pearls for im nailing femur/tibia cme...objectives • be able to identify femur and tibia fracture...
TRANSCRIPT
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?
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
Malreduction of Fractures
Indirect Reduction Techniques
• External Forces • Pushing/Pulling • Reduction Clamps • Provisional Fixation
Indirect Reduction Techniques
• External Forces • Pushing/Pulling • Reduction Clamps • Provisional Fixation
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
Direct Reduction Techniques
• External Forces • Pushing/Pulling • Reduction Clamps • Provisional Fixation
Direct Reduction Techniques
• External Forces • Pushing/Pulling • Reduction Clamps • Provisional Fixation
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
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
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