A Hand-Palm Technique for Localization of the Greater Trochanter Tip During Proximal Femoral Nailing: A Prospective Pilot Validation Study.

Abstract

Introduction: An accurate localization of the tip of the greater trochanter (GT) is required for proper skin incision placement and correct entry point creation during proximal femoral nailing (PFN) for intertrochanteric femur fractures. Direct palpation of the GT tip may be unreliable in obese or edematous patients, potentially resulting in extended incisions and improper entry points. This study describes the "hand-palm technique," a surface landmarking method for localization of the GT tip.

Materials and methods: The technique was applied in two variations based on the surgeon's glove size. For surgeons with glove size ≥7, the width of four medial fingers placed along the iliac crest from the anterior superior iliac spine was used to identify the GT tip. For surgeons with glove size ≤6.5, the entire palm, including the thumb, was used similarly. Fluoroscopic confirmation was performed in all cases. In addition, an observational pilot study involving 41 patients undergoing PFN was conducted to assess localization accuracy, fluoroscopy usage, operative parameters, and reproducibility of the technique. Descriptive statistical analysis and subgroup comparison between obese and non-obese patients were performed. A body mass index-based subgroup analysis was additionally performed to assess localization accuracy, fluoroscopy usage, reproducibility, and operative parameters across different body habitus categories.

Results: A total of 41 patients were included in the pilot study. The mean localization error from the fluoroscopically confirmed GT tip was 2.19 ± 1.74 mm, and the mean number of fluoroscopic images required was 1.66 ± 0.62. The mean operative time was 39.90 ± 7.01 min, the mean blood loss was 119.51 ± 49.85 mL, and the mean incision length was 5.61 ± 0.40 cm. Obese patients demonstrated a trend toward higher localization error and fluoroscopy requirement compared with non-obese patients.

Conclusion: The hand-palm technique is a simple and practical surface landmarking method with satisfactory localization accuracy in this pilot study. It may reduce repeated fluoroscopic localization attempts and unnecessary incision extension, particularly in obese or edematous patients. However, fluoroscopic confirmation remains essential, and further prospective studies are needed to validate it.