[1/18] Kicking off the new year with some tips of how I do a short cephalomedullary nail for an intertrochanteric fracture. The cases I use here are not all the same and aren’t always “perfectly done” but I try to showcase the best example of the technique itself.

[2/18] If you don’t have table with overlapping legs like Hana (sigh), and have a limit to adduction (red), and don’t want to tape nonop leg to the bar or do lithotomy (I hate that position as can cause compartment syndrome), there are a few things you can do with fracture table.

[3/18] I turn the gross traction bars so that the little wheels (the ones with the spokes) face inward (yellow) to get additional adduction and bring legs closer together. I also get extra extension of nonop leg by turning the fine traction bar downwards (blue).

[4/18] The correct amount of traction, if you don’t want to judge by the other side, is usually close when greater trochanter lines up w/center of femoral head (yellow). You can play around with it and see how it looks. Can also always clamp if traction alone isn’t good enough.

[5/18] Most important: starting point. I draw horizontal line on top of greater troch (green), and hold guidewire up to leg to line up with center of head/neck on perfect lateral & draw line (blue). Stab Incision about 4 finger-breadths proximal / 1 FB anterior to cross of lines.

[6/18] If original start point isn’t good, I leave wire in so new wire doesn’t keep falling into same hole. Also I gently tap to get a foothold instead of using driver so that I can make minute redirections in either plane (yellow). ONLY when I’m happy, I extend stab incision.

[7/18] Once I’m happy with direction, I switch to driver, drive guidewire in metaphysis, then stop and gently tap again. I look for the guidewire to “bounce” off the medial cortex, ensuring it is in bone (not in fracture) and obviating having to go back to the lateral to check.

[8/18] I nearly always use a 10 nail (data to support). It should advance with every whack of the mallet. If it doesn’t, you need to stop and get a long guidewire and ream it out. I’ve seen iatrogenic fractures otherwise.

[9/18] This is where the drawn line comes into play. When you put jig in, you line it up with that line (blue) so that sleeves for the cephalic screw go directly on it. Keep gentle hold on jig (yellow) to keep it from sagging. This way, screw will be close to perfect trajectory.

[10/18] At least in Synthes set they have long knife I call Big Bird. You can stick it through sleeve holes to get soft tissue trajectory right away instead of moving jig to use regular knife (sometimes you’ll still need it anyway, as excursion of Big Bird not always extensive).

[11/18] I bring wire up to about blue level (I also like to stay inferior, yellow) in order to see it on lateral. Be sure to remove impactor (metal) otherwise will get in way of visual. If I need to change adjustment on lateral, I drill in reverse & redirect wire also in reverse.

[12/18] To see head well, the c-arm has to be sufficiently “wagged” proximally (yellow). Usually that solves most of my problems with lateral. My angle is about 75 deg from vertical in the other plane, to make up for the usual 15 degrees of anteversion (not quite a full lateral).

[13/18] When drilling/inserting screw, I usually do it on fluoro, I don’t just rely on the stopping point of sleeves because sometimes you can drive guidewire into pelvis. Also wire can come back out with drill so you need to be ready with obturator or another wire to stop it.

[14/18] If you line up screw handle with the line of the femur (blue) your screw end will be in the right plane. If it’s a left hip (clockwise screwing can flex the proximal fragment) I also build in an extra turn to derotate the proximal fragment if needed.

[15/18] I always try to build in some compression. The place to watch is the inferior medial portion of the fracture (arrow). Don’t overdo it or the nail starts to migrate medially.

[16/18] Big Bird makes hole for distal screw sleeve(always lock distal!). Can measure off drill as enter far cortex(if plunge at 30, do 32). In large person/loose skin can put sleeve thru cephalic screw hole (yellow; stretch SKIN w/ArmyNavy & poke NEW hole in fascia w/ Big Bird).

[17/18] Before you remove jig, do a lateral and make sure distal screw is actually in the nail (blue). It seems impossible but I have seen it miss the nail. You don’t ever want to be cocky with trauma— just when you think you’re good enough to skip steps is when it humbles you.

[18/18] The troch fragment is little abducted here, I don’t worry so much about screw being close to fracture line because nails don’t rely on lateral wall to work. Keep TAD (or calTAD as I do) small and most ITs heal without an issue. I also don’t use blades. Thanks for reading!