Dear Magdy

King Fahd Hospital -Medina Munawrah-Orthopedic Surgery Department

Dear ----,

The best option in this case is retrograde femoral nail but I think it is not yet available in Madinah. Why not go for simple option and that is close Nacy nails, 2 or three will do the job with out opening the fracture site. If You happen to be over enthusiastic you can fix it with a moulded plat.

even putting in a retrograde nail would be a problem in this case,
unless the table is "broken" at the knee and the knee kept in flexion
while operating.

a minimally invasive plate would be the simplest solution for him,
especially if it is a locking plate, which can be slid in from above,
and the screws passed percutaneously

Mangal Parihar

Myles Clough wrote:

> The other reason to do it retrograde is (as Rajesh mentioned) it
> might be difficult to align the proximal fragment with the distal one
> because the hip doesn't move. 3 reasons for persisting with antegrade, none of
> which have overwhelming strength

: "HESHAM EL-MOWAFY" <heshammowafy@hotmail.com>
> bi lateral cemented bi polar and long plate if he is 48 y or more
> or repositinal ostiotomy and repositional ostiotomy plade plate 120 d- 110 d
> with long plate
>
> Dr HESHAM EL-MOWAFY. Prof. Ortho.

I think the priority in this case is to fix the #, first choice is antegrade nail + soft tissue release of add?abd contracture . second choice plate fixation + soft tissue release

DEAR DR ----

ALSALAM ALIKOM WARAHMAT ALLA WABARACATO
about this case their is fracture neck of femur also
so broad DCP plat is very good with contouring the
plate over the proximal femur to insert at least 2
canscellus screws in the neck and dont fotget bone
graft around comminuted fracture

Mahmoud Yasser
Alex students university hospital

I would do a CT scan of his proximal femur/hip region to rule out occult femoral neck fracture. I presume you have xrays of the distal femur which show no problem, but it is hard to rule out neck fracture at the best of times (see PubMed Search)

Then I would do a locked IM nail, probably antegrade as long as the CT scan shows you have the right anatomy proximally to get a straight shot down the femoral shaft. Putting in a rod will not compromise an eventual joint replacement if that is a concern.

What is his age and pre-injury pain status? Even if he was a pre-injury candidate for THR I doubt I would offer him a one stage operation with reduction over a long stem femoral component, but it might be a debating point.

Myles Clough mylesclough@shaw.ca
Consultant Orthopaedic Surgeon (Retired), Kamloops, BC, Canada
Clinical Instructor, University of British Columbia
Editor, OWL (Orthopaedic Web Links) http://www.orthopaedicweblinks.com
Orthogate Workshop Pages http://www.orthogate.com/clough/index.htm

I think it would be a difficult one to nail due to the possible restricted movement in the hip.I would do a locked plate if available .if not, a broad DCP.

Rajesh

Mr.K.R.Rajesh,MS,DNB,FRCS,FRCS(Orth)
Consultant Upper Limb Surgeon,
Division of Upper Limb & Joint Replacement Surgery.
Cosmopolitan Hospital,
Trivandrum,Kerala,
India.
Mobile-9447191205

Hello Mangal,

Monday, May 15, 2006, 10:49:22 AM, you wrote:

MP> even putting in a retrograde nail would be a problem in this case,
MP> unless the table is "broken" at the knee and the knee kept in flexion

That is why we use only distractor+flat radiolucent table, never
traction table.

--
Best regards,
Alexander N. Chelnokov
Ural Scientific Research Institute
of Traumatology and Orthopaedics
7, Bankovsky str. Ekaterinburg 620014 Russia

Hello Myles,

Saturday, May 13, 2006, 11:45:30 PM, you wrote:

> What would be your reasons for favoring the retrograde approach in this
> case?

In our settinfs any problem preventing smooth antegrade nailing is
indication to retrograde.

> and which would you actually do, assuming you can line up the fracture
> when you get the patient on the table?

I would apply a small wire distractor, and check whether any adducton
can be added. If yes - any antegrade nail, better with lateralized
proximal end, may be used. Either with transverse or neck screws. If no
adduction - though the proximal fragment is short but it is enough to
place two AP screws.

--
Best regards,
Alexander N. Chelnokov
Ural Scientific Research Institute
of Traumatology and Orthopaedics
7, Bankovsky str. Ekaterinburg 620014 Russia

The other reason to do it retrograde is (as Rajesh mentioned) it might be
difficult to align the proximal fragment with the distal one because the hip
doesn't move. 3 reasons for persisting with antegrade, none of which have
overwhelming strength
1. Not everyone is happy with retrograde technique. This might not be the
first case to do the retrograde approach on.
2. You would need a very long nail to get two locking screws into the
proximal fragment. I would insist on a CT scan if I were going to do a
retrograde nail to make sure there was no proximal extension of the
diaphyseal fracture, as well as checking the neck as I mentioned before.
3. The fracture is above the isthmus so you are not going to get good
intramedullary contact on both sides of the fracture. This means that only
the proximal locking screws are holding the reduction proximally. Other
things being equal I prefer an antegrade nail for more proximal shaft
fractures.
What would be your reasons for favoring the retrograde approach in this
case? and which would you actually do, assuming you can line up the fracture
when you get the patient on the table?
Myles Clough mylesclough@shaw.ca
Consultant Orthopaedic Surgeon (Retired), Kamloops, BC, Canada
Clinical Instructor, University of British Columbia
Editor, OWL (Orthopaedic Web Links) http://www.orthopaedicweblinks.com
Orthogate Workshop Pages http://www.orthogate.com/clough/index.htm

> Hello Myles,
>
> Saturday, May 13, 2006, 5:45:44 AM, you wrote:
>
> > Then I would do a locked IM nail, probably antegrade as long as the
>
> Why not use retrograde nails which would allow to ignore any problem
> with the proximal femur.
>
> --
> Best regards,
> Alexander N. Chelnokov

Prof. DR. Bahaa Ali Kornah

Prof. of Orthopaedic Surgery

Al-Azhar university . Cairo Egypt