BACKGROUND
Flexible intramedullary nails have revolutionised paediatric femoral fracture management.1–4 Achieving a closed reduction may sometimes be difficult, requiring special measures that can cause additional trauma, including use of a traction table, or an ‘F’-shaped radiolucent reduction device (Fig. 1), or even an open reduction. We describe a novel and effective method of achieving reduction whilst the nails are being inserted.
Figure 1.
The fracture reduction ‘F’ tool.
TECHNIQUE
With the patient on a radiolucent table, nails are inserted in a standard retrograde manner into the distal fragment. Once both nails reach the fracture, the surgeon applies longitudinal traction on the nails, which pulls the fracture out to length. There is sufficient friction between the correctly sized nails and endosteal surface that the rods do not back out. The nails can be levered antero-posteriorly or side-to-side until the medullary canals of the distal and proximal fragments are aligned. The surgeon maintains the traction on the nails while the assistant strikes the impacting surface of the chuck handles with a mallet to advance the nails across the fracture (Figs 2 and 3). This overcomes the traction and frictional resistance, advancing the nails in a controlled manner across the fracture without displacing the reduction. The operation is completed in a standard manner, but nail ends should be left flush to the bone to avoid irritation.5
Figure 2.
Intra-operative images demonstrate how traction applied to the nails pulls the fracture out to length and aligns the medullary canal to allow the nails to be advanced across the fracture.
Figure 3.
While maintaining traction on the nails, the mallet is used to strike the chuck handles to advance the nails across the fracture.
DISCUSSION
The advantages of this method are that a traction table is not needed, soft tissues are not injured from direct reduction manoeuvres such as an ‘F’ tool or open reduction.
References
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