INTRAMEDULLARY FIXATION FOR SUBTROCHANTERIC FRACTURES USING A PROXIMAL FEMORAL NAIL (PFN)

Indications

• Low and extended subtrochanteric fractures.

• Ipsilateral femoral neck and shaft fractures.

• Unstable inter-trochanteric fractures.

• Failed plate fixation of subtrochanteric fractures.

• Pathological fractures.

Pre-operative planning

Clinical assessment

• Obtain a thorough patient's history (mechanism of injury, past medical records).

• Mechanism of injury: as a result of low-energy trauma in patients with osteoporotic bones (watch for underlying pathology).

• High-energy trauma: motor vehicle accidents, falls from a height, gunshot injuries.

• In polytrauma patients the Advanced Trauma Life support (ATLS) protocol must be followed.

• Look for associated injuries, especially in polytrauma patients.

• The extremity is shortened, the thigh is swollen and there is a prominence of the proximal fragment.

• Neurologic and vascular injuries are uncommon; however, neurovascular assessment is mandatory.

• Although rare, be alert for signs of compartment syndrome.

Radiological assessment

• High-quality anteroposterior (AP) and lateral radiographs of the femur including the knee, the femoral neck and head (Fig. 10.1a,b).

• Anteroposterior radiograph of the pelvis.

• Look for extension of the fracture into the greater trochanter and piriformis fossa.

• Contralateral radiographs of the unaffected femur are useful in assessing the width of the medullary canal, the shaft-neck angle and for the determination of the nail's length.

Operative treatment

Anaesthesia

• Spinal or general anaesthesia.

• Prophylactic antibiotic as per local hospital protocol.

Table and equipment

• PFN set (Fig. 10.2).

• Standard osteosynthesis set as per local hospital protocol.

• An image intensifier.