Executive Editor: Chris Colton, Rick Buckley

Authors: Peter V Giannoudis, Hans Christoph Pape, Michael Sch├╝tz

Femur shaft - Segmental, fragmentary, middle 1/3 fractures - ORIF - Bridge plating

back to skeleton


Scissor position


Scissoring makes length, alignment and rotational confirmation easy. Raising the injured leg facilitates reduction of any flexed proximal fragment (iliopsoas muscle).

Careful pre-cleaning of the soft tissues should be performed especially if gross contamination occurs.

Preoperative preparation

Operating room personnel (ORP) need to know and confirm:

  • Site and side of fracture
  • Type of operation planned
  • Ensure that operative site has been marked by the surgeon
  • Condition of the soft tissues (fracture: open or closed)
  • Implant to be used
  • Patient positioning
  • Details of the patient (including a signed consent form and
  • appropriate antibiotic and thromboprophylaxis)
  • Comorbidities, including allergies


This procedure is performed with the patient under general or regional anesthesia

Long-lasting postoperative complete pain blocks for the patient with injured leg should be avoided as this could hide symptoms of a subsequent compartment syndrome.



  • Supine with bilateral boots and traction
  • Reconfigure the fracture table to establish the bilateral traction boot position and transfer the patient to a fracture table.
  • Position the fractured leg with traction in a 20° hip flex position with traction. The unaffected leg is positioned in a 30° hip extension position on the other side of the post in a traction boot.
  • Reduce the fracture with traction and manipulation before preparing and draping the patient.
  • Pad all pressure points carefully (especially in the elderly). Place the ipsilateral arm across the chest to be out of way.
  • Position the image intensifier on the opposite side of the injury and perpendicular to the patient.
  • Ensure that you can get good-quality AP and lateral x-ray views of the entry point (piriform fossa should be more easily reached with the affected leg slightly adducted), fracture site, and distal femur before draping.


Skin disinfecting and draping

  • Maintain traction on the limb during preparation to avoid excessive deformity at the fracture site.
  • Disinfect the exposed area from above the iliac crest to the mid-tibia with the appropriate antiseptic. Free drape the affected limb or use a vertical isolation drape.
  • Ensure the adhesive portion of the drape is large enough to reach from the iliac crest to the knee joint to allow distal locking.
  • A single-use exclusion drape is used.
  • Place the image intensifier on the nonsterile side of the exclusion drape.
  • Drape the image intensifier.
  • Traditional drapes may be used. Ensure a waterproof environment for the operative site.


Operating room set-up

  • Position the operating table (if feasible) within the operating room to allow maximum space on the operating side for the surgeon, staff, and trolleys.
  • The surgeon, assistant, and ORP stand on the side of the injury.
  • Place the image intensifier on the opposite side of the patient, perpendicular to the patient.
  • Place the image intensifier display screen in full view of the surgical team and the radiographer at the foot of the table.

v2.0 2018-07-05