Executive Editor: Chris Colton, Rick Buckley

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

Femur shaft

back to skeleton

Glossary

Supine with manual traction
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Introduction

This positioning is recommended for bilateral fractures because it can allow for the reduction and fixation of both fractures without requiring re-draping. However, the axial view may be difficult to obtain because elevation of the contralateral leg is required.


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

  • 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.

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Skin disinfecting and draping

  • Maintain light manual 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(s) with a single-use U-drape. A stockinette covers the lower leg and is fixed with a tape. The leg is draped to be freely moved.
  • Drape the image intensifier

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Operating room set-up

  • The surgeon, assistant, and ORP stand on the side of the injury.
  • Place the image intensifier on the opposite side of the injury or surgeon.
  • Place the image intensifier display screen in full view of the surgical team and the radiographer

v2.0 2018-07-05