An Alternative Direction for Proximal Locking in Retrograde Femoral Nails

Document Type

Article

Publication Date

8-1-2008

Abstract

While there is some risk to neurovascular structures with either technique, externally rotating, abducting, and flexing the leg will maintain a relative safe zone for lateral-to-medial screw locking and facilitate obtaining radiographic circles, thus minimizing the complications reported with lateral-to-medial locking in previous reports.4–6 Additionally, the femoral nerve commences its arborization as proximal as 4 cm distal to the piriformis fossa, such that 70% of patients have branches that cross the femur proximal to the lesser trochanter.7 Therefore, a larger incision (beyond what is considered percutaneous) is often used to ensure that adjacent neurovascular structures are not injured. Figure 4: - A simulated operative scenario demonstrating an assistant supporting the extremity in approximately 45° of hip flexion, 20° of abduction, and 20° of external rotation (A) while the C-arm is rotated to a position to obtain radio-graphic circles for interlocking screw placement (B). Fluoroscopic images are obtained to confirm screw position, seating, and length, along with fracture reduction, limb length, and rotational alignment. The authors recommended proximal locking screws be inserted at or above the level of the lesser trochanter to lessen the chance of injury to the arterial branches.7 Neurologic and vascular structures at risk of iatrogenic injury from proximal interlocking screw insertion during retrograde nailing may be increased in acetabular or pelvic fractures due to displacement of soft tissues secondary to hematoma formation and soft tissue swelling.

DOI

10.3928/01477447-20080801-25

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