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IM Nailing Technique for Femoral Shaft Frx: Surgical Incision

- Technique:

     - at a point 3-5 cm above post. tip of greater troch., an incision is made which extends obliquely (proximally & posteriorly) for 10 cm;
           - for obese pts begin incision well above greater troch. (7-10 cm) & again extend proximally and posteriorly;
           - otherwise one will be fighting w/ a thick layer of subQ fat;
     - incise tensor fascia & split gluteus max in line w/ its fibers;
           - this incision needs to be at least as long as the skin incision;
     - define interval between insertions of piriformis & tendinous posterior aspect of medius into greater trochanter;
     - the surgeon can run his long finger along the posterior edge of the proximal femur to accurately judge the direction of the femur w/o need for flouro;
           - the surgeon's index finger can simultaneously palpate the gluteus medius tendon about 2 cm from its posterior edge at the level of the greater trochanter;
                   - this marks the location for splitting the tendon w/ a tonsil clamp;
           - when the lateral position is used, the hip can be flexed which allows nail to be inserted behind the tendon (hence no splitting is required);

- Hazards:
    - trochanteric pain and stiffness may occur in over 40% of patients and may be related due to rough handling of the gluteus medius tendon;
    - it is essential to carefully split the medius tendon no higher than 5 cm above the greater trochanter inorder to avoid injury to the superior gluteal nerve;
    - after the gluteus medius tendon is split for the first time, further trauma to the tendon should be avoided

Gluteus medius tendon injury during reaming for gamma nail insertion.

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