Proper preoperative planning is essential to successful recon nailingof the femur. To determine the appropriate nail size, an ossimeter, roentgenogramtemplates and an x-ray film of the unaffected extremity are necessary fordetermining canal size at the isthmus and for measuring the length of thefemur.
X-rays taken at a 36-inch distance from the x-ray source result in 10%-15% magnification of bone. The ZMS Ossimeter has both an actual size scaleand one that takes into account this magnification. It should be used routinelyto determine nail diameter and length.
The proper length of the nail should extend from the tip of the greatertrochanter to the epiphyseal scar. The diameter of the femoral nail shouldmatch the isthmus in the lateral x-ray projection.
The surgeon should review the x-ray to assure that there are no unusualanatomic variations.
The patient may be placed in either the supine or the lateral decubitusposition (click figure to enlarge). In multiple trauma patients,the supine position may be used for easier access to the airway as wellas to facilitate the treatment of other injuries. The supine position alsofacilitates fracture reduction and rotational alignment of the femur. Thedisadvantage to the supine position is that it impairs access to the tipof the greater trochanter for insertion of the nail. It is essential thatexcellent AP and lateral images are obtained of the femoral head and neckprior to beginning the surgery regardless of which patient position is used.
The use of image intensification or other xray imaging is required. Theimage intensifier should be sterile-draped and may be positioned from eitherthe contralateral or ipsilateral side of the operating table. Visualizationof the hip as well as the shaft of the femur is confirmed
using image intensification prior to prepping and draping. The patient'storso is bent away from the affected extremity to improve access to thegreater trochanter. If access to the greater trochanter is still inadequate,the affected leg may be adducted. However, to achieve proper alignment ofthe fracture, this adducted position must be corrected prior to insertionof the nail.
After proper positioning and reduction, the patient's extremity is preppedand draped in the usual manner using sterile technique. The prep extendsfrom the rib cage distal to the knee and includes the entire buttocks andlateral thigh.
