Trauma 101: Orthopedics Study Tool

Indication

The great majority of adult diaphyseal femoral fractures once the patient is physiologically stable.

Implant design notes

A load-sharing internal splint working close to the mechanical axis, with interlocking screws controlling length and rotation. Reaming stimulates union but adds fat embolic load. Piriformis entry gives a straight line down the canal, while trochanteric entry is easier and safer in the obese and in the growing child.

Approach

Percutaneous, on a traction table or a radiolucent flat table, using fluoroscopy throughout.

Steps overview

1. Resuscitate and assess for associated injuries; specifically image the femoral neck and knee
2. Position supine on a traction table or lateral, with the image intensifier able to reach both hip and knee
3. Establish the entry point precisely — piriformis fossa or tip of trochanter — and confirm on both views
4. Pass the guide wire across the reduced fracture; reduce with traction, a reduction finger or a percutaneous clamp
5. Ream sequentially to the planned diameter and insert the nail
6. Set length and rotation by comparing the lesser trochanter profile and cortical widths with the normal side
7. Lock proximally and distally with the limb held in correct rotation
8. Confirm alignment, then mobilise with weight bearing as the pattern allows

Notes

Malrotation is the commonest technical complication and is often only noticed by the patient afterwards. Always exclude an associated femoral neck fracture before and after nailing.

Indication

Physiologically unstable polytrauma patient, severe open injury with contamination, or vascular injury requiring rapid skeletal stabilisation.

Implant design notes

Simple bridging frame with pins proximal and distal to the fracture, designed for speed and minimal physiological insult, later converted to definitive internal fixation.

Approach

Percutaneous pin placement avoiding the eventual nail or plate track and the zone of injury.

Steps overview

1. Prioritise resuscitation and control of haemorrhage and contamination
2. Place pins clear of the planned definitive implant and away from the wound
3. Reduce to approximate length and alignment and lock the frame
4. Debride and manage the wound according to open fracture principles
5. Reassess physiology; convert to definitive fixation once resuscitated, typically within a few days
6. Watch pin sites closely — infection along a pin track complicates later nailing

Notes

The frame is a bridge, not a destination; delayed conversion raises infection risk.

Indication

Periprosthetic fractures, fractures with an ipsilateral femoral neck fracture or hip implant that precludes nailing, very distal or very proximal extension, and paediatric submuscular plating.

Implant design notes

Long locking plate applied as a bridging construct, preserving the fracture haematoma with minimally invasive percutaneous technique. Working length and screw density are chosen to allow controlled elastic deformation rather than a rigid short construct that concentrates stress.

Approach

Minimally invasive lateral submuscular tunnel, or open lateral approach where direct reduction is needed.

Steps overview

1. Position on a radiolucent table with the limb free for length and rotation control
2. Restore length, alignment and rotation indirectly using traction and fluoroscopy
3. Slide the plate submuscularly along the lateral femur through proximal and distal windows
4. Fix distally first, then proximally, checking alignment before committing to screws
5. Choose a long working length with spread-out screws to avoid a stress concentration
6. Confirm alignment and rotation, then define weight-bearing status by construct strength

Notes

Short rigid bridging constructs over a comminuted zone fail; length of plate and screw spread matter more than screw number.