186 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES

FEMUR

CHAPTER 71 Application of an Intramedullary

Pin or Interlocking Nail to the Femur
INDICATIONS bone-holding forceps, Jacob pin chuck, IM pins, cerclage
Candidates include animals with single or comminuted femoral wire, wire tightener, wire cutter, external fixator clamps and
diaphyseal fractures. connecting bars (or ILN equipment, including high-speed
drill), bone curette for harvesting graft
OBJECTIVES
• To achieve anatomic reduction of single fracture lines or PREPARATION AND POSITIONING
restoration of normal bone alignment for nonreducible com- Prepare the rear limb circumferentially from dorsal midline to
minuted fractures tarsus. Position the animal in lateral recumbency, with the
The intramedullary (IM) pin is used in animals with high affected limb up. Drape the limb out from a hanging position to
fracture-assessment scores. The IM pin neutralizes bending allow maximal manipulation during surgery. Prepare the ips-
forces at the fracture; it is combined with cerclage wire for long ilateral proximal humerus or ipsilateral ilial wing for surgery for
oblique fractures and with external fixation for transverse or harvesting cancellous bone graft.
short oblique fractures to neutralize rotational and axial com-
pressive forces. The interlocking nail (ILN) neutralizes bending, PROCEDURE
rotational, and axial compressive forces at the fracture; it can Approach: Incise the skin and subcutaneous tissue on the
be used for animals with medium and low fracture-assessment lateral surface of the thigh, from the greater trochanter to the
scores.1 femoral condyles. Incise the tensor fascia lata along the cranial
border of the biceps femoris to expose the vastus lateralis and
ANATOMIC CONSIDERATIONS biceps femoris muscles. Retract the muscles to expose the
The narrowest part of the medullary canal, the isthmus, is femur.2 Insert the IM pin into the proximal femur in either a nor-
located within the proximal third of bone, just distal to the third mograde or retrograde manner. Extend the hip and adduct the
trochanter. The distal femur has a pronounced cranial bow in limb when retrograding the IM pin, to avoid injuring the sciatic
most dogs, but it is straight in the cat. Both anatomic features nerve (Plate 71A).3 Insert the ILN in a normograde manner,
constrain the size of the IM pin or ILN selected. The starting at the trochanteric fossa. Use an “open but do not
trochanteric fossa is directly in line with the medullary canal, disturb the fragments” technique to expose the proximal and
allowing normograde or retrograde placement of an IM pin and distal bone segments with minimal disturbance of the fracture
normograde placement of the ILN. The adductor magnus hematoma and bone fragments for nonreducible fractures.4
muscle attaches to the caudal surface of the femur and serves Incise the skin, and create soft tissue tunnels to the bone for
as a guide for rotational alignment. Additionally, the greater fixator pin placement.
trochanter is 90 degrees to the patella when the rotational align- Continued
ment of the femur is correct.

EQUIPMENT
• Surgical pack, periosteal elevator, Gelpi retractors, Myerding
or Hohmann retractors, pointed reduction forceps, Kern
CHAPTER 71 A P P L I C AT I O N O F A N I M P I N O R I N T E R L O C K I N G N A I L T O T H E F E M U R 187

P L AT E 7 1

Biceps femoris
muscle retracted

Shaft of the femur

Vastus
lateralis Adductor magnus
muscle muscle
retracted

Vastus
intermedius
muscle

A
188 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES

Reduction: Place an IM pin (sized to equal 70% to 80% of POSTOPERATIVE EVALUATION

the medullary canal at the isthmus) in the proximal segment. Radiographs should be evaluated for bone alignment and
Retract the pin within the medullary canal of the proximal seg- implant placement.
ment. Reduce transverse and short oblique fractures by tenting
the bone ends and levering the bone back into position. Reduce POSTOPERATIVE CARE
long oblique fractures by distracting the bone segments and The animal should be confined, with activity limited to leash
approximating the fracture surfaces. Use pointed reduction for- walking, until the fracture is healed. External fixator manage-
ceps to manipulate the bone segments into reduction. Drive the ment includes daily pin care and pin packing as needed.
IM pin distally to seat in the femoral condyle. Maintain the Physical therapy is needed to restore stifle range of motion.
reduction manually for transverse fractures and with pointed Radiographs should be evaluated in 6 weeks. Fixator pins
reduction forceps for oblique fractures. Reduce comminuted should be removed after radiographic signs of bone bridging are
nonreducible fractures by distracting the distal end with the IM observed. If a tie-in is used, the top fixation pin and its connec-
pin or ILN and aligning the major segments of the bone. tion to the IM pin should be retained. Radiographs should be
Stabilization: Apply an IM pin and a type Ia external repeated at 6-week intervals until the fracture is healed. The IM
fixator to the lateral surface of the femur to stabilize a trans- pin should be removed when the fracture has healed.
verse or short oblique fracture. Place fixation pins in the meta-
physis of each segment and close to the fracture line. The EXPECTED OUTCOME
external fixator can be connected or tied in to the IM pin to Bone healing is usually seen in 12 to 18 weeks, depending on
strengthen the fixation (Plate 71B). Apply an IM pin and mul- fracture and signalment of the animal.
tiple cerclage wires to a long oblique fracture (Plate 71C). An
external fixator can be added for additional strength. Apply an
ILN and four screws to the femur to treat comminuted nonre- References
ducible fractures (Plate 71D). 1. Johnson AL, Hulse DA: Decision making in fracture management.
In Fossum TW (ed): Small Animal Surgery, 2nd ed. St. Louis, Mosby,
CAUTIONS 2002.
To avoid penetrating the sciatic nerve when retrograding the IM 2. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the
Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
pin, the limb should be held in a hip extended and adducted
Saunders, 2004.
position while the pin exits the trochanteric fossa. It is impor-
3. Palmer RH, Aron DN, Purinton PT: Relationship of femoral
tant to avoid the femoral head and distal joint surface with the intramedullary pins to the sciatic nerve and gluteal muscles after
IM pin or ILN. The range of motion of the stifle should be pal- retrograde and normograde insertion. Vet Surg 17:65, 1988.
pated to detect pin interference in the joint. Angular and rota- 4. Aron DN, Palmer RH, Johnson AL: Biologic strategies and a
tional alignment should be monitored during the realignment of balanced concept for repair of highly comminuted long bone frac-
comminuted fractures. tures. Compend Cont Educ Pract Vet 17:35, 1995.
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C D