A novel idea for patient positioning and surgical technique for osteosynthesis of a subtrochanteric fracture in a patient with Duchenne muscular dystrophy

A 37-year-old patient with advanced Duchenne muscular dystrophy (DMD) on mechanical ventilatory support presented to our clinic with pain in his right hip after dressing by a caregiver. Imaging revealed a subtrochanteric fracture (32A1) with a very narrow medullary canal. Due to DMD the patient could not be operated in a lateral decubitus position and he also could not be operated on a fracture table with traction because of lower leg deformity and fear of iatrogenic fracture due to bone fragility. The only possible position was a supine position with gentle manual traction and additional elevation of the distal femur with a tunnel to compensate for proximal fragment flexion deformity and achieve adequate fracture reduction and nail trajectory (Fig.1). This position also allowed adequate intraoperative X-ray imaging. Osteosynthesis with an Expert Adolescent Lateral Femoral Nail was performed as this was the narrowest cephalomedulary nail available. The nail entry point was enlarged with a manual bone reamer as the original drill bit (Ø 13.0 mm) was considered too wide. After the introduction of SynReam Reaming Rod the femoral canal was reamed up to Ø 9 mm to accommodate the nail (Ø 8.2 mm). Follow-up imaging showed satisfactory fracture reduction and nail position (Fig. 2). The patient recovered successfully and was discharged.

DMD is associated with an increased bone fragility and great care must be taken to prevent additional iatrogenic fractures to the injured femur as well as other parts of the skeleton. Although femoral fractures are common in patients with DMD no literature was found about the surgical technique and patient positioning. Good patient positioning is essential for reduction and fixation of proximal femur fractures without complications even in otherwise healthy patients and even more so in patients with DMD. To our knowledge, this patient position is an original idea that has not yet been described in the literature.

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