Preoperative Conference

Francis Fuller M.D.

 ME/30/M
CC: Right leg pain

• DOI: 4.24.23

• MOI: MVA

• POI: Jalajala- Taytay

• 10 days prior to consult as patient was stepping off the truck he

was blindsided by a 4 wheeled vehicle near a highway in Taytay.
Patient has unrecalled duration of unconsciousness and was
immediately brought to ER where he was resuscitated, and
subsequently admitted.
 Past Medical History
• No allergies
• No previous surgeries
• Non Smoker
• No hypertension
• Occasional Alcohol beverage Drinker
• No diabetes
• Right hand Dominant - Plumber

• With Cataract Right Eye - (10 years prior) which causes slight
blurring of vision as described by patient.

• Patient height is 5’9

 Physical Exam
• GCS 15, stable VS, Afebrile at time of exam

• Cervical collar in place

• Patient seen in bed connected to balanced skeletal traction device with 10lbs of
weight connected

• Steinmann Pin inserted in proximal tibia.

• Patient able to wiggle toes and dorsiflex foot

• No sensory or motor deficits noted

• Full and equal pulses, with CRT <2 seconds

• Clinical length of femur measured at 40cm

Labs – Complete Blood Count
• Hemoglobin: 122

• Hematocrit: 0.36

• White blood cell count: 8.75

• Differential count:

• Neutrophils: 0.69

• Lymphocytes: 0.12

• Monocytes: 0.08

• Eosinophils: 0.1
 Labs - Electrolytes

• Sodium: 139.6

• Potassium: 4.34

• Chloride: 105.7

• Creatinine: 75.97

• Blood Urea Nitrogen: 6.93

Labs – Bleeding Parameters
• Bleeding time: 2’00”

• Clotting time: 8’00”

• Prothrombin Time: 12.90

• PT INR: 0.97

• APTT: 29.8

• PT Percent activity: 106%

 Assessment

• Fracture Closed Complete Displaced Distal Femur, Right (AO

32B2)

• Non-displaced vertebral compression fracture C6

 Planned Procedure

• Closed Reduction Reamed Retrograde IM nailing of right femur

 Indication for Retrograde IM nailing

• Multiply injured patient with injury in cervical spine

• Distal third femur fracture

 Goals

• Achieve an adequate anatomical reduction

• Stable fixation

• Preservation of blood supply

• Early Weight Bearing

 Prophylactic Antibiotics

• Cefoxitin 1g IV as loading dose then q8 for 3 doses post

operatively
Patient Positioning
 Surgical Technique
• Position knee over radiolucent bolsters that
allow flexion between 30 and 35 degrees.

• Identify proper starting point based on AP and

lateral radiographic imaging of the knee

• Make incision centered between patella and

tibial tubercle, based on the radiographic
estimation of the starting point

• Insert guide pin just anterior to confluence of

femoral groove and blumensaat line on lateral
fluoroscopic view
 Surgical Technique
• Establish the entry portal using large cannulated drill over a
terminally threaded pin

• Place a ball tipped guidewire through entry portal up the canal of

femur

• Reduction of the fracture with strategic bumps, Schanz pins such

as joystricks traction, Poller screws.

• Placement of guidewire across the fracture and central into the

proximal femur past level of the lesser trochanter

• Determine anticipated nail length using guidewire

 Surgical Technique
• Ream canal while the reduction is maintained

• Place the nail with the proper rotation of the implant and the
proper length and rotation of the femur

• Confirm the nail length (cannot be sticking out from cartilage)

implant rotation and femoral rotation

• Interlock proximally and distally

• Confirm lastly before closing.

 Postoperative Care
• Immediate full weight bearing is permitted and encouraged.

• Active and passive range of motion is started without restrictions.

• Knee flexor, extensors, abductors and external hip rotators should not be
neglected.

• Focus on strength balance, endurance and gait.

• CPM may be used to help with ROM of knee.

• Radiographic evaluation post operatively.

• Follow up radiographs at 6 and 12 weeks are standard.