Download - Nail Femur Vda
-
8/3/2019 Nail Femur Vda
1/35
David Haryadi
Departemen Orthopaedi dan Traumatologi
RS. Dr. Soetomo
-
8/3/2019 Nail Femur Vda
2/35
A femoral shaft fracture is a diaphyseal
fracture of the femur that does not extend
into the articular or metaphyseal region
-
8/3/2019 Nail Femur Vda
3/35
Winquist & Hansen classification:
Based on the degree of comminution
Type I: minimal or no comminutionType II: comminution at least 50% of the
circumference of the cortices of
two major fr fragments intact
Type III: 50 to 100% of the circumference
of two major fracture fragments
is comminuted
Type IV: all cortical contact is lost
-
8/3/2019 Nail Femur Vda
4/35
-
8/3/2019 Nail Femur Vda
5/35
-
8/3/2019 Nail Femur Vda
6/35
The femoral shaft is subjected
to major muscular forces thatdeform the thigh after a
fracture:
A.Abductors mm : abduct the
proximal femur
B.Iliopsoas : flexes & externally
rotates the prox fragment
C.Adductors mm: medial
angulated the distal fragment
D.Gastrocnemius : flexes the
distal fragment
E.Fascia lata : as tension band
vs adductors
-
8/3/2019 Nail Femur Vda
7/35
Restore the alignment and length of thefemur
Restore cortical contact for axial stability
Preservation of the blood supply to aidunion and prevent infection
Restore and maintain full range ofmotion of the knee and hip
Improve the strength of the muscles thatare affected by fracture
Restore normal gait pattern
-
8/3/2019 Nail Femur Vda
8/35
NON OPERATIF
Skin traction
in adult only for emergency fracture immobilization inthe field & to facilitate transportation
for definitive fracture management, indicated only inyoung children
Skeletal traction
for early fracture care before a definitive operation
for patient who are too sick for surgery
to restore femoral length, to limit rotational & angulardeformity
union rates 97-100%, delayed union up to 30%
problems :
knee stiffness, limb shortening, malunion, prolonged
hospitalization, respiratory & skin problems
-
8/3/2019 Nail Femur Vda
9/35
Cast brace
an external support device permits progressiveweight bearing
best used after skeletal traction
high rates of union (>90%)
problems :
lost of reduction & subsequent malunion,shortening, & angulation
-
8/3/2019 Nail Femur Vda
10/35
External fixation
load-sharing device
excellent bony fixation & wound access
early mobilization
treatment of choice for open fracture gr IIIB &IIIC
may be placed laterally or anteriorly
possible complications :distraction of the fracture, pin-tract infection(up to 50%), pin loosening & lost of kneemotion (due to tethering of quadriceps
muscle to the shaft)
-
8/3/2019 Nail Femur Vda
11/35
load/stress-sharing device
stress-sharing system if the
nail is dynamically locked;
partial stress shielding if it is
statically locked
mode of bone healing :
secondary
benefits :
less extensive exposure &
dissection, lower infectionrates, less quadriceps
scarring, early mobilization,
rapid fracture healing, & low
refractured rate
-
8/3/2019 Nail Femur Vda
12/35
reamed locked nails are the best treatment for
most shaft fracture for weight-bearing bones, it is fixation method
superior to plates or external fixation
it guarantees proper axial alignment androtational alignment. Can be ensured by using
interlocking screws union rate 98%, infection rate
-
8/3/2019 Nail Femur Vda
13/35
Intramedullary nail
1.Open technique
2.Closed technique
-
8/3/2019 Nail Femur Vda
14/35
involves inserting the nail after exposing
the fracture.
-
8/3/2019 Nail Femur Vda
15/35
1. Pre-operative Planning
a. Diagnostic radiograph must be sufficient quality
to assess the extend of fracture comminutionb. Dimensions of the femoral shaft must be assessed
on plain radiograph
c. A systemic antibiotic is administered 30 minutesbefore skin incision and continued for 24 hours
after the surgery (usually a 1st
generationcephalosporin)
d. Length of the nail is determined pre-operativelyon the normal extremity measuring tip of thegreater trochanter to the lateral epicondylus
-
8/3/2019 Nail Femur Vda
16/35
Length of the nail isdetermined pre-
operatively on the
normal extremity
measured from the
proximal portion of
the greater
trochanter to thelateral epicondylus
-
8/3/2019 Nail Femur Vda
17/35
-
8/3/2019 Nail Femur Vda
18/35
Positioning
- Position the patients on his side withthe injured limbs upwards.
- Flex the hip and the knee
-
8/3/2019 Nail Femur Vda
19/35
Surgical technique
The fracture is
exposed through a
straight lateral
incision made alongan imaginary line
joining the posterior
aspect of the greater
trochanter with the
lateral epicondyle
(posterolateral
incision)
-
8/3/2019 Nail Femur Vda
20/35
Incise the fasciaof the thigh in linewith its fibers andthe skin incision
Identify the vastuslateralis under the
incised fascia lata
-
8/3/2019 Nail Femur Vda
21/35
Elevate the vastus lateralis anteriorly,separating the muscle from the septum
Detach those portion of the vastus lateralis thatarise from the septum until the femur and linea
aspera are reached.
-
8/3/2019 Nail Femur Vda
22/35
Expose the shaft ofthe femur and
debride the fractureends of frayed soft
tissue that is impaled
on sharp bone edges
and irrigate
-
8/3/2019 Nail Femur Vda
23/35
Deliver the distal
fragment from the
wound, check thesize of the
medullary canal
with medullary
reamer to find theone that fits snugly
in the opening.
By using reamers
of progressively
increasing size,
ream medullary
canal proximal
fragment
-
8/3/2019 Nail Femur Vda
24/35
Mobilize the fragments and reduce the
fracture to correct rotary alignment
-
8/3/2019 Nail Femur Vda
25/35
After reducing fracture, make sure thelength of nail by measure from the greater
trochanter tip to epicondylus lateralis
-
8/3/2019 Nail Femur Vda
26/35
Inserting guide nail Insert it proximally through the upper end of the femur until its
point resides in a subcutaneous position. Adduct and full flexion the hip as this is done so that the guide
pin will emerge subcutaneously just proximal to the trochanter
The guide pin should exit from the superior neck at the base of
trochanter
Details of insertion ofmedullary nail. Guide
pin emerges throughsmall incisionin upper outerquadrant of buttock.
-
8/3/2019 Nail Femur Vda
27/35
Introduce intramedullary nail over the guide pin withthe extraction eye of the nail facing posteromedially
and drive the nail into trochanteric region of femur
Kntscher nail
inserted into proximalfemoral fragmentover guide pin. Whennail has been drivendown to level of
fracture guide pin isremoved and fracturereduced.Nail is then drivencorrect distance intodistal
fragment
-
8/3/2019 Nail Femur Vda
28/35
As the advancing nail in
the proximal fragment
approaches the fracture
site, reduce the fracture
under direct vision
-
8/3/2019 Nail Femur Vda
29/35
Reduce the fracture
Maintain the reduction while an assistant
drives the nail with steady blows on the
driver at the proximal end. As the nail is driven into the distal fragment
of the femur, fair resistance is desirable
because it indicates a snug fit
-
8/3/2019 Nail Femur Vda
30/35
Its eye faces posteromedially and its proximalend does not extend more than 2.5cm
proximal to the trochanter The distal end of nail should extend to level of
proximal pole patella
Before closing the wound, check
anteroposterior and lateral roentgenograms ofthe distal end of the femur and manuallycheck the stability of the fracture fixation,especially the stability of rotation
-
8/3/2019 Nail Femur Vda
31/35
-
8/3/2019 Nail Femur Vda
32/35
-
8/3/2019 Nail Femur Vda
33/35
-
8/3/2019 Nail Femur Vda
34/35
-
8/3/2019 Nail Femur Vda
35/35
terimakasih.