股骨髓内钉经梨状窝手术入路

1、概述

As a general rule, draping should always be applied up to the pelvic rim, in order to find the correct individual location for the skin incision.

Care should be taken to make the skin incision in line with the curved axis (dashed line) of the femoral canal in order to minimize the risk of injury to the superior gluteal nerve.

Another reason to make the skin incision in line with the bow of the femur is to minimize the risk of eccentric reaming of the proximal fragment, leading to the risk of perforation of the posterior femoral shaft cortex.

作为一般原则，不要把骨盆环覆盖在铺单下，这样有助于确定切口的位置；

皮肤切口要与股骨髓腔在一个轴线（稍弯曲），以便减少损失臀上神经的风险；另一个原因是减少贯穿股骨干后侧皮质的风险。

2、正确的进针点

The correct position for the piriformis fossa entry point is just medial to the tip of the greater trochanter. In certain cases the greater trochanter may be curved and

medialized. It may then be necessary to ream through the medial tip of the greater trochanter.

If the first guide wire is not in line with the femoral canal, eccentric nail placement may result. This may ultimately cause iatrogenic femoral neck fracture when the nail is inserted, because the oblique insertion increases stress upon the femoral neck.

梨状窝正确进针点：位于大粗隆内侧。在一些患者，大粗隆可能弯曲或靠内侧，这时则需要挖去大粗隆内侧部分以显露进针点。

如果导针没有与股骨干髓腔在一个轴线，将导致髓内钉的偏心置入，这最终引起医源性股骨颈骨折，因为斜行插入髓内钉增加其对股骨头压力。

3、确定切口位置

To locate the site of the skin incision, the tip of the greater trochanter and the axis of the femur are marked with the help of the image intensifier and by palpating the trochanter.

切口标志：大粗隆顶点及股骨轴线（通过透视确定）和大转子（触及）

4、图解（1）

Image shows palpation with temporary external fixation in place.

本图片显示触及大转子，临时外固定架固定。

5、图解（2）

Incision on the extension of the femoral bow

The 3-5 cm incision should be made 10-15 cm proximal to the tip of the greater trochanter on the proximal extension of the anatomical femoral bow (A). B marks a horizontal line drawn from the top of the greater trochanter, which represents an incorrect skin incision.

切口应位股骨解剖轴上，即股骨粗隆上10-15cm，再向下3-5cm处。B代表不正确的切口位置。

6、切开

A 3-5 centimeter incision is made in line with the femoral bow. (Image shows external fixator used as temporary fixation device.) 确定位置后，沿股骨轴线切开3-5cm。

7、确定位置

If in doubt whether to make the incision ten or fifteen cm proximal to the tip of the greater trochanter (eg, in an obese patient), the correct entry point may be assessed with a K-wire and the AP view of the hip.

In cases of morbid obesity it may be necessary to make the incision even further proximally (up to 20 cm).

如果怀疑切口的位置，可以用克氏针在CB透视下正位用1枚克氏针确定。在肥胖病人，切口位置还要靠上。