JANUARY 2015
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The Surgical Technologist
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17
balance. If this occurs, this condition will need to be treated
prior to surgery. These patients will likely remain hospital-
ized and in traction while being treated.
When a patient has been stabilized and is cleared to
undergo surgery, the surgeon has several options. The com-
pression hip screw, plates and screws and intramedullary
nails are modern options. This article will focus on trochan-
teric fixation nail. It is in the class of cephalomedullary nail,
an intrameduallary nail implanted from the head of the fem-
oral bone and it uses a helical blade and a proximal locking
screw and a distal locking screw. The distal locking screw
may or may not be used based on the surgeon’s preference.
S U R G I C A L T E C H N I Q U E
The patient should be positioned in the lateral decubitus
position or supine position, depending on a surgeon’s pref-
erence. In most cases, the supine position on a fracture table
is the best position for a trochanteric fracture. The fracture
is reduced by a combination of flexion, rotation and traction.
The C-arm needs to be placed so that it will visualize the
proximal femur in both the anterior-posterior and lateral
positions. The patient’s affected hip should have 10-15° of
adduction.
The surgeon will use the radiographic ruler preoperative-
ly to measure the femoral neck angle using the three oblique
slots and the 3.2-mm diameter, 400-mm length guidewire.
The nail comes in three angles, 125°, 130°, 135°. The surgeon
will position the ruler over the proximal femur and take an
AP image. He or she will select the angle that most closely
matches the femural neck angle.
The same ruler will be used to determine the proper
nail length. The short nail comes in two lengths, 170 mm
and 235 mm. The long nail comes in lengths between 300
mm - 460 mm. The surgeon will determine the diameter of
the femural shaft by placing the diameter tabs of the ruler
perpendicular to the femur and reading the measurements
through the image.
The patient’s affected hip will be prepped with an iodine-
based prep depending on the surgeon’s preference. After
the prep is dry, an isolation drape will be used to drape
the patient and the surgical technologist will throw off the
cautery cord. After the timeout, the surgeon will make an
incision using a #10 blade on a #3 knife handle, superior
to the greater trochanter. The nail’s entry point will need to
be inline with the medullary canal of the femur. The sur-
geon will dissect the gluteus maximus fascia longitudinally,
seperate the underlying muscle fibers and palpate the tip of
the greater trochanter. Once that area is exposed, the surgi-
cal technologist will hand the surgeon the protection sleeve
with the 3.2-mm guidewire with the 3.2-mm trochar installed.
The 3.2-mm guidewire must be inserted at a 6° angle lateral
to the femoral shaft. The surgeon will remove the trocar and
insert the 3.2-mm guidewire. He or she will either insert the
guidewire on power or use the universal T-handle for manual
insertion. Using the C-arm, the surgeon will verify the guide-
wire placement on both AP and lateral planes, and continue
the insertion of the guidewire to approximately 15 cm. The
3.2-mm guidewire will then be removed. The surgical tech-
nologist will hand the surgeon a drill with the 17-mm can-
nulated drill. The surgeon will place the cannulated drill over
the guidewire and drill to the stop. The 17-mm cannulated drill
and the protective sleeve then will be removed. Alternatively,
A Word About X-Ray Safety
Through out the surgery, the C-Arm will be used to verify
nail length, width and angles. It will also be used to ver-
ify placement of the nail, the locking screws, the helical
blade and the guidewires. Modern C-Arms use the minimal
amount of radiation to get the image needed. However,
there are still safety considerations you should follow.
•
Know the risks: If the C-arm is improperly used, the
patient, the surgeon, the surgical technologist and the
circulator could be put at an undue risk. Do not be afraid
to ask the X-ray technician if the C-Arm has passed the
latest safety tests.
•
Dose Reduction: The technician should use as little flou-
roscopy as possible. He still needs to get a good image for
the surgeon, but overexposure by keeping the flouro live
when not needed increases exposure. Keep it to required
amounts to get the image but no more.
•
Lead Aprons and Other Personal Protective Equipment:
Wear lead. Lead aprons, lead-lined gloves and even lead
glasses should be provided by your facility. Wear your
radiation badge to measure your exposure doses. Thyroid
cancer and other cancers are caused by excessive radia-
tion exposure. If you or someone on your team is preg-
nant or suspect pregnancy, avoid being in the OR where
the C-Arm is being used if at all possible. Birth defects
can result from any exposure.
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