- Lateral approach
When open plating is performed, the incision is made on the lateral aspect of the thigh. The fascia lata is split longitudinally and the vastus lateralis muscle is elevated off of the intermuscular septum. The perforating vessels run across the operative field and are usually ligated. As the fibers of origin of the vastus lateralis are devated from the intermuscular septum, take care, as the femur is approached, to try to pick up the perforating vessels and ligate them before they are inadvertently ruptured. If they are torn close to the septum, the posterior ends can retreat into the posterior compartment of the thigh, with the occasional risk of troublesome occult bleeding.
The major vessels and nerves are located medially/posteromedially to the femoral shaft and are not exposed using this approach.
An incision is made along an imaginary line between the lateral femoral epicondyle and the greater trochanter, along the length of the femur required by the specific fracture pattern.
Opening the fascia lata
The fascia lata is incised with a scalpel and split with scissors parallel to the skin incision, along its fibers.
The muscle fascia over the vastus lateralis is exposed.
Separation of vastus lateralis from fascia lata
In the next step, the vastus lateralis is separated by blunt dissection from the fascia lata.
Incision of the fascia vastus lateralis
The vastus lateralis is now retracted anteromedially.
The muscle fascia investing the vastus lateralis is incised about 1 cm anterior to the intermuscular septum.
Mobilization of vastus lateralis from intermuscular septum
The muscle is detached from the lateral intermuscular septum and the linea aspera with a periosteal elevator.
Ligation of perforating vessels
The perforating vessel bundles must be identified.
These vessels perforate the lateral intermuscular septum from the posterior side and run anteriorly, remaining closely applied to the femoral shaft.
Larger vessel bundles must be ligated, smaller ones can be alternatively cauterized with the diathermy.
Exposure of the bone
After further detachment of the vastus lateralis, using the elevator, the femoral shaft is exposed extraperiosteally.
Exposure of the proximal femoral shaft
If exposure of the proximal femoral shaft is necessary, mostly only for subtrochanteric fractures, the origin of the vastus lateralis must be identified.
The muscle is retracted anteriorly and an L-shaped incision is made down to the bone. The muscle origin is then dissected off with the periosteal elevator.
The proximal femoral shaft is exposed after the L-shaped detachment of the vastus lateralis has been performed. The vertical part of the incision lies in the interval between gluteus medius and vastus lateralis.