Common pitfalls and complications in hip nailing

Abstract

I T is not the purpose of this paper to discuss the advantages of early open reduction of fractures of the hip, anesthesia or preoperative care, alI of which have been treated thoroughty in previous papers presented before the American Association for the Surgery of Trauma, but (I) to discuss a simplified method for the accurate introduction of a nai1 into the neck of the femur and (2) to discuss the complications encountered in the treatment of open reduction of fractured hips. In our hands, the use of a guide wire accurately placed and good x-ray technic has been suficient to insert a nail properly in the neck of the femur. As soon as the patient has been prepared for surgery, the first essentia1 is an accurate reduction of the fracture obtained by a Leadbetter reduction if necessary. The injured leg is then pIaced in traction with the Ieg sIightIy abducted and the foot in interna rotation. Now a point mid-way between the pubic tubercIe and the anterior superior spine of the ilium is Iocated. This point wiIl be directIy over.the head of the femur. Then the greater trochanter of the femur is palpated and a Kirschner wire is Iaid on the anterior surface of the thigh between the mid-point and a point about I inch beIow the greater trochanter. Anteroposterior and Iateral x-rays are taken, and white the films are being deveIoped, this line is marked on the skin with a soIution of siIver nitrate, the wire is removed and the area prepared and draped for surgery. In taking the anteroposterior x-ray it is important that the x-ray tube be directly over the wire so that the tube, wire and neck of the femur are in the same pIane, and in order to do this a pIumb line is used. If this is not done and the tube is at an angle, there wiI1 be considerable error on the x-ray pIate. If the reduction as shown on these preliminary x-rays is satisfactory, the operation is then carried out. A 6 to 8 inch incision is made on the IateraI surface of the thigh extending downward from the greater trochanter and parallel to the shaft of the femur, the fascia and muscles split and the upper end of the femur exposed. A hole is driIIed through the cortex of the femur and, using the line marked on the skin with siIver nitrate as a guide, a guide wire heId paraIIe1 to the top of the tabIe is drilled into the neck and head and into the acetabulum in order to transfix the head. This is important especially in high intracapsular fractures; for when the head is first struck by the reIativeIy blunt point of the nail, it may twist around and be displaced. A second series of anteroposterior and IateraI x-rays are now taken and if they show a proper pIacement of the guide wire, a Johannson modification of the Smith-Petersen nai1 of the proper length, which is determined by measuring the length of the wire projecting from the cortex and subtracting it from the known length of the wire, is driven over the guide wire. Care must be exercised in driving the nail over the wire so that the wire is not bent at the point of the nail, and subsequently driven ahead of the nai1 into the peIvis. After the nai1 is driven, anteroposterior and lateral x-rays are again taken; and if the position of the nai1 is satisfactory and if it is necessary, a 4or j-holed Thornton flange is attached to the nai1 and then securely screwed to the shaft of the femur. AI1 screws must traverse both cortices of the femur. As stated before, accurate reduction of the fracture, insertion of the nai1 and impaction are essentia1. In spite of a11 this, the foIlowing complications, in our experience, have occurred. In two cases there was evidence that the materia1 used was defective. The first case was a sIipped femoral epiphysis in which a stainless steel wood screw was broken on insertion. The proximal fragment was removed and the case treated by fixation with two Kirschner wires. The second was a fractured hip which was treated by the insertion of a Smith-Petersen nail and Thornton flange in which the machine screw used to attach the ffange to the naiI broke and had to be replaced by a new screw. These compIications, at Ieast in part, can be prevented by better controt in manufacturing. There was one case in which there was a