Standard OT Notes Format for CRIF + ILN Femur

1. Header Information

• Patient name and ID
• Date and time of surgery
• Surgeon name and assistant(s)
• Operative time (start and end times)

2. Pre-operative Diagnosis

• Example: "Closed femoral shaft fracture (mid-third) - AO/OTA classification type (specify pattern: simple, comminuted, segmental, etc.)"
• Include laterality (left/right femur)

3. Operative Procedure

• "Closed reduction and internal fixation of femoral shaft fracture with intramedullary locking nail"
• Note any additional procedures (e.g., percutaneous joystick reduction, cerclage wiring if used)

4. Anaesthesia

• Type: General/Spinal/Regional (specify)
• Complications if any

5. Position

• "Patient placed supine on fracture table with bilateral lower limbs on supports"
• "Unaffected leg positioned in neutral/extended position to avoid compartment syndrome"
• Note traction application: "Traction applied via lateral foot support to reduce fracture" - Rockwood and Green's recommends applying traction with hip in neutral position, then releasing during entry portal creation, and reapplying only when ready for fracture reduction to minimize pudendal and peroneal nerve injury risk

6. Incision and Approach

• "A 3-5 cm longitudinal skin incision made 10-15 cm proximal to greater trochanter"
• "Approach to piriformis fossa identified and marked"
• "Subcutaneous tissues and fascia lata sharply dissected"

7. Reduction Technique

• "Fracture reduced under fluoroscopic guidance by maintaining length, alignment, and rotation"
• Note any reduction maneuvers: "Percutaneous joystick used for assist (if required)"
• Specify if reduction was difficult: "Traction force required: X pounds" or "Length maintained at (measurement)"

8. Guide Wire and Reaming

• "2.0 mm guide wire placed into distal femoral metaphysis under fluoroscopic control"
• Nail size and length: "Ball-tipped reaming rod inserted to determine nail length approximately (X mm)"
• "Sequential reaming performed to (X mm size) - ensure adequate medullary canal assessment"

9. Nail Insertion and Positioning

• Nail brand and diameter (e.g., "8 mm titanium locked femoral nail")
• "Entry point: piriformis fossa, located directly in line with femoral shaft on both AP and lateral views"
• "Nail inserted under fluoroscopic control, ensuring nail passes through fracture site without creating new fracture"
• Critical point (from textbooks): "Nail fully seated in planned position, with proximal end flush or just beneath bone surface"
• Document reduction confirmation: "Fracture reduction confirmed on intraoperative fluoroscopy - length, alignment, rotation maintained"

10. Locking Screw Insertion

• "Proximal locking performed using integral guide attached to nail"
• Specify number of screws: typically 2 (dynamic - allows compression or static - rigid)
• Document screw size: "5.2 mm cortical screws inserted proximally"

• "Distal locking performed under fluoroscopic control (due to nail deformation during insertion)"
• Method: "Cannulated targeting or freehand technique"
• Document screw type: "Static screws (for rigid fixation in comminuted fractures)" or "Dynamic screws (for simple fractures allowing load sharing)"
• Number and position of screws: typically 2 distal screws

11. Fluoroscopy Documentation

• "Intraoperative fluoroscopy used to confirm: entry point, nail position, fracture reduction, screw placement"
• Estimated fluoroscopy time: "(X seconds/minutes)"
• Final check: "Nail and screws confirmed to be in proper position on AP, lateral, and rotational views"

12. Closure

• "Subcutaneous tissues and skin closed in layers"
• Suture type and number: "Skin closed with 2.0 nylon sutures" or staples (count them)
• Dressing applied: "Sterile dressing applied; splinting/immobilization documented"

13. Estimated Blood Loss

• Document: "Minimal/Moderate/Significant" and approximate amount

14. Drain Placement (if used)

• "No drain placed" or "Hemovac drain placed and secured"

15. Complications During Surgery

• Document any: "No intraoperative complications" or specify any issues encountered and how managed
• For example: "Difficulty with distal locking due to... managed by..." or "Reduction loss occurred, successfully re-reduced"

16. Post-operative Plan

• Immobilization: "Posterior splint for X weeks" or "Off-the-shelf brace applied"
• Weight-bearing status: "Non-weight bearing, partial weight bearing, or full weight bearing as tolerated" (depends on fracture stability and surgeon preference)
• Follow-up imaging: "X-rays at 2-4 weeks, 6 weeks, 12 weeks, and 6 months"
• Physical therapy: "PT to begin for ROM exercises post-op day 1 (if tolerated)"

17. Implant Details to Document

• Nail manufacturer and catalog number
• Nail diameter: typically 8-11 mm
• Nail length: typically 360-460 mm depending on patient
• Screw sizes and types used
• Any cerclage wires or supplemental fixation

Clinical Tips from Textbooks:

1. Entry Point is Critical - Campbell's emphasizes that eccentric portal entry can cause comminution and loss of fixation. Ensure entry is directly in center of femoral shaft on both AP and lateral views.
2. Traction Timing - Per Rockwood and Green's, carefully manage traction timing to minimize pudendal and peroneal nerve palsy. Release traction during entry portal preparation.
3. Early Nailing is Easier - Early nailing (within 12 hours) requires less traction force and achieves easier fragment reduction. If delayed, pre-operative traction helps maintain length.
4. Nail Seating - Nail must be fully seated; the proximal end should be flush with or just beneath bone surface for better biomechanics.
5. Distal Locking Challenge - Distal locking requires fluoroscopic guidance because nails deform slightly during insertion, making proximal guides inaccurate for distal screw placement.