OT notes · Orthopaedics

Intramedullary interlocking nailing of femur

Usual anaesthesia
Spinal (subarachnoid block) with or without epidural; general in polytrauma
Position
Supine on fracture table with perineal post and traction (or lateral); supine on radiolucent table for retrograde nailing
Setting
emergency

Operative note template for interlocking nailing of a femoral shaft fracture, with a filled example for closed reamed antegrade nailing of a transverse midshaft fracture in a young man under spinal anaesthesia.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • failure of closed reduction, need to open the fracture
  • malrotation or shortening of the limb
  • missed or new fracture of the femoral neck
  • fat embolism during reaming
  • nerve injury from traction or the perineal post
  • infection, especially in open fractures
  • delayed union or nonunion needing further surgery
  • hip pain (antegrade) or knee pain (retrograde)
  • later removal of implant

Pre-operative details for this operation

  1. Side and fracturelevel (proximal / middle / distal third), pattern, comminution; AO/OTA type
  2. Open or closedif open: Gustilo-Anderson grade, wound size, time of injury, debridement done
  3. Femoral neck and knee checkedinternal rotation AP hip / CT; knee ligament and patella injury
  4. Associated injuries and physiologychest, head, abdomen; whether early total care or damage control was chosen
  5. Distal neurovascular status before surgerypulses, sciatic / peroneal function, thigh compartments
  6. Current tractionskeletal traction pin site and weight, if any
  7. Nail system and sizes availableentry type, diameters, lengths; external fixator set in room as backup

Anaesthesia and position

  1. AnaesthesiaSpinalCombined spinal-epiduralGeneral
  2. DirectionAntegradeRetrograde
  3. PositionSupine on fracture tableLateral on fracture tableSupine on radiolucent table, leg freeperineal post padded; trunk adducted; injured hip flexed 15-30 degrees; other leg scissored
  4. TractionFoot bootSkeletal pin (distal femur / proximal tibia)Manual
  5. Reference C-arm images of the normal sidetrue lateral of hip and knee / lesser trochanter profile saved before draping
  6. TourniquetNot applicable

Operative findings

  1. Fracture on C-armpattern, comminution, butterfly fragment, extension proximally or distally
  2. ReductionClosedClosed with reduction tool / joystickMini-openOpen
  3. Canalnarrowest diameter; reamer size at which chatter began
  4. Femoral neck at endIntact on AP and lateral C-arm

Procedure (steps)

  1. Painting and drapingbuttock and thigh to popliteal crease; C-arm arm draped
  2. Incisionantegrade: oblique, starting 4-6 cm above the tip of greater trochanter; retrograde: parapatellar or through patellar tendon
  3. Entry pointPiriformis fossaTrochanteric (medial slope of greater trochanter)Intercondylar notch (retrograde)must match nail design; guide wire checked in AP and lateral
  4. Entry reamingrigid / entry reamer size, depth to below lesser trochanter
  5. Reduction and ball-tip guide wirereduction tool / joystick; wire central distally at physeal scar
  6. Nail length measuredruler over wire or two-wire method; nail tip between upper pole of patella and physeal scar
  7. ReamingReamedUnreamedstart size, final size, increments; SpO2 during reaming
  8. Nail inserteddiameter x length; by hand with gentle taps; not proud at entry; fracture site not distracted
  9. Length and rotation checked before lockingagainst saved images of the other side / cortical width / clinical rotation
  10. Order of locking and compressionDistal first then proximalProximal first then distalDistal first, backslap / compression, then proximal
  11. Proximal lockingStatic, jigDynamic, jigCephalomedullary screws into necknumber and lengths
  12. Distal lockingFreehand, perfect circleJig-guidednumber of screws, static / dynamic, lengths
  13. End capInsertedNot usedsize
  14. Final C-arm check and images savedwhole nail, fracture, screws, femoral neck in AP and lateral; number of images; screening time

Closure, drains and dressing

  1. Wounds washedsaline
  2. Fascia and subcutaneous tissuesuture material
  3. SkinInterrupted nylonStaples
  4. Open fracture woundclosed / left open / negative pressure dressing; antibiotic beads if used
  5. Thigh compartmentsSoftTense, pressures measured
  6. Knee ligaments examined under anaesthesiaStableLaxity noted
  7. Neurovascular status at enddistal pulses, capillary refill; ankle and toe movement when block allows; perineum checked after removal from post

Specimens and implants

  1. Nailtype (piriformis / trochanteric / retrograde), diameter x length, make, lot / batch number, sticker in case sheet
  2. Proximal locking screw(s)number, diameter and length, lot / batch, sticker
  3. Distal locking screw(s)number, diameter and length, lot / batch, sticker
  4. End cap / compression screwsize, lot / batch, sticker
  5. Specimen / cultureNoneWound swab / tissue for culture (open fracture)

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Vitals and SpO2watch for breathlessness, confusion, petechiae (fat embolism) for 72 hours
  2. Limb checkdistal pulses, toe movement, sensation, thigh swelling and pain on stretch; hourly for 4 hours then 4-hourly
  3. Check X-rayfull-length AP and lateral femur with hip and knee; AP pelvis with hips internally rotated for neck
  4. Rotation and leg length check on wardcompare both legs with hips flexed 90 degrees
  5. Analgesiadrug, dose, frequency
  6. Antibioticsprophylaxis only for closed; open fractures as per open fracture protocol
  7. Mobilisationquadriceps, straight leg raise, knee and hip motion; walker or crutches, weight bearing as the note states
  8. Thromboprophylaxisas per unit protocol unless contraindicated
  9. Follow-upsuture removal at about 2 weeks; X-rays at 6 weeks and until union

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. V.S., 28 years, motorcycle accident, closed transverse fracture of the right femoral shaft at the middle third (AO/OTA 32A3), no other injuries, on upper tibial skeletal traction since admission.

Case details

Date: 03/05/2026. Emergency list, day 1 of injury. OT 2.

In OT 11:00. Spinal given 11:10. Skin incision 11:45. Skin closed 13:05.

Surgeon: Dr A. (3rd-year resident, Orthopaedics). Assistant: Dr B. (1st-year resident). Consultant: Dr C., present in OT.

Anaesthetist: Dr D. Scrub nurse: Sr E. C-arm technician: Mr F.

Indication and pre-op

Indication: closed transverse midshaft fracture right femur, 32A3. Right hip X-ray with internal rotation view: femoral neck intact. Knee X-ray normal.

Right foot: dorsalis pedis and posterior tibial pulses palpable, sciatic and peroneal function normal, thigh compartments soft.

Hb 11.9 g/dl. Blood group O positive, 2 units cross-matched.

Consent: general, procedure-specific and anaesthesia consent taken in Hindi from patient, brother as witness. Malrotation, shortening, neck fracture, fat embolism and nonunion explained.

Right thigh marked. WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 11:30, before skin incision.

Anaesthesia and position

Spinal anaesthesia. Supine on fracture table, well-padded perineal post, trunk adducted. Traction through the upper tibial pin on the traction stirrup. Left leg scissored in boot. Right hip in 20 degrees flexion.

True lateral of left hip and left knee taken and saved as rotation reference: C-arm angle 34 degrees at the hip and 12 degrees at the knee.

Closed reduction by traction and manipulation: acceptable on AP and lateral C-arm.

Parts painted with povidone-iodine and chlorhexidine-alcohol. Buttock and thigh to popliteal crease draped. C-arm arm draped.

Procedure

5 cm oblique incision starting 5 cm above the tip of the greater trochanter. Gluteus maximus fascia split in line with fibres. Piriformis fossa palpated.

Guide wire placed in the piriformis fossa, central in AP and lateral C-arm views, advanced below lesser trochanter. Entry opened with 12 mm rigid reamer.

Reduction tool passed across fracture. 3 mm ball-tip guide wire passed to the distal physeal scar, central in both views.

Nail length measured with ruler over the wire: 380 mm.

Canal reamed from 9 mm in 0.5 mm steps. Chatter at 11.5 mm. Final reamer 12.5 mm. SpO2 stayed 98 to 99 percent during reaming.

Interlocking nail (piriformis entry) 11 mm x 380 mm inserted by hand with gentle taps. Nail flush at entry, tip between upper pole of patella and physeal scar. Fracture reduced, no gap.

Rotation matched to saved images of the left side. Cortical widths equal across the fracture.

Distal locking first: freehand perfect-circle technique, two static 5 mm screws, 40 mm and 38 mm, through a lateral stab incision. Traction released.

Proximal locking with jig: one static 5 mm screw, 55 mm, from greater towards lesser trochanter. End cap 0 mm inserted.

Final C-arm: whole nail, fracture, both distal screws and proximal screw satisfactory. Femoral neck intact on AP and lateral with dynamic screening. 9 images saved. Screening time 2 min 10 s.

Closure

Wounds washed with saline. Fascia closed with polyglactin 910 (Vicryl) No. 1. Subcutaneous tissue with Vicryl 2-0. Skin with interrupted polyamide (Ethilon) 2-0. No drain. Sterile dressing.

Upper tibial traction pin removed and pin sites dressed.

Thigh compartments soft. Right knee stable to varus, valgus, anterior and posterior stress under anaesthesia.

Clinical rotation with both hips flexed 90 degrees: equal. Leg lengths equal at the heels.

Specimens and implants

Interlocking femoral nail 11 x 380 mm (piriformis entry). Distal locking screws 5 x 40 mm and 5 x 38 mm. Proximal locking screw 5 x 55 mm. End cap 0 mm.

Make and lot / batch numbers as on the implant stickers. All 5 stickers pasted on the implant page of the case sheet and entered in the OT implant register.

No specimen. No tourniquet. No cement.

End of procedure

Estimated blood loss 250 ml (suction 100 ml + mops). No transfusion.

Mop, needle and instrument count correct, confirmed by scrub nurse.

No intra-operative complications. Perineum checked after removal from post: no pressure mark.

Right foot warm, dorsalis pedis and posterior tibial pulses palpable, capillary refill under 2 seconds. Motor check when block wears off.

Shifted to recovery in stable condition. Pulse 86/min, BP 122/74 mmHg, SpO2 99 percent.

Post-op orders

Pulse, BP, SpO2 and distal pulses hourly for 4 hours, then 4-hourly. Inform if breathless, confused or rash appears.

Report thigh tightness or pain on passive toe stretch at once.

Analgesia as per unit acute pain protocol (drug, dose and times written on the drug chart).

Thromboprophylaxis as per unit protocol.

Full-length X-ray right femur AP and lateral, and AP pelvis with both hips internally rotated.

Quadriceps and straight leg raise from POD 1. Walk with walker, weight bearing as tolerated, from POD 1.

Suture removal at 2 weeks. X-ray at 6 weeks.

Signature

Dr A., JR-3, Orthopaedics. Reg. no. ________. 03/05/2026, 13:20.

Must document for this operation

  • State of the femoral neck before surgery and on final C-arm views. An ipsilateral neck fracture is easily missed, and the note must show it was looked for before and after nailing.
  • How rotation and length were checked, with the reference used. Malrotation over 15 degrees may need revision, and the note is the only record of how alignment was judged.
  • Final reamer size, nail diameter, length and entry type. Needed for exchange nailing or implant removal, which is common after femoral nailing.
  • Number, position and mode (static or dynamic) of locking screws, and whether compression or backslapping was done. They decide weight bearing and whether dynamisation is possible later.
  • Implant make and lot / batch numbers with stickers pasted, and C-arm images saved. Needed for recall, the implant register and to show the final position at the end of surgery.
  • Distal neurovascular status and thigh compartments at the end. Traction and reaming can cause nerve palsy or compartment syndrome, and a baseline is needed to time any change.
  • For open fractures: grade, debridement done, and how the wound was managed. Infection risk and the plan for later wound cover depend on this.

Common mistakes in these notes

  • Writing 'ILN done' without nail size, length or number of locking screws.
  • Not recording that the femoral neck was checked on the final images.
  • No record of how rotation was checked.
  • Leaving out SpO2 or any event during reaming.
  • Implant stickers not pasted or screw lengths missing.
  • No distal pulses or compartment check at the end.

Indian practice and paperwork

  • Record the batch and serial number of the nail and every screw in the case sheet; NABH also expects them in the OT implant master logbook and the discharge summary. (NABH Hospital Standards 5th ed., MOM.10(d))
  • When the nail is removed later, the metal implant goes into the blue (metallic body implants) biomedical waste container. (CPCB/MoHFW guidelines under Bio-Medical Waste Management Rules 2016, blue (b))

Sources

  • Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier; copyright 2027, Ch 59 Fractures of the lower extremity: fractures of the femoral shaft, intramedullary fixation, Techniques 59.26 (antegrade) and 59.27 (retrograde), pp. 2637-2649.
  • Tornetta P III, ed. (Wiesel SW, editor-in-chief). Operative Techniques in Orthopaedic Trauma Surgery. 2nd ed. Wolters Kluwer, Ch 44 Antegrade intramedullary nailing of the femur (Ziran NM, Ziran BH), pp. 449-478.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Table 1: cefazolin 2 g IV (3 g if 120 kg or more) within 60 min before incision. academic.oup.com/ajhp/article/70/3/195/5112717

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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