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Supine with manual traction

Positioning

  • Reconfigure the table or transfer the patient to a fracture table.
  • Reduce the fracture with manual traction and manipulation to ensure reduction is possible before preparing and draping the patient.
  • Pad all pressure points carefully (especially in the elderly).
  • Position the image intensifier on the opposite side of the injury and the operating surgeon
  • Ensure that you can get good-quality AP and lateral x-ray views of the entry point (piriform fossa), fracture site, and distal femur before draping.
  • In obese patients it may be technically easier to perform antegrade femoral nailing in a lateral position without skeletal traction. Place the patient lateral (or supine with a large sandbag under the ipsilateral buttock) on a radiolucent table.
  • Adduct and slightly flex the affected leg anteriorly in front of the unaffected one to ensure the position is reasonable for obtaining X-rays.
  • A firm cushion placed in the midline beneath the pelvis may be used to elevate the pelvis from the table edge and facilitate the skin incision.
  • The ipsilateral arm should not be positioned on an arm board or abducted, since it would interfere with nail insertion. An adducted (pictured) or elevated position is favored.
  • The surgeon must be satisfied with the position before the patient is prepared for surgery.