Fixation Options

Aim

Aim to achieve stability of fracture to promote solid union with anatomical mechanical alignment in all 3 planes (coronal & sagittal angulation, length, rotation)
(in the shortest time, whilst promoting early rehabilitation, with the lowest risk of complications)

Type	Decriptions
1A	below lesser troch, above isthmus
1B	into lesser but below piriform fossa
2A	into piriform fossa but below lesser
2B	into fossa & lesser

Russel Taylor Classification of Subtrochanteric Femoral Fractures

Type	Description
0	no comminution
1	small butterfly
2	larger butterfly, <50% of diameter
3	large butterfly, > 50% of diameter
4	segmental comminution
5	bone loss

Winquist & Hansen Classification of Femoral Shaft Fractures

Open fracture
- nail unless unable to debride back to clean bone or there is significant delay or other injuries that change management
Neck fractures take precedence & need to be fixed prior to fixation of shaft
Floating Knee
- fix femur first, ? up & down knee nails

Depends on the patient, the injury, surgeons skill, available hardware, etc
- Eg: Try to avoid growth plates in skeletally immature
Some open fractures better exfixed at least temporarily
Soft tissue easier to cover over nail
Preexisting bone deformity may preclude use of nails ( Fracture, Pagets, FD)

Steinman pin just to metaphyseal side of metaphyseal – diaphyseal junction in line with longitudinal axis of shaft on lateral.
This position is extra articular & should avoid the saphenous nerve & vein.
Place with knee in flexion to avoid tethering of vastus lateralis

Useful for children not amenable to flexible nails or closed techniques
Unilateral frame with 5 or 6 mm Schanz screws
flex knee during insertion distally
Flexible nails for transverse stable fracture configurations in children with open physes

Position supine +/- ± traction table or lateral if obese (lateral has ↑ risk of valgus deformity especially if distal fracture)
Antegrade
- start in piriform fossa or greater trochanter & in line with the shaft on the lateral.
- Err anteriorly with high fractures as fracture dissipates Hoops stresses on bone & entry point allows easier reduction & proximal recon cross bolting
Retrograde
- starting point just anterior to PCL insertion & in line with the shaft in 2 planes
Proximal screws should be above lesser trochanter
Reaming
- ↑ percentage & speed of union
- ↑ risk of H/O
Static Locking
- dynamic locking results in 10% failure rate even in fractures judged “stable”
X 1 cross bolt OK if “stable”
X 2 cross bolt if grade 3-5

Acceptable deformity
- LLD <2cm
- rotational mal alignment <15°
- coronal malalignment < 5°
Non union is treated with reaming & exchange nail
Fat embolus syndrome
- less with stabilistion within 24 hours
- higher with concomitant chest injury or pulmonary dysfunction
- ?? effect of reaming
Nerve
- Pudendal nerve palsy from Post
- Peroneal nerve palsy
Loss of fixation, hardware failure
Irritation from prominent metal ware
Heterotopic ossification