OT notes · Orthopaedics

Proximal femoral nailing (PFN)

Usual anaesthesia
Spinal (subarachnoid block)
Position
Supine on fracture table with perineal post, injured leg in traction, opposite leg scissored or in well-leg holder
Setting
emergency

Operative note template for proximal femoral nailing, with a filled example for closed reduction and short PFN of an unstable intertrochanteric fracture in an elderly woman 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 to achieve closed reduction, need to open the fracture site
  • lag screw cut-out through the femoral head
  • varus collapse, shortening and limp
  • fracture of the femur around or below the nail tip
  • malrotation of the limb
  • nonunion needing revision or hip replacement
  • wound infection
  • deep vein thrombosis and pulmonary embolism
  • high risk of death within the first year in elderly patients, from the injury itself

Pre-operative details for this operation

  1. Side and diagnosisright / left, AO/OTA 31A1 / A2 / A3, stable or unstable, reverse obliquity or subtrochanteric extension
  2. Mechanism of injuryLow-energy fallHigh-energy traumahigh-energy fractures are less likely to reduce closed
  3. Lateral wallIntactFractured / thin
  4. Pre-op X-raysAP pelvis with both hips, AP and lateral of the injured hip, full-length femur if long nail planned
  5. Contralateral neck-shaft angledegrees, used to choose nail angle
  6. Anticoagulant / antiplatelet statusdrug, last dose, plan
  7. Blood grouped and cross-matchedgroup, units reserved
  8. Implant set and C-arm checked before anaesthesianail system, lengths and diameters available, working C-arm

Anaesthesia and position

  1. AnaesthesiaSpinalSpinal with fascia iliaca / femoral blockGeneral
  2. PositionSupine on fracture tableLateral decubitusperineal post padded, well leg scissored (extended) or in well-leg holder, ipsilateral arm across chest
  3. TractionFoot bootSkeletal traction pin (distal femur / proximal tibia)
  4. C-arm positionfrom the opposite side; true AP and true lateral of hip obtained before painting
  5. TourniquetNot applicable

Operative findings

  1. Fracture pattern on C-armnumber of fragments, lesser trochanter fragment, lateral wall, posterior comminution
  2. Closed reduction achievedYes, closedPercutaneous joystick / bone hook neededOpen reduction neededmanoeuvre used: traction, internal rotation, correction of posterior sag
  3. Reduction check on C-armneck-shaft angle, no varus, no posterior sag, anterior cortex aligned on lateral view
  4. Bone qualityGoodOsteoporotic

Procedure (steps)

  1. Closed reduction on fracture tabletraction, rotation, flexion 20 to 30 degrees, posterior sag corrected; confirm on AP and lateral before incision
  2. Painting and drapingantiseptic used, isolation drape
  3. Incision3 to 4 cm, proximal to the tip of greater trochanter; gluteus maximus fascia incised
  4. Entry point and guide wireTip / medial trochantericLateral trochantericPiriformis fossaentry must match the nail design; confirm on AP and lateral
  5. Proximal reaming / entry reamerentry reamer size, depth to just below lesser trochanter
  6. Guide rod passed and nail length measuredball-tip guide rod, length measured
  7. Shaft reamingReamedUnreamedfinal reamer size in mm
  8. Nail insertedtype, diameter x length, neck-shaft angle; inserted by hand, depth checked on C-arm
  9. Head fixationTwo screws (lag + antirotation)Single lag screwHelical bladeIntegrated screwsguide wire centre-centre or inferior-centre, within 5 mm of subchondral bone; lengths; order of insertion; compression applied?
  10. Tip-apex distanceAP + lateral distance in mm, aim under 25 mm
  11. Traction released and compressionYesNot done
  12. Distal lockingOne screw, staticOne screw, dynamicTwo screwsNot lockedjig-guided or free-hand, screw length
  13. Rotation and length checkedcompared with the other side
  14. End capInsertedNot used
  15. Final C-arm images savedAP and lateral of whole construct; number of images saved; screening time if displayed

Closure, drains and dressing

  1. Wound washsaline
  2. Fasciasuture material
  3. Subcutaneous tissuesuture material
  4. SkinInterrupted nylonStaplesSubcuticular
  5. DrainNoneSuction drain
  6. Dressingsterile dressing to all incisions
  7. Neurovascular status at enddistal pulses, capillary refill, toe movement if block allows; perineum checked after removal from post

Specimens and implants

  1. Nailtype, diameter x length, neck-shaft angle, make, lot / batch number, sticker pasted in case sheet
  2. Proximal (head) screws / bladeeach: type, length, make, lot / batch number, sticker
  3. Distal locking screw(s)number, length, lot / batch number, sticker
  4. End capsize, lot / batch number, sticker
  5. Cerclage wire (if used)gauge, number
  6. SpecimenNone

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 limb checkpulse, BP, distal pulses, toe movement and sensation, dressing soakage; hourly for 4 hours then 4-hourly
  2. Check X-rayAP and lateral of hip with whole nail, if not already done as final C-arm images
  3. Analgesiadrug, dose, frequency
  4. Mobilisationsit up in chair on post-op day 1; walk with walker, weight bearing as tolerated unless the note says otherwise
  5. Exerciseship abductor, quadriceps and ankle pump exercises
  6. Thromboprophylaxisas per unit protocol; watch for calf swelling or breathlessness
  7. Nutrition and pressure carediet, back care, heel protection
  8. Hb on post-op day 1transfuse only as per unit threshold
  9. Wound review and suture removaldressing on day 2 to 3; sutures or staples out at about 2 weeks
  10. Follow-upreview with X-ray at 2 weeks, then monthly 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: Mrs. S.K., 74 years, slipped at home, closed unstable intertrochanteric fracture of the left femur (AO/OTA 31A2), fit for surgery on day 2 of admission.

Case details

Date: 04/02/2026. Elective trauma list. OT 3.

In OT 10:05. Spinal given 10:15. Skin incision 10:48. Skin closed 11:50.

Surgeon: Dr A. (3rd-year resident, Orthopaedics). Assistant: Dr B. (1st-year resident). Consultant: Dr C., scrubbed for the proximal screws.

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

Indication and pre-op

Indication: closed left intertrochanteric fracture, AO/OTA 31A2.2, separate lesser trochanter fragment, lateral wall intact. Low-energy fall.

Right hip neck-shaft angle 130 degrees on pre-op X-ray.

On aspirin 75 mg, continued. Hb 10.8 g/dl. Blood group O positive, 1 unit cross-matched.

Consent: general, procedure-specific and anaesthesia consent taken in Marathi from patient, son as witness. Risks explained including cut-out, shortening and need for further surgery.

Left thigh marked. WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 10:30, before skin incision.

Implant set (short PFN, 130 degrees, 9 to 12 mm) and C-arm checked before spinal.

Anaesthesia and position

Spinal anaesthesia. Supine on fracture table with padded perineal post. Right leg scissored in extension in boot. Left foot in boot.

Closed reduction by traction and internal rotation of about 15 degrees, posterior sag corrected with a crutch under the thigh. Hip in 20 degrees of flexion. C-arm from the right side. Reduction acceptable on AP (neck-shaft angle about 130 degrees) and lateral (anterior cortex in line).

Parts painted with povidone-iodine and chlorhexidine-alcohol, isolation drape applied.

Procedure

4 cm incision starting 3 cm above the tip of the greater trochanter. Gluteus maximus fascia split in line with fibres.

Guide wire at the tip of the greater trochanter, slightly medial, confirmed central in the neck on lateral view. Entry reamer taken to below the lesser trochanter.

Guide rod passed across the fracture. Short nail chosen. Shaft reamed to 11.5 mm.

Proximal femoral nail 10 mm x 250 mm, 130 degrees, inserted by hand with the jig. Depth adjusted so the lag screw would lie in the lower half of the neck.

Inferior guide wire along the calcar, within 5 mm of subchondral bone, central on lateral view. Second guide wire above it, parallel.

Inferior (neck) screw 95 mm inserted first, then superior (antirotation) screw 85 mm. Traction released before final tightening. Tip-apex distance about 20 mm.

One distal locking screw, 36 mm, in static hole through the jig. End cap inserted.

Leg length and rotation checked against the right side: equal.

Final AP and lateral C-arm images of the whole construct saved (6 images). Screening time 58 seconds.

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.

Specimens and implants

Proximal femoral nail 10 x 250 mm, 130 degrees. Neck screw 95 mm. Antirotation screw 85 mm. Distal locking screw 36 mm. End cap.

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

No specimen. No tourniquet. No cement.

End of procedure

Estimated blood loss 200 ml (suction 80 ml + mops). No transfusion in OT.

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

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

Left foot warm, dorsalis pedis and posterior tibial pulses palpable, capillary refill under 2 seconds. Motor and sensory check deferred till block wears off.

Shifted to recovery in stable condition. Pulse 84/min, BP 128/76 mmHg.

Post-op orders

Pulse, BP, distal pulses and toe movement hourly for 4 hours, then 4-hourly.

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

Thromboprophylaxis as per unit protocol.

Sit up in chair on POD 1. Walk with walker, full weight bearing as tolerated, from POD 1 under physiotherapist.

Hip abductor, quadriceps and ankle pump exercises.

Hb on POD 1. Check X-ray of left hip with whole nail on POD 1.

Dressing on POD 3. Suture removal at 2 weeks with X-ray.

Signature

Dr A., JR-3, Orthopaedics. Reg. no. ________. 04/02/2026, 12:05.

Must document for this operation

  • Fracture classification and whether the lateral wall was intact. It explains the choice of a nail over a dynamic hip screw (DHS) and is looked at first if the fixation fails.
  • How reduction was achieved: closed, with joystick, or open. Open reduction adds blood loss and infection risk, and the next surgeon needs to know what was done.
  • Nail type, diameter, length and neck-shaft angle, and each screw length. These are needed to order the right extraction set if the nail has to be removed or revised.
  • Tip-apex distance (TAD) or at least the position of the lag screw in the head. A TAD above 25 mm is linked with cut-out, so it is the first thing checked in an audit of failures.
  • Implant make and lot / batch number, with stickers pasted in the case sheet. Needed for implant recall, for the implant register, and for the discharge summary.
  • Final C-arm images saved, with the number of images. They are proof of reduction and implant position at the end of surgery.
  • Distal neurovascular status at the end. A deficit found later cannot be timed unless the note records a normal limb at the end.

Common mistakes in these notes

  • Writing 'PFN done' with no nail size, angle or screw lengths.
  • Not recording whether traction was released before final seating and tightening, which matters if the fracture heals distracted.
  • Forgetting to paste the implant stickers or write the lot number.
  • Not recording the distal locking mode (static, dynamic, or none).
  • No mention of C-arm images saved or of the check X-ray.
  • Leaving out the distal pulses at the end of surgery.

Indian practice and paperwork

  • Record the batch and serial number of every implant 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))

Sources

  • Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier; copyright 2027, Ch 60 Fractures and dislocations of the hip: intertrochanteric femoral fractures, Techniques 60.4 and 60.5, pp. 2666-2672.
  • Tornetta P III, ed. (Wiesel SW, editor-in-chief). Operative Techniques in Orthopaedic Trauma Surgery. 2nd ed. Wolters Kluwer, Ch 39 Cephalomedullary nailing of the proximal femur (Russell TA), pp. 383-407.
  • Azar FM, Beaty JH, eds. Campbell's Core Orthopaedic Procedures. 2nd ed. Elsevier; 2024, Technique 29 Intramedullary nailing of subtrochanteric fractures (Weinlein JC), pp. 140-143.
  • 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.

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