Scissor position

Scissoring makes length, alignment and rotational confirmation easy. Raising the injured leg facilitates reduction of any flexed proximal fragment (iliopsoas muscle).

Careful pre-cleaning of the soft tissues should be performed especially if gross contamination occurs.

Operating room personnel (ORP) need to know and confirm:

• Site and side of the fracture
• Type of operation planned
• Ensure that the operative site has been marked by the surgeon
• Condition of the soft tissues (fracture: open or closed)
• Implant to be used
• Patient positioning
• Details of the patient (including a signed consent form and appropriate antibiotic and thromboprophylaxis)
• Comorbidities, including allergies

This procedure is performed with the patient under general or regional anesthesia

Long-lasting postoperative complete pain blocks for the patient with injured leg should be avoided as this could hide symptoms of a subsequent compartment syndrome.

• Supine with bilateral boots and traction
• Reconfigure the fracture table to establish the bilateral traction boot position and transfer the patient to a fracture table.
• Position the fractured leg with traction in a 20° hip flex position with traction. The unaffected leg is positioned in a 30° hip extension position on the other side of the post in a traction boot.
• Reduce the fracture with traction and manipulation before preparing and draping the patient.
• Pad all pressure points carefully (especially in the elderly). Place the ipsilateral arm across the chest to be out of way.
• Position the image intensifier on the opposite side of the injury and perpendicular to the patient.
• Ensure that you can get good-quality AP and lateral x-ray views of the entry point (piriform fossa should be more easily reached with the affected leg slightly adducted), fracture site, and distal femur before draping.

• Maintain traction on the limb during preparation to avoid excessive deformity at the fracture site.
• Disinfect the exposed area from above the iliac crest to the mid-tibia with the appropriate antiseptic. Free drape the affected limb or use a vertical isolation drape.
• Ensure the adhesive portion of the drape is large enough to reach from the iliac crest to the knee joint to allow distal locking.
• A single-use exclusion drape is used.
• Place the image intensifier on the nonsterile side of the exclusion drape.
• Drape the image intensifier.
• Traditional drapes may be used. Ensure a waterproof environment for the operative site.

• Position the operating table (if feasible) within the operating room to allow maximum space on the operating side for the surgeon, staff, and trolleys.
• The surgeon, assistant, and ORP stand on the side of the injury.
• Place the image intensifier on the opposite side of the patient, perpendicular to the patient.
• Place the image intensifier display screen in full view of the surgical team and the radiographer at the foot of the table.