

^{Compartment syndrome of the thigh (especially in intubated, polytrauma victims) may occur, especially with crush injuries or prolonged hypotension. Clinical signs should be used to dictate treatment, and release of the anterior compartment is generally sufficient. If compartment pressures are to be monitored, threshold pressure is 30 or 40 mm Hg or one that is based on the patient's diastolic blood pressure (within 30 mm Hg).}

 

^REFERENCES

1. ^{Anglen JO, Choi L. Treatment options in pediatric femoral shaft fractures. J Orthop Trauma 2005;19:724-733.}

    

    

2. ^{Archdeacon M, Ford KR, Wyrick J, et al. A prospective functional outcome and motion analysis evaluation of the hip abductors after femur fracture and antegrade nailing. J Orthop Trauma 2008;22(1):3-9.}

    

    

3. ^{Bone LB, Anders MJ, Rohrbacher BJ. Treatment of femoral fractures in the multiply injured patient with thoracic injury. Clin Orthop Relat Res 1998;(347):57-61.}

    

    

4. ^{Bone LB, Johnson KD, Weigelt J, et al. Early versus delayed stabilization of femoral fractures. A prospective randomized study. J Bone Joint Surg Am 1989;71(3):336-340.}

    

    

5. ^{Bong MR, Koval KJ, Egol KA. The history of intramedullary nailing. Bull NYU Hosp Jt Dis 2006;64(3-4):94-97.}

    

    

6. ^{Bosse MJ, MacKenzie EJ, Riemer BL, et al. Adult respiratory distress syndrome, pneumonia, and mortality following thoracic injury and a femoral fracture treated either with intramedullary nailing with reaming or with a plate. A comparative study. J Bone Joint Surg Am 1997;79(6):799-809.}

    

    

7. ^{Brumback RJ. The rationales of interlocking nailing of the femur, tibia, and humerus. Clin Orthop Relat Res 1996;(324):292-320.}

    

    

   ^P.464

    

8. ^{Brumback RJ, Ellison TS, Molligan H, et al. Pudendal nerve palsy complicating intramedullary nailing of the femur. J Bone Joint Surg Am 1992;74(10):1450-1455.}

    

    

9. ^{Brumback RJ, Ellison TS, Poka A, et al. Intramedullary nailing of femoral shaft fractures. Part III: long-term effects of static interlocking fixation. J Bone Joint Surg Am 1992;74(1):106-112.}

    

    

10. ^{Brumback RJ, Reilly JP, Poka A, et al. Intramedullary nailing of femoral shaft fractures: part I: decision-making errors with interlocking fixation. J Bone Joint Surg Am 1988;70(10):1441-1452.}

     

     

11. ^{Brumback RJ, Uwagie-Ero S, Lakatos RP, et al. Intramedullary nailing of femoral shaft fractures: part II: fracture-healing with static interlocking fixation. J Bone Joint Surg Am 1988;70(10):1453-1462.}

     

     

12. ^{Collinge C, Liporace F, Koval K, et al. Cephalomedullary screws as the standard proximal locking screws for nailing femoral shaft fractures. J Orthop Trauma 2010;24(12):712-722.}

     

     

13. ^{Della Rocca GJ, Crist BD. External fixation versus conversion to intramedullary nailing for definitive management of closed fractures of the femoral and tibial shaft. J Am Acad Orthop Surg 2006;14(10 spec no):S131-S135.}

     

     

14. ^{Flynn JM, Schwend RM. Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg 2004;12:347-359.}

     

     

15. ^{Hajek PD, Bicknell HR Jr, Bronson WE, et al. The use of one compared to two distal screws in the treatment of femoral shaft fractures with interlocking intramedullary nailing. A clinical and biomechanical analysis. J Bone Joint Surg Am 1993;75(4):519-525.}

     

     

16. ^{Helmy N, Jando VT, Lu T, et al. Muscle function and functional outcome following standard antegrade reamed intramedullary nailing of isolated femoral shaft fractures. J Orthop Trauma 2008;22(1):10-15.}

     

     

17. ^{Jaarsma RL, Pakvis DF, Verdonschot N, et al. Rotational malalignment after intramedullary nailing of femoral fractures. J Orthop Trauma 2004;18:403-409.}

     

     

18. ^{Jaarsma RL, van Kampen A. Rotational malalignment after fractures of the femur. J Bone Joint Surg Br 2004;86(8):1100-1104.}

     

     

19. ^{Johnson KD, Tencer AF, Sherman MC. Biomechanical factors affecting fractures stability and femoral bursting in closed intramedullary nailing of femoral shaft fractures, with illustrative case presentations. J Orthop Trauma 1987;1:1-11.}

     

     

20. ^{Kao JT, Burton D, Comstock C, et al. Pudendal nerve palsy after femoral intramedullary nailing. J Orthop Trauma 1993;7(1):58-63.}

     

     

21. ^{Lindsey JD, Krieg JC. Femoral malrotation following intramedullary nail fixation. J Am Acad Orthop Surg 2011;19:17-26.}

     

     

22. ^{Nork S. Femoral shaft fractures. In: Bucholz RW, Heckman JD, Court-Brown C, et al, eds. Rockwood & Green's Fractures in Adults, ed 7. Philadelphia: Lippincott Williams & Wilkins, 2010:1655-1718.}

     

     

23. ^{Nowotarski PJ, Turen CH, Brumback RJ, et al. Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients. J Bone Joint Surg Am 2000;82(6):781-788.}

     

     

24. ^{Pape HC, Hildebrand F, Pertschy S, et al. Changes in the management of femoral shaft fractures in polytrauma patients: from early total care to damage control orthopedic surgery. J Trauma 2002;53:452-461.}

     

     

25. ^{Paterno MV, Archdeacon MT. Is there a standard rehabilitation protocol after femoral intramedullary nailing? J Orthop Trauma 2009;23(5 suppl):S39-S46.}

     

     

26. ^{Reichert IL, McCarthy ID, Hughes SP. The acute vascular response to intramedullary reaming. Microsphere estimation of blood flow in the intact ovine tibia. J Bone Joint Surg Br 1995;77:490-493.}

     

     

27. ^{Rhinelander FW. Effects of medullary nailing on the normal blood supply of diaphyseal cortex. Instr Course Lect 1973;22:161-187.}

     

     

28. ^{Rudloff MI, Smith WR. Intramedullary nailing of the femur: current concepts concerning reaming. J Orthop Trauma 2009;23 (5 suppl):S12-S17.}

     

     

29. ^{Scalea TM, Boswell SA, Scott JD, et al. External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: damage control orthopedics. J Trauma 2000;48:613-621.}

     

     

30. ^{Smith RM, Giannoudis PV. Femoral shaft fractures. In: Browner BD, Levine A, Jupiter J, et al, eds. Skeletal Trauma, ed 4. Philadelphia: Saunders, 2009:2035-2072.}

     

     

31. ^{Sprague MA, Yang EC. Early versus delayed fixation of isolated closed femur fractures in an urban trauma center. Bull Hosp Jt Dis 2004;62:58-61.}

     

     

32. ^{Stannard JP, Bankston L, Futch LA, et al. Functional outcome following intramedullary nailing of the femur: a prospective randomized comparison of piriformis fossa and greater trochanteric entry portals. J Bone Joint}

    ^{Surg Am 2011;93(15):1385-1391.}

     

     

33. ^{Streubel PN, Desai P, Suk M. Comparison of RIA and conventional reamed nailing for treatment of femur shaft fractures. Injury 2010;41(suppl 2):S51-S56.}

     

     

34. ^{Talbot M, Schemtisch EH. Fat embolism syndrome: history, definition, epidemiology. Injury 2006;37(suppl 4):S3-S7.}

     

     

35. ^{Tornetta P III, Kain MS, Creevy WR. Diagnosis of femoral neck fractures in patients with a femoral shaft fracture. Improvement with a standard protocol. J Bone Joint Surg Am 2007;89(1):39-43.}

     

     

36. ^{Tornetta P III, Ritz G, Kantor A. Femoral torsion after interlocked nailing of unstable femoral fractures. J Trauma 1995;38:213-219.}

     

     

37. ^{Tornetta P III, Tiburzi D. Antegrade nailing of distal femoral shaft fractures after gunshot wounds. J Orthop Trauma 1994;8:220-227.}

     

     

38. ^{Tornetta P III, Tiburzi D. The treatment of femoral shaft fractures using intramedullary interlocked nails with and without reaming: a preliminary report. J Orthop Trauma 1997;11:89-92.}

     

     

39. ^{Volgas DA, Burch T, Stannard JP, et al. Fat embolus in femur fractures: comparison of two reaming systems. Injury 2010;41(suppl 2): S90-S93.}

     

     

40. ^{Winquist RA, Hansen ST Jr. Comminuted fractures of the femoral shaft treated by intramedullary nailing. Orthop Clin North Am 1980;11:633-648.}

     

     

41. ^{Yang EC. Inserting distal screws into interlocking IM nails. Orthop Rev 1992;21:779-781.}

     

     

42. ^{Ziran BH, Smith WR, Zlotolow DA, et al. Clinical evaluation of a true percutaneous technique for antegrade femoral nailing. Orthopedics 2005;28:1182-1186.}