ISPUB.COM The Internet Journal of Third World Medicine Volume 5 Number 2 1 of 6 Closed Interlocked Nailing Of A Fractured Femur Without X-Ray Guide In First Trimester Pregnancy: A Case Report A Ogbemudia, R Enemudo, E Edomwonyi Citation A Ogbemudia, R Enemudo, E Edomwonyi. Closed Interlocked Nailing Of A Fractured Femur Without X-Ray Guide In First Trimester Pregnancy: A Case Report. The Internet Journal of Third World Medicine. 2006 Volume 5 Number 2. Abstract Diagnosis and treatment of fractures of the long bones of the lower limbs in pregnant patients in the first trimester present a peculiar risk of exposing the foetus to ionizing radiations during X-ray evaluation and X-ray guided treatment, which may cause deranged embryogenesis. The mother is also at risk of having deep vein thrombosis from prolonged confinement during non- operative treatment with traction. The alternative to conservative treatment which is open reduction and internal fixation in the first trimester of pregnancy, apart from the complications that follow surgery and anaesthesia, is reasonably safe. We are reporting this case to highlight a technique of closed interlocked intramedullary fixation of a comminuted diaphyseal femoral fracture which was devoid of radiation risk to the patient and foetus because no X-ray imaging assistance was used and did not require a special targeting device and the fracture table. CASE REPORT I. J. is a 23 year- old pregnant woman who fell from a storey building which had no protective railings. She landed on her right side and noticed painful swelling and deformity of the right thigh with inability to get up and walk. She did not suffer any other injury. Initial x-rays revealed a displaced comminuted fracture of the right femur. During secondary survey, she gave a history of amenorrhoea of 8 weeks duration. Ultrasound scan showed a gravid uterus of 10 weeks gestational age. Her packed cell volume was 30% (haemoglobin concentration was 10g/dl). Electrolytes and urea, and fasting blood sugar levels were normal. She was evaluated by the obstetricians who excluded threatened abortion. She had closed reduction and internal fixation with a size 13mm/40cm Kuntscher nail which was modified to enable application of one proximal and two distal interlocking screws. The C-arm image intensifier was not used during this procedure because of the risk of irradiation to the foetus. The estimated blood loss at surgery was 400ml. The entire procedure which lasted 118 minutes was done under epidural anaesthesia 48 hours after the injury. OPERATIVE PROCEDURE Informed consent was obtained from the patient. The patient was placed in the supine position under epidural anaesthesia with a sand bag under the ipsilateral gluteal region with the trochanteric bulge of the same side at the edge of the operating table. The skin was prepared and draped with the ipsilateral lower limb draped free. Prophylactic antibiotics (Ceftriazone 1gram and metronidazole 500mg) were given intravenously. The greater trochanter was exposed through a longitudinal skin incision. The piriform fossa was located with the gloved finger and an awl (Herzog awl) was used to perforate it to gain access to the proximal end of the intramedullary canal. A blunt tipped 2mm guide wire was introduced into the proximal fragment. A longitudinal incision was made over the lateral condyle of the femur and developed to expose the condyle. The intramedullary cavity of the distal end of the right femur was exposed through a longitudinal anterolateral cortical window that was made on the lateral condyle. The limb was put under traction through the ipsilateral ankle by a scrubbed assistant while counter traction was applied by a non-scrubbed assistant whose hands were placed under the axillae. The guide wire was advanced into the distal fragment at the third attempt. Confirmation of distal intramedullary placement of the guide wire was made by visualizing the wire through the cortical window. The intramedullary canal was reamed over the guide wire with hand-held, hollow reamers to size 14. A size 13mm/40cm Kuntscher nail was then inserted over the guide wire which