Patient under spinal anaesthesia is laid on his side keeping the fracture side up with the hip extended and thigh supported on a thick pillow. After proper preparation and draping, a 6" long incision is made starting fron the tip of greater trochanter distally. Same incision is extended proximally for 3" curving posteriorly towards PSIS. Deep fascia (fascia lata) is cut inline with the incision exposing posterior border of the gluteus medius muscle, greater trochanter and proximal part of vastus lateralis. The vastus lateralis muscle is elevated extra periosteally to expose the lateral surface of proximal part of the femoral shaft. At this point the fracture ends of the proximal and distal fragment are identified. Generally the proximal fragment that is the femur neck is in flexion, adduction & internal rotation. To align the fracture fragments it is necessary to manipulate the proximal fragment in alignment. For this fracture fragments are disengaged by lifting the proximal end of the femut while applying longitudinal traction to the the leg. The reduction is then checked in anteroposterior projection with C-arm image intensifier. In case the reduction is unsatisfactory it should be repeated. A stable anatomic reduction is usually acheived in case there is no comminution of the calcar. This reduction is stabilized with two K-wires; the first one of 3 mm diameter is passed through the base of greater trochantor into the superior part of head and neck of the femur and the second one a 2 mm diameter guide wire is passed through a drill hole in the lateral surface of femur shaft 4 cms distal to the base of greater trochantor passing through the central axis of neck up to the sub-articular bone of the femoral head. At this stage it is necessary to confirm the position of guide wire with image intensifier in both AP and frog-lateral projection of femoral neck.
In case the position of guide wire is satisfactory a right size Jewett nail-plate device having proper nail length and matching nail-plate angle is selected. To facilitate passage of the Jewett nail through the femur-neck, an 8 mm diameter bone-hole is made using a cannulated triple reamer over the guide wire through the lateral cortex of the femur up-to the center of the femoral head. The hole in the lateral cortex is further enlarged to 14 mm diameter to avoid its breakage while hammering to insert the Jewett-nail. The nail is now hammered in in the femoral neck till the plate part of the Jewett device sits well over the lateral surface of the femur shaft. It is then fixed with adequate number of screws. Finally confirm the position of fracture alignment and position of Jewett nail plate with C-arm. Satisfied with the fracture alignment and fixation wound is lavaged thoroughly and closed in layers.
Post operatively patient is given antibiotics and necessary analgesics and kept on bed rest with a POP boot and derotation bar for 6 weeks. After which patient is mobilised non weight bearing on crutches. Full weight bearing is allowed after bony union that is nearly 3 months.
We have been using somewhat modified Jewett nail plate with core of trifin nail 8 mm with 12 mm overall nail diameter and plate part now has locking screw facilities of 5 mm diameter.
In case the position of guide wire is satisfactory a right size Jewett nail-plate device having proper nail length and matching nail-plate angle is selected. To facilitate passage of the Jewett nail through the femur-neck, an 8 mm diameter bone-hole is made using a cannulated triple reamer over the guide wire through the lateral cortex of the femur up-to the center of the femoral head. The hole in the lateral cortex is further enlarged to 14 mm diameter to avoid its breakage while hammering to insert the Jewett-nail. The nail is now hammered in in the femoral neck till the plate part of the Jewett device sits well over the lateral surface of the femur shaft. It is then fixed with adequate number of screws. Finally confirm the position of fracture alignment and position of Jewett nail plate with C-arm. Satisfied with the fracture alignment and fixation wound is lavaged thoroughly and closed in layers.
Post operatively patient is given antibiotics and necessary analgesics and kept on bed rest with a POP boot and derotation bar for 6 weeks. After which patient is mobilised non weight bearing on crutches. Full weight bearing is allowed after bony union that is nearly 3 months.
We have been using somewhat modified Jewett nail plate with core of trifin nail 8 mm with 12 mm overall nail diameter and plate part now has locking screw facilities of 5 mm diameter.
Posterior transolecranon exposure: - 6"-7" long longitudinal incision is made on posterior aspect of elbow curving laterally around olecranon. Sides of the olecranon is cleared of its muscle attachments. Narrow part of the olecranon is identified for osteotomy. Before osteotomizing the olecranon, a drill hole (3.5mm) is made through the olecranon starting at its tip upto the coronoid process anteriorly and tap it with a 4.5 mm tap for fixing it back in position at the end of surgery. The osteotomized olecranon with the attached triceps muscle is lifted proximally to expose the posterior surface of distal 4" of the humerus extraperiosteally and the condylar fragments with their articular surface. At this point it is necssary to give a good saline lavage to clear haematoma and visualize the fracture anatomy and displacement of the fragments. Muscles and soft tissues attached to posterior surface of condylar fagments and the distal 2" of the shaft are cleared extraperosteally. On medial side the ulnar nerve is mobilized carefully along with mucle mass from the medial epicondyle medial side of the ulna. No attempt is made to isolate it from other soft tissues.
