Theoretically, this increases the risk of infection, particularly relevant for open fractures. However, clinical studies have not demonstrated that this is very significant. The surgeon should consider whether or not the benefits of reaming are worth the associated risks when choosing whether or not to use reaming for tibial intramedullary nails. These may be either cannulated, and motor driven, or solid hand reamers.
Reamers should be sharp so they cut the bone with little friction, and should have deep flutes and a small diameter shaft. The goal is to minimize pressure in the canal ahead of the reamer, and to avoid friction and resulting overheating of bone and surrounding soft tissues with resulting full-thickness necrosis of both!
If the reamer is not cutting bone easily, remove it, clear bone clogging the flutes, and resume reaming slowly and cautiously. The first reamer of a series should be shaped so that its tip cuts into the bone. Subsequent reamers need only cut against the sides of the medullary canal. The illustration shows a solid hand reamer left and a power reamer right.
Non-reamed nailing was developed in hopes of reducing risks of infection and pulmonary dysfunction from embolized medullary debris. These benefits are usually not clinically significant.
Such nails may be used for smaller diameter medullary canals, or selected indications, e. Modern IM nails permit placement of locking screws through bone and nail, to improve fixation both proximally and distally.
Locked nails permit stable fixation which controls length, rotation, and alignment of proximal and distal fractures. However, locking prevents impaction of distracted fractures, and interferes with their healing.
When locking nails were first introduced, their potential for impaired healing was recognized. This is usually not necessary if distraction is avoided, but may be considered when a fracture fixed with length-stable locking is healing slowly. Some locking screw holes are designed with an oval shape so that a screw at one end of the oval will allow some fracture impaction, but still control rotation as well as limit shortening to the length of the oval.
To ensure adequate fixation of acute tibial fractures, use of locking screws both proximally and distally is advisable. Dynamic oval rather than static round holes may be used when the fracture pattern prevents shortening. This procedure is normally performed with the patient in a supine position for nailing. For this procedure an intramedullary nailing approach is used. Reduction is an essential part of intramedullary nailing. The fracture must be reduced to allow guide-wire placement, during reaming, and during nail insertion.
Length, angulation, and rotation are all important to restore. Even after guide-wire insertion, further correction of alignment may be needed to avoid deformity. This should be done before reaming and nail insertion. Reduction is usually more challenging with proximal and distal fractures as well as with delayed treatment.
Sometimes only mild traction and rotational adjustment are required. Percutaneous reduction aids pointed reduction forceps, Schanz screws or ball-spike pusher may allow reduction without opening the fracture. With other fractures, open reduction may be necessary. Unless the fracture is older and consolidated, the surgeon usually begins with less invasive reduction techniques, and if they do not succeed, progresses to techniques which require more fracture exposure.
The following illustrations of the different reduction techniques provide examples that can be used or modified as necessary. The illustration shows a triangular radiolucent supporting frame, with padding over top, placed proximal to the popliteal fossa. For patients positioned on a radiolucent table without knee support, one person holds the leg and the other pulls the leg distally.
During traction, the reduction is controlled by palpating the tibial crest and the anteromedial surface. A large distractor is usually placed in a coronal plane. It lies posterior to the tibia, either laterally or medially. Do not obstruct planned locking screws or x-rays.
The proximal Schanz screw must be proximal and sufficiently posterior to avoid blocking the nail. Place it parallel to the tibial plateau to aid proximal fracture alignment. Oblique or spiral fractures can often be reduced with a pointed reduction forceps applied percutaneously.
In the event of delayed treatment, or if a bone fragment is stuck in the canal, open reduction is performed. In open reduction, the preservation of the periosteum, and peripheral soft-tissue attachments is recommended. Incision Locate the fracture by palpation or with image intensifier.
Make a small longitudinal incision over the fracture. Extend the incision sufficiently for access. Free up one side of the fracture at a time, with minimal dissection. If the fracture is oblique, a bone clamp, placed percutaneously, with its tips perpendicular to the fracture plane, can be used to compress the fracture surfaces.
Together with some traction, this helps restore length as well as fracture apposition. If the fracture is transverse, it may be reduced with manipulation using clamps on the bone ends. This may require excessive exposure. Percutaneous Schanz screws, or percutaneously applied pointed reduction forceps, as illustrated, are less invasive. The technique with clamps is as follows: Free up the ends of both fracture fragments.
Align the crest of both fragments. This will assure proper rotation. Flex the fracture to 45 degrees, or enough to place one fragment onto the other. Approximate the cortical edges, and gradually straighten the fracture, which compresses the fracture site. Recheck alignment. Alternatively, a Hohmann retractor can be used for reduction by placing it between the fracture fragments and prying them apart. It is important to hold this position for at least 30 seconds in order to allow the visco-elastic tissues to stretch gradually.
It is very important to maintain the reduction while the nail is inserted. This often requires an assistant, or temporary use of distractor, external fixator, or plate with unicortical screws. Particularly for proximal tibial fractures it may be difficult to achieve and maintain reduction while inserting the nail.
As illustrated, a small plate with unicortical screws can be used, both as a reduction aid and to hold the reduction during nail insertion. Brands Hellermann Tyton Signamax Inc. Brands Platinum Tools, Inc. Fire Protection. Safety Equipment. Fiber Optic. Cable Management. Network Products. Electrical Supplies.
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This ensures the correct IV solution is used. Pause the EID or close the roller clamp on a gravity infusion set. Stops the infusion to prevent air bubbles from forming in IV tubing. Remove protective plastic cover from the new IV solution tubing port.
Keep IV tubing port sterile at all times. If IV tubing port becomes contaminated, dispose of it immediately and replace. Remove the old IV solution bag from the IV pole. Turn IV bag upside down, grasping the tubing port.
Ensure IV tubing spike remains sterile during removal to avoid contaminating IV tubing. Spike new IV solution. Fill the drip chamber by compressing it between your thumb and forefinger. Ensure the drip chamber is one-third to one-half full. Check IV tubing for air bubbles. Fluid in the drip chamber helps prevent air from being introduced into IV tubing. Fill drip chamber IV tubing label. Open clamp and regulate IV infusion rate via gravity, or press start on the EID as per physician orders.
Once rate is set, count the drops per minute on the gravity set or ensure the EID is running at the correct rate as per physician orders. Regulate IV tubing with a roller clamp. Label new IV solution bag as per agency policy. Time tape gravity IV solutions as per agency policy. Labelling IV solutions provides easy viewing of infusing solutions and additives. Dispose of used supplies, perform hand hygiene, and document IV solution bag change according to agency policy.
Document time, date, type of solution, rate, and total volume. Verify physician orders for the type of solution, rate, and duration. Collect necessary supplies. It also confirms the correct rate and solution for patient safety. Identify yourself, identify the patient using two identifiers, and explain the procedure to the patient. Proper identification of patient prevents errors. Compare MAR with patient wristband.
Prime new administration set using a new IV solution bag and new IV tubing.
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