$Illustration of perfectly aligned bone fracture being mended by robotic surgeons.$

Nail It! A Simple Guide to Avoiding Misalignment After Proximal Femur Fracture

Mira Elwood in Health & Wellness June 2025 • 4 min read.

"Simple strategies to ensure correct alignment during cephalomedullary nailing, reducing complications and improving recovery outcomes."

Dealing with proximal femur fractures is a significant challenge in orthopedic surgery. These fractures, located near the hip joint, demand precise treatment to ensure patients regain full mobility and function. Before modern methods, dynamic hip screws and condylar screws were common, especially for unstable fractures. However, as medical technology advances, less invasive techniques have gained popularity, making cephalomedullary nails a preferred choice.

Cephalomedullary nails are designed to stabilize fractures with minimal disruption to the surrounding tissues. These nails come in different designs; some use a helical blade that impacts directly into the bone, while others rely on a sliding lag screw. Although these nails offer many advantages, surgeons sometimes encounter challenges, such as rotational malalignment. This occurs when the fractured bone fragments don't line up correctly during the healing process, which can lead to discomfort and impaired function.

Rotational malalignment can happen for several reasons. One common issue arises when inserting the lag screw, as the proximal fragment (the part of the bone closest to the hip) can rotate unexpectedly, particularly if the screw doesn't get a solid grip right away. Additionally, the surgical tools themselves can sometimes hinder accuracy. For example, the opaque nature of the lag screw jig in certain areas can obstruct the surgeon's view, making it difficult to precisely guide the guidewire into the femoral head and neck. In response to these challenges, researchers are developing practical strategies to minimize malalignment and improve outcomes after proximal femur fracture surgery.

Essential Surgical Techniques for Optimal Alignment

Illustration of perfectly aligned bone fracture being mended by robotic surgeons.

To tackle these issues, here are three key techniques that can help surgeons ensure proper alignment and reduce the risk of complications during cephalomedullary nailing.

Technique 1: Preventing Malrotation During Lag Screw Insertion When inserting the lag screw, it's essential to monitor and control any potential rotation at the fracture site. Here’s how to do it: Begin by carefully inserting the cephalomedullary screw guidewire into the femoral head. Once the guidewire is in place, reaming is performed to prepare for the screw. As the cephalomedullary sliding screw is inserted, watch the fracture site closely using fluoroscopic imaging. If you notice any rotation, pause the clockwise insertion and gently turn the screw counterclockwise to restore the correct alignment.

Ensure the cortices (outer layers of bone) match up correctly.
Use the compression device on the jig to compress the fracture fragments together.
Make sure the fracture is stable before fully inserting the sliding screw.
This method can also help realign the screw handle with the jig, which is necessary for proper nail positioning.

Technique 2: Central Guidewire Placement with Minimal Fluoroscopy Accurate guidewire placement is crucial for the correct positioning of the cephalomedullary nail. Here’s a technique to achieve central placement in the lateral view, minimizing the need for extensive fluoroscopy: While central and inferior placements are generally favored in the anteroposterior view, a central position in the lateral view is preferred. The radio-opaque handle of the cephalomedullary screw jig can sometimes block the view during guidewire placement. To overcome this, use the jig handle as a guide. Visualize the jig handle in the lateral view, aligning its anterior and posterior edges parallel to the visualized part of the femoral neck. Once aligned, you can confidently pass the guidewire centrally without relying heavily on image intensification.

Conclusion

By adopting these straightforward techniques, surgeons can enhance the precision of cephalomedullary nailing procedures, diminish the likelihood of malreduction, and ultimately foster improved results for patients undergoing proximal femur fracture repair.

About this Article -

This article was crafted using a human-AI hybrid and collaborative approach. AI assisted our team with initial drafting, research insights, identifying key questions, and image generation. Our human editors guided topic selection, defined the angle, structured the content, ensured factual accuracy and relevance, refined the tone, and conducted thorough editing to deliver helpful, high-quality information.See our About page for more information.

This article is based on research published under:

DOI-LINK: 10.1016/j.jcot.2018.11.008, Alternate LINK

Title: Avoiding Malalignment In Proximal Femur Fractures Treated With Newer Generation Cephalomedullary Nails: Some Technical Tips

Subject: Orthopedics and Sports Medicine

Journal: Journal of Clinical Orthopaedics and Trauma

Publisher: Elsevier BV

Authors: Arvind Kumar, Samarth Mittal, Aditya Jain, Vivek Trikha

Published: 2019-10-01

Everything You Need To Know

Why are cephalomedullary nails now favored over dynamic hip screws and condylar screws for treating proximal femur fractures?

Cephalomedullary nails are preferred due to their minimally invasive nature. They stabilize fractures while minimizing disruption to surrounding tissues. These nails come in different designs, such as those using a helical blade that impacts directly into the bone or those that rely on a sliding lag screw. Although these nails offer advantages, surgeons may face challenges like rotational malalignment, which occurs when fractured bone fragments don't align correctly, potentially impairing function.

What factors can contribute to rotational malalignment when using cephalomedullary nails in proximal femur fracture surgery?

Rotational malalignment can stem from issues during lag screw insertion, where the proximal fragment rotates unexpectedly if the screw doesn't achieve a firm grip. Additionally, surgical tools like the opaque lag screw jig can obstruct the surgeon's view, complicating the precise guidance of the guidewire into the femoral head and neck. Addressing these challenges requires strategies to minimize malalignment during proximal femur fracture surgery.

What steps should surgeons take during lag screw insertion to prevent malrotation at the fracture site when performing cephalomedullary nailing?

To prevent malrotation during lag screw insertion, one should carefully insert the cephalomedullary screw guidewire into the femoral head, reaming to prepare for the screw. Closely watch the fracture site using fluoroscopic imaging as the cephalomedullary sliding screw is inserted. If any rotation is noted, pause clockwise insertion to gently turn the screw counterclockwise to restore alignment. Ensure the cortices match, use the compression device to compress fragments, and ensure stability before fully inserting the sliding screw.

How can the cephalomedullary screw jig be utilized to ensure accurate guidewire placement with reduced reliance on fluoroscopy?

Accurate guidewire placement involves achieving a central position in the lateral view while minimizing fluoroscopy. To do this, use the radio-opaque handle of the cephalomedullary screw jig as a guide. Visualize the jig handle in the lateral view, aligning its anterior and posterior edges parallel to the visualized part of the femoral neck. Once aligned, you can confidently pass the guidewire centrally with less reliance on image intensification.

What is the expected impact of implementing the described techniques in cephalomedullary nailing procedures on surgical precision and patient outcomes?

The techniques focus on preventing malrotation during lag screw insertion and ensuring accurate guidewire placement with minimal fluoroscopy. By adopting these techniques, surgeons can enhance the precision of cephalomedullary nailing procedures, diminishing the likelihood of malreduction, and ultimately foster improved results for patients undergoing proximal femur fracture repair. These techniques aim to minimize complications and improve patient outcomes, aligning with the broader goals of orthopedic surgery.