1. Preoperative planning
   • AP and lateral radiographs of the entire femur, including hip and knee.
   • Exclude associated femoral-neck fracture and ipsilateral knee/hip injury.
   • Select nail type, entry portal, length, diameter, and locking plan.
   • Give antibiotics, position on a radiolucent or fracture table, and prep from iliac crest to foot.
2. Position and reduction
   • Supine on fracture table or radiolucent table.
   • Obtain AP and lateral fluoroscopic images of hip, fracture, and distal femur before starting.
   • Restore length, alignment, and rotation using traction and closed reduction maneuvers. Use a percutaneous reduction tool, temporary external fixator, or limited open reduction only if needed.
3. Choose the entry point
   • Trochanteric entry for a compatible trochanteric-entry nail.
   • Piriformis-fossa entry for a straight nail.
   • Confirm the point on both AP and lateral views. A malpositioned entry or off-axis guidewire can cause eccentric reaming, cortical injury, or iatrogenic femoral-neck fracture. The AO entry-point guidance emphasizes centering the entry in the axial view and maintaining an aligned soft-tissue track.
4. Proximal exposure and canal opening
   • Make a small proximal incision in line with the femoral canal.
   • Split fascia/gluteal fibers, protect soft tissues, and insert the entry guidewire under image intensifier control.
   • Recheck AP and lateral positions.
   • Open the proximal cortex/canal with the manufacturer-specific cannulated awl or opening reamer over the guidewire.
5. Pass the ball-tipped guidewire
   • Advance the guidewire down the proximal fragment.
   • Reduce the fracture under fluoroscopy and pass the wire across the fracture into the distal fragment.
   • Ensure it reaches the appropriate distal endpoint without violating the knee joint.
   • Confirm length, coronal and sagittal alignment, and rotation before reaming.
6. Measure and ream
   • Measure nail length over the guidewire using the implant system.
   • Sequentially ream over the ball-tipped wire if using a reamed technique, preserving reduction and monitoring resistance.
   • Choose nail diameter according to the reamed canal and the implant system. Avoid forceful reaming or nail insertion.
7. Insert the nail
   • Exchange to the appropriate guidewire if required by the system.
   • Attach the selected nail to the insertion handle.
   • Advance gently across the fracture under fluoroscopy, maintaining reduction.
   • Seat the nail at the correct proximal and distal depth. Do not hammer aggressively if resistance is unexpected: reassess reduction, entry point, reaming, and nail size.
8. Interlocking
   • Insert proximal locking screws using the targeting jig.
   • Insert distal locking screws using the system's freehand fluoroscopic technique or targeting system.
   • For most acute, unstable, comminuted, segmental, or distal-third shaft fractures, static locking is used initially. Locking configuration depends on fracture pattern, bone quality, and the nail system.
9. Final fluoroscopic check
   • AP and lateral images of hip, fracture site, and distal femur.
   • Confirm:
     • Nail depth and screw length
     • Screw position outside the joint
     • Restoration of length, alignment, and rotation
     • No femoral-neck fracture, cortical perforation, or missed fracture extension
     • No prominent proximal implant
10. Closure and postoperative plan

• Irrigate and close fascia/skin.
• Document neurovascular status and rotational assessment.
• Start thromboprophylaxis, analgesia, early knee/hip ROM, and weight-bearing according to fracture stability and surgeon protocol.
• Obtain postoperative AP/lateral femur radiographs.

Important intraoperative pitfalls

• Missed ipsilateral femoral-neck fracture
• Wrong entry point or eccentric reaming
• Varus/valgus, procurvatum/recurvatum, shortening, or malrotation
• Failure to obtain and maintain reduction before nail passage
• Distal screw malposition or excessive screw length
• Iatrogenic cortical perforation or femoral-neck fracture
• Inadequate locking for an unstable fracture pattern