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14Proximal locking

Drilling of screw hole

Proximal AP locking has to be performed by the freehand method. After you have verified the correct position of the distal end of the nail under the image intensifier, visualize the shape of the proximal locking hole.

Then, bring the image intensifier into a strict AP position at 90° to the nail. The proximal static holes must project a perfect circle and the tip of a scalpel is projected into the center of the hole.

Make a skin incision and bluntly dissect the muscle.

Place the radiographic projection of the tip of the drill bit as centered as possible into the hole image. Start drilling but assess the position of the tip of the drill bit repeatedly, with the drill temporarily uncoupled.

Maintaining lower extremity position
While drilling the locking hole, the assisting surgeon must prevent the leg from moving, in order not to miss the target hole.

Pearl: radiolucent drill
If available, a radiolucent angled drill can be used as described in distal locking of antegrade nailing for femoral shaft fractures (click here for the description).