Sub trochanteric fractre nailing in lateral position

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  Sub Trochanteric femoral fractures are difficult to operate on a orthopaedic table due to the strong muscles causing flexion, abduction and external rotation of the proximal fragment. It can be operated easily on a simple table in lateral position. Here are some slides showing the tips for such fracture surgery.
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  • 1. Surgery of SUB TROCHANTERIC FRACTURES on simple table Dr. B. Shivashankar. Iyer Orthopaedic Centre, Solapur ISO 9001:2008 Certified Hospita President 2008-09 National Association of Interlocking Surgeons
  • 2. Ordinary Table • Either •Radio Lucent – C arm compatible •Radio Opaque – C arm IITV Non compatible
  • 3. On Ordinary Non Radio Lucent Table Hip AP Position of C Arm
  • 4. On Ordinary Non Radio Lucent Table Lateral Hip Position for C Arm Hip abducted and made way for X ray beam
  • 5. On Ordinary Radio Lucent Table C arm position for Hip AP view
  • 6. On Ordinary Radio Lucent Table C arm Position for Cross Table hip lateral View X Ray tube under the table, Image intensifier Near the operative hip to avoid too much zooming
  • 7. C arm Pictures of Hip in Cross Table lateral view Both hips seen, the one nearer the X ray tube (underneath table)will be magnified, the operative side hip will be seen comparatively smaller as the Camera is nearer to same, confirmed by Passing Steinmann pin passed into the pirifiormis fossa of operative hip. For Doing PFN Pass an anteversion Guide wire parallel to anterior cortex as marked with the arrow in next slide.
  • 8. C arm Picture of Hip in Cross Table lateral view Anteversion Guide wire For Doing PFN Pass an anteversion Guide wire Parallel to anterior cortex as marked with the arrow in the slide and keep the jig parallel to the same while passing guide wires for neck fixation as shown on right.
  • 9. Advantage – When surgeon inserts Guide Pin, he need not have to get out of the way just for C Arm pictures, He can manipulate the Guide pin to best position!(seen here) IITV for Hip Lateral View IITV for Hip AP View C arm monitor is towards foot end of the table . Surgeon, Assistant and the X ray technician, all of them can see the picture
  • 10. Cross Table Lateral View See the normal B and Operative side A (enlarged as the hip is nearer To X ray tube underneath) A B
  • 11. Passing Anteversion Pin placed very anteriorly in the neck
  • 12. Passing the anteversion pin AP
  • 13. Passing Anteversion Pin placed very anteriorly in the neck Final position- note it is parallel to anterior cortex marked with arrow
  • 14. Entry with Guide Pin Note entry medial to tip of Trochanter almost from piriformis fossa
  • 15. Guide pin in lateral view Note it is in the centre of neck
  • 16. Advancing the guide pin Parallel to anterior cortex in lateral view
  • 17. Advancing the guide pin Parallel to lateral cortex in AP view
  • 18. Enlarging the entry with centering Awl
  • 19. Passing the beaded Guide Wire for reaming
  • 20. Sequential Reaming with flexible reamers
  • 21. Passing the nail and final seating
  • 22. Inferior Cervical screw Guide Wire Passing after making entry with a sharp Awl marked with an arrow
  • 23. Superior Derotational screw Guide Wire Passing after making entry with a sharp Awl lmarked with an arrow
  • 24. Both Guide Wires passed As seen in AP view
  • 25. Nail Blocking the view of Guide Wires in Lateral View, But both anterior and posterior cortex of the neck seen
  • 26. By rotating the jig along with anteversion Guide wire Guide wires in the neck can be seen. Please do not rotate only the jig, that will cause Bending of the guide wires, Rotate along with anteversion Guide wire to control the rotation of proximal fragment
  • 27. First drill and pass superior Derotation Screw
  • 28. Then drill and pass Cervical screw
  • 29. Final AP with jig in situ
  • 30. Flex the knee to enable heel to touch ischeal tuberosity to Align fragments rotationally correct and then do distal locking by free hand. Proximal jig not removed To hold and keep the nail hole perpendicular to ground
  • 31. Drill at the distal end of oblong hole to avail Dynamisation possible and pass distal IL Bolt
  • 32. Final AP
  • 33. Final Cross table lateral
  • 34. Pre and immediate post operative Xrays
  • 35. X ray at 6 weeks on 4-11-2011
  • 36. Few More Cases
  • 37. 28 Year Male
  • 38. Function at 8 Weeks
  • 39. 14-02-2011
  • 40. ST fracture with Brachial Plexus Injury
  • 41. 30-1-2009
  • 42. 13-3-2009 28-4-2009
  • 43. Scar of Nailing Scar of Nerve Graft donor site
  • 44. Video Clip on You Tube • Short Video Clip of 3.2 minutes on You Tube is available as http://www.youtube.com/watch?v=o2v-ewedvWQ Copy paste above link on your browser
  • 45. Thank you Any Query: Contact: drbshivashankar@gmail.com Dr. B. Shivashankar. Iyer Orthopaedic Centre An ISO 9001 : 2008 Certified Hospital 103, Railway Lines SOLAPUR 413001, Maharashtra INDIA
  • 46. Disclaimer • For educational purpose only for use by Medical students and Orthopaedic Surgeons. • View expressed are personal • If copied for presentation purpose kindly give credit to the author. • No financial interest involved • Any Query Contact : Dr. B. Shivashankar on <drbshivashankar@gmail.com>
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