Pearls for IM Nailing Femur/Tibia CME...Objectives • Be able to identify femur and tibia fracture patterns amenable to intramedullary nailing • Be able to identify complications

$Page 1: Pearls for IM Nailing Femur/Tibia CME...Objectives • Be able to identify femur and tibia fracture patterns amenable to intramedullary nailing • Be able to identify complications$
Pearls for IM Nailing Femur/Tibia

Avoiding T-R-O-U-B-L-E using Intramedullary Nails

James Ostrander MD Orthopaedic Trauma Fellow Cooper University Hospital –

Cooper Bone and Joint Camden, New Jersey

Objectives

• Be able to identify femur and tibia fracture patterns amenable to intramedullary nailing

• Be able to identify complications of Femoral Intramedullary Nailing

• Know tips for avoiding complications of Femoral Intramedullary Nailing

• Be able to identify complications of Tibial Intramedullary Nailing

• Know tips for avoiding complications of Tibial Intramedullary Nailing

Outline • Femur fracture patterns amenable to IM nails • Femoral IM Nailing Complications and how to avoid them

– Iatrogenic Fractures – Malreduction of Fractures – Leg Length Inequality – Malrotation of Femur

• Tibial fracture patterns amenable to IM nails • Tibial IM Nailing Complications and how to avoid them

– Iatrogenic Fractures – Malreduction of Tibia Fractures

• Questions

Femur Fracture Patterns AO/OTA 32 Bone: 3 (Femur) Segment: 2 (Diaphysis)

A

C

B

Femoral IM Nailing Complications and how to avoid them

• Iatrogenic Fractures

– Anterior Cortical Perforation

• Malreduction of Fractures • Leg Length Inequality • Malrotation of Femur

https://medapparatus.com/Ortho/Images/Complications/LtFemurIMrodFx_AP.jpg

Iatrogenic Fractures • Starting point

– Too medial --> femoral neck fracture

– Too posterior --> anterior perforation

– Too lateral --> medial femoral wall blowout

• Where is the appropriate starting point?

Presenter

Presentation Notes

For the residents - question about what happens if you use a piriformis nail with the trochanter starting point Varus malalignment

Antegrade Femoral Nail Starting Point

Antegrade Femoral Nail Starting Point

Retrograde Femoral Nail Starting Point

https://upload.orthobullets.com/topic/1040/images/starting%20point%20retrograde.jpg

Anterior Cortical Perforation

• Kanawati J Orthopaedics 2014 – 10 synthetic femora

• Roberts J Trauma Acute Care Surg 2012

– Retrospective 150 patient Review Starting Point Distal Anterior 1/3

Anterior 2 of 18

Middle 64 of 124

Posterior 5 of 8

Presenter

Presentation Notes

Kanawati Journal of Orthopedics 2014 Australia Used 10 synthetic femurs and studied radius of curvature, size of nail, and entry point Synthetic femora w/ 5 entry points A-P on Greater Trochanter Looked at distal placement More posterior starting point independent predictor of anterior placement Larger Radius of curvature independent predictor of anterior placement Roberts 2012 UC Davis Retrospective review of 150 patients Posterior starting point increased likely hood of anterior placement Also shorter patients were at more risk as well as increased “Radiographic femoral angle of incidence” Less than 160cm (5’3”) in height had 49% likelihood of impingement

Malreduction of Fractures

Indirect Reduction Techniques

• External Forces • Pushing/Pulling • Reduction Clamps • Provisional Fixation

Presenter

Presentation Notes

External Forces - also includes traction

Indirect Reduction Techniques


https://www2.aofoundation.org/AOFileServerSurgery/MyPortalFiles?FilePath=/Surgery/en/_img/surgery/FurtherReading/PFxM2/3.1.1-13a-c.gif

http://ee_ce_img.s3.amazonaws.com/cache/ce_img/media/remote/ce_img/https_ee_channel_images.s3.amazonaws.com/article-figures/14041/article-g03_400_415.jpg

http://www.innomed.net/Images/prod_shots_430/BallSpikewithBellHandle_8032.jpg

Presenter

Presentation Notes

Pushing and Pulling percutaneous -bone hook -ball spike pusher -Hohmann retractor -Schanz pin +/- Spin down T-handle

Direct Reduction Techniques


Presenter

Presentation Notes

Clamps Point to point Reduction clamps Bone Holding Forceps Lobster Claw Lowman Bone clamps Collinear Reduction clamps

Direct Reduction Techniques


Presenter

Presentation Notes

Provisional Fixation -Unicortical plating -external fixator -Femoral distractor

Leg Length Inequality

• Bilateral less of a problem – just make them the same

• Comminution makes more difficult • Techniques

– CT scanogram preop – Xray measurement of contralateral femur

Malrotation of the Femur • Jaarsma JOT 2004

– 76 patients, 28% (21/76) mal rotated greater than 15 degrees

– 9 internal rotation, 12 external rotation

• Stephen JBJS 2002

Manual Traction 12 of 42 >10deg

Fracture Table 3 of 45 > 10deg

Presenter

Presentation Notes

Netherlands 1989-1999 112 patients with 76 participants Did use two different nails, but no difference between the two Measured both CT and physical exam prone and supine No significant difference in functional scores (Oxford, WOMAC, Harris Hip Score, and Knee Society Score) External had worse Oxford and Knee Society Scores then internal rotation Ontario Randomized trial 87 patients 45 Manual traction – Supine with Bump (about 30 degrees) 42 on Fracture Table Internal rotation >10 degrees higher with Fracture Table EBL greater with fracture table mean dif of 159ml Manual traction shorter OR time 119min vs 139min

Avoiding Malrotation

• Measure femoral version un-injured side • Use the antiversion built into the nail • Be aware of “imperfect circles” • Cortical Step Sign

Cortical Step Sign

Langer, JOT, Feb 2010

Presenter

Presentation Notes

Langer, Gardner and Ricci St. Louis, MO 20 cadaveric lower extremity specimens 3 levels, 1cm segment Anterior was marked, neutral medial and lateral were 90 degrees to anterior Measured at neutral, 10, 20, and 30 degrees of internal and external rotation Cortical Width was greatest at neutral and decreased in both internal and external rotation for middle and proximal specimens Should be noted that the greatest change was only 2.2mm Bigger difference proximal and middle Medial may be more accurate than lateral

Take home message

• Starting Point is Key • Check 3 things prior to leaving OR

1. True AP X-ray of femoral neck 2. Leg length exam 3. Range of motion (femoral version)

Tibial Fracture Patterns AO/OTA 42 Bone: 4 (Tibia) Segment: 2 (Diaphysis)

A

C

B

Tibial IM Nailing Complications and how to avoid them

• Iatrogenic Fractures • Malreduction of Tibia Fractures

Starting Point is Key • Starting point

– Too medial Valgus deformity with proximal fractures

– Too posterior meniscal/ACL injury

– Too anterior Possible anterior cortical reaming/anterior wall blowout

– Where is the appropriate starting point?

Tibial Nail Starting Point

• AP view – Medial edge of lateral tibial spine

• Lateral View – just anterior to the articular plateau

Iatrogenic Fractures

• High insertion angle

Malreduction of Tibial Fractures

http://www.wheelessonline.com/ortho/im_nailing_of_proximal_tibial_fractures

Reduction Techniques

• Indirect Reduction Techniques – External Forces – Pushing/Pulling

• Direct Reduction Techniques – Reduction Clamps – Provisional Fixation


Proximal Tibial shaft fractures

• Semi extended position • Provisional plating • Lateral starting point • Use nail with more

proximal bend • Poller screws

Ricci, et al. JOT 2001

Malreduction of Tibial Fractures

http://www.wheelessonline.com/ortho/im_nailing_of_proximal_tibial_fractures

Documents

Pearls for IM Nailing Femur/Tibia CME...Objectives • Be able to identify femur and tibia fracture patterns amenable to intramedullary nailing • Be able to identify complications