Hip Fractures: Repair With a Bone Nail and Screws

Hip Fractures: Repair With a Bone Nail and Screws

This video will provide a demonstration of a hip fracture repair using a bone nail and screws. Hip fractures can occur in various patterns and locations at the top of the femur, or thigh bone. In this demonstration, a bone nail and screws will be used for a specific type of fracture called an intertrochanter fracture. This hip fracture lies between the 2 bony projections at the top of the femur, called the greater and lesser trochanters.

Let us begin by getting oriented. The patient is lying flat on a specialized operating room table called a fracture table. The patient's left hip is shown covered in sterile surgical drapes. The patient's foot is to the left of the hip and their head is towards the right. To access the top of the femur, the surgeon makes an incision on the side of the hip.

A temporary wire will be used to make a starting path in the tip of the greater trochanter, which is the starting location for the nail. X-ray is shown of the wire's position at the top of the femur. Once the initial wire is placed, an instrument called an entry reamer will be placed over the wire to make a larger starting hole in the femur in preparation to place the eventual nail. An x-ray is shown of this position.

The reamer will be removed, and a long guidewire will be placed down the length of the femur. Then, multiple reamers will be used to make a hole all the way down the femur for the nail. Following this, the surgeon will measure the length of the wire in the femur to choose the appropriate length nail. The bone nail will be gently hammered into the femur, and an x-ray showing the nail in place will be taken. The long guidewire will then be removed.

Attached to the bone nail is a black guide. This guide allows the placement of screws from the outside of the skin that directly correspond to holes in the nail beneath. After making a small incision in the side of the thigh, a metal sleeve is inserted into the guide pointing towards the ball of the femur. A guidewire will then be drilled through the sleeve to create a starting position for the first screw, called a lag screw. An x-ray shows the wire in the correct position.

The length of the wire will be measured. A hole will be drilled to the set measurement from the wire, and the lag screw will be inserted. Specifically, this left-sided hip screw is designed to be screwed in counterclockwise, which prevents unwanted clockwise force on the fracture, which could cause it to displace.

The surgeon then rotates a component of the screw called the compression sleeve, which will allow the lag screw to further compress the fracture for healing. The handle for the lag screw and the initial wire will then be removed, followed by removal of the activation sleeve for the lag screw. This allows the screw to telescope and compress further during the healing process. This telescoping feature of the lag screw is important, as it prevents the screw from coming out of the side of the bone while the fracture compresses together and heals.

Once the activation sleeve is removed, the surgeon will prepare to place a screw further down the bone and nail. A small incision will be made on the side of the thigh to push a guide sleeve down to the bone. A hole will be drilled in the bone, then the bone will be measured, and the appropriately sized screw will be placed.

All the hardware is now placed and the guide is removed. Final x-rays are taken to confirm the placement of the nail and screws. The surgery is now complete.