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PreOp Planning for IM Nailing

- IM Nailing Technique

- Open Femur Frx

- Radiographs:
    - look for evidence of a pathologic lesion on x-ray, noting that it would be disasterous if a nail were driven through an occult osteosarcoma or chondroscaroma;
    - AP pelvis: (rule out concomitant injuries)
          - Hip Dislocation
          - Femoral Neck Frx
    - Lateral of Knee:
          - look for knee effusion (as evidenced by anterior displacement of supra-patellar pouch fat pad) which may indicate knee ligament injury;
    - Leg Lengths:
           - w/ comminuted frx it is of paramount importance to achieve equalization of leg lengths;
                  - obtain long leg cassette of uninjured leg w/ a radiolucent ruler included on film;
                  - long leg cassettes w/o a ruler are notoriously inaccurate;
    - Canal Width:
           - in adolescents and young adults carefully assess the width of the canal at the isthmus on both the AP and Lateral views;
                  - a tight canal leads can lead to special problems during the case such as difficulty in reaming, difficulty in reducing the fracture (and even passing the guide wire across the frx)
                 - it is important ahead of time to have the proper selection of nails available, small hand held reamers, and one or more surgical assistants to help with the reduction;
                  - since frx reduction will be difficult, skeletal traction is a must, since it allows the knee to be flexed (which relaxes the hamstrings and gastrocnemius) which facilitates reduction;
                  - one method that can be helpful is to first ream the proximal fragment to the desired canal width;
                         - subsequently, it will be easier to pass the guide wire across the fracture site;

- Classification:
    - it is necessary to consider frx location and comminution;
    - Comminuted Frx;
          - comminution extending proximally or distally to the frx site needs to be carefully assessed prior to IM nailing;
          - preoperative measurements of uninjured femur are needed inorder to obtain equal leg lengths postoperatively;
          - w/ longitudinal fissures extending away from the frx site, consider open cerclage wiring prior to IM nailing;
    - Proximal Frx:
    - Distal Frx:
          - w/ distal fractures, its essential to obtain perfect nail length since and nail that is too short may have interlocks at the level of the frx, and a nail that is too long will end up lying proud above the greater trochanter;

- Traction

- Positioning

- Frx Reduction
proximal frx
Distal Frx

- Implant Selection (Synthes)

- IM Nail Insertion Technique