Executive Editor: Chris Colton, Rick Buckley

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

Femur shaft

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Glossary

Lateral approach
Lateral approach to femoral shaft - Principles enlarge

Principles

The major vessels and nerves are located medially/posteromedially to the femoral shaft and are not exposed using this approach.


Lateral approach to femoral shaft – Skin incision enlarge

Skin incision

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.


Lateral approach to femoral shaft – Opening the fascia lata enlarge

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.


Lateral approach to femoral shaft – Vessels enlarge

Principles of a safe approach

As the fibers of origin of the vastus lateralis are elevated 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 torn. If they are torn close to the septum, the posterior ends can retract 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.


Lateral approach to femoral shaft – Vastus lateralis fascia lata enlarge

Separation of vastus lateralis from fascia lata

In the next step, the vastus lateralis is separated by blunt dissection from the fascia lata.


Lateral approach to femoral shaft – Incision fascia vastus lateralis enlarge

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.


Lateral approach to femoral shaft – Mobilization of vastus lateralis enlarge

Mobilization of vastus lateralis from intermuscular septum

The muscle is detached from the lateral intermuscular septum and the linea aspera with a periosteal elevator.


Lateral approach to femoral shaft – Ligation of perforating vessels enlarge

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.


Lateral approach to femoral shaft – Ligation of vessel bundles enlarge

Larger vessel bundles must be ligated, smaller ones can be alternatively cauterized with the diathermy.


Lateral approach to femoral shaft – Exposure of femoral shaft enlarge

Exposure of the bone

After further detachment of the vastus lateralis, using the elevator, the femoral shaft is exposed extraperiosteally.


Lateral approach to femoral shaft – Exposure of proximal femoral shaft enlarge

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.


Lateral approach to femoral shaft – Detachment of vastus lateralis enlarge

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.


Closure

The vastus lateralis is allowed to fall back over the top of the lateral femur and the tensor fascia lata is closed with heavy stitches.

v2.0 2018-07-05