Drape the patient so that the iliac crest is exposed, since the incision will need to be quite proximal. The incision for nail insertion must lie on the curved “axis” (dashed line) of the femoral canal. This is somewhat posterior to what one might expect. By making the incision in line with the path that instruments and nail must travel, it is easier to avoid errors that might lead to eccentric reaming, or perforation of the posterior femoral shaft cortex.
Determination of the entry point
Note that most IM nails designed for trochanteric fractures enter through the greater trochanter and not the trochanteric fossa. The precise entry point in the greater trochanter depends upon the design of the nail. The surgeon must be familiar with the selected implant system. Fracture deformity (typically flexion and/or abduction) may make it difficult to locate the desired entry point. Realigning the proximal femur with a Schanz screw and/or ball-spike, placed percutaneously, are helpful solutions. Particularly for long nails, it is important that the incision and entry point lie somewhat posteriorly, on the “axis” as described above.
2. Localization of incision
Begin by identifying the tip of the greater trochanter and the axis of the femur. Mark these on the skin with the help of the image intensifier, if necessary.
Make a 3-5 cm skin incision several centimeters proximal to the tip of the greater trochanter. As shown, this lies on the proximal extension of the bowed axis of the femoral shaft. The exact location of the skin incision depends on the type of insertion handle / type of nail used.
3. Deep incision
Superficial dissection Make a 3-8 cm straight longitudinal incision in the fascia of the gluteus muscle, centered on the skin mark.
Deep dissection Split the fibers of the gluteus maximus muscle by blunt dissection to gain access to the tip of the trochanter, which is best identified with a finger or instrument.