Proximal Femoral (PF) Nailing - Surgical Steps

1. Patient Positioning

• Patient supine on a fracture table with a perineal post (lateral decubitus may be used for morbidly obese patients or certain fracture patterns).
• Contralateral lower extremity placed in a boot and scissored (hip extended relative to the injured side) to allow fluoroscopy access.
• Adduct the torso and secure the ipsilateral arm across the patient's chest - this is critical to allow the entry point at the proximal trochanter to be accessible.
• Affected extremity placed in 20-30 degrees of hip flexion after reduction.

2. Fracture Reduction

• Reduction performed before placing the affected extremity in the boot.
• Apply traction + internal rotation to achieve reduction.
• Correct the typical posterior sag (sagittal plane deformity) by applying an anterior force to the distal fragment first, then completing reduction with traction and internal rotation.
• Image the contralateral hip for varus/valgus templating - this is stored on the C-arm for comparison, as a poor reduction (aberrant neck-shaft angle) is a major cause of fixation failure.

3. Fluoroscopy Setup

• Position the C-arm on the contralateral side (or between legs).
• Obtain both AP and lateral views before making any incision.
• Confirm adequate fluoroscopy is attainable before proceeding - this is a go/no-go checkpoint.

4. Entry Point - Incision and Guide Pin

• Make a 3 cm incision approximately 5 cm proximal to the greater trochanter (some describe it directly over the tip of the greater trochanter).
• Incise the fascia lata; split the muscle down to the greater trochanter.
• Insert a guide pin into the tip of the greater trochanter.
• Check on AP view: pin should lie just lateral to the medial aspect of the greater trochanter.
• Check on lateral view: pin should be centered or slightly posterior in the femoral neck/head.
• Correct entry point position is essential - errors here propagate throughout the procedure.

5. Opening the Proximal Femur (Reaming)

• Open the proximal femur with an appropriately sized solid channel reamer (awl/reamer over the guide pin).
• Ream or core out the proximal 5 cm of femur (or per implant manufacturer's instructions).
• If needed, ream the medullary canal further to accommodate the selected nail diameter.
• Reaming depth and diameter depend on the specific nail system used (e.g., Gamma nail, PFNA, InterTAN, TFN).

6. Nail Insertion

• Insert the intramedullary nail over a long guide wire, down the femoral canal.
• Advance under fluoroscopic guidance.
• Confirm correct rotation and position on both AP and lateral views before proceeding.
• The nail tip should be positioned appropriately (considerations for short vs. long nail are outlined below).

7. Proximal Locking - Lag Screw/Blade Insertion

• Using the targeting jig, insert a guide wire into the femoral neck and head.
• Check position carefully on both AP and lateral views:
  • AP view: central or inferior (low) position in the femoral head (tip-apex distance < 25 mm is the goal)
  • Lateral view: central position
• Determine lag screw length from the guide wire.
• Ream the appropriate channel in the femoral neck.
• Insert the lag screw (or helical blade in some designs) to within 5-7 mm of the joint line (subchondral bone).
• The lag screw must be able to slide to allow dynamic compression at the fracture site.

8. Distal Locking

• Insert the distal locking screw(s) using the targeting jig (static or dynamic locking, per fracture pattern and nail system).
• Confirm position fluoroscopically.
• Static locking is generally preferred for unstable fractures.

9. End Cap (if applicable)

• Insert end cap over the proximal nail if the system requires it.
• This prevents bone ingrowth and facilitates future removal.

10. Wound Closure

• Close the fascia lata with absorbable sutures.
• Close skin with absorbable subcuticular sutures.
• Apply a pressure dressing to the wound.

11. Post-op

• Transfer the patient to a bed with a pressure-relieving mattress as soon as possible.
• Weight bearing as tolerated is usually allowed immediately depending on fracture pattern and fixation stability.

Key Technical Points