- Scissor position
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Introduction
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
Anesthesia
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.
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Positioning
- 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.
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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.
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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.