Background
Modern intramedullary nailing for long bone fractures relies on the use of fluoroscopic images obtained from an image intensifier in theatre. In order to confirm the positioning of the implant and fracture reduction, images in at least two planes are necessary. These are usually obtained by rotating the image intensifier C-arm through 90º. This technique is time consuming, difficult and risks contamination of the operative field.
Technique
We recommend the use of two image intensifiers (a standard and a mini) to obtain biplanar images of the fracture and implant positioning. The image intensifiers can be set up as shown in Figure 1 (in this case, for insertion of a retrograde femoral intramedullary nail). This set-up allows the surgeon to have simultaneous anteroposterior and lateral images without moving the patient or equipment.
Figure 1. Using the standard and mini image intensifiers for insertion of a retrograde femoral intramedullary nail.
Discussion
Anecdotally, this technique saves time and prevents the need for repositioning the patient. Furthermore, it exposes the patient and staff to less overall radiation due to fewer images being required and the substitution of radiographs taken on the mini image intensifier rather than the standard image intensifier. We have used this technique successfully for retrograde intramedullary nailing of the femur and intramedullary nailing of the tibia.