A special kind of neck-shaft combo. Healed an old GSW femur, but only after auto-dynamizing, then presented with this injury several years later after a high speed MCC. (1/-)

Learning point 1- do not let crazy injuries distract you from doing the right thing. You must get good films, joint above and below, and scrutinize them. I initially missed the ipsilateral tibial plateau but recognized it intraop, prior to prep&drape (2/-)

Learning pt 2- have other options to bail out when the "typical" thing you do doesn't work. I initially intended to fetch the tip of the broken interlock by tapping it out medially with a drill bit, but the HO around the screw tip wasn't budging. Enter the endoscopic grabber (3/

Learning point 3- must pre-op plan. We got back on track after the endograb. We wanted to remove all the old implants, then prioritize neck > shaft. The lag screw will torque your reduction, even with the fx clamped and an extra guidewire up (antirotation screw to follow) (4/-)

Even shifting the plate posterior or anterior, we couldn't *quite* get the nail interlocks to match the side plate holes, and also couldn't sneak more than 1 screw around the nail. Our 4 hole plate with 1 bi- and 3 uni-screws was nerve-wracking but ended up being enough. (5/-)

Learning point 4- not all metaphyseal fx need locking screws. This plate is applied as a buttress plate, perfect for a partial articular (B-type) fracture. The cranial 3.5mm cortical screws had great purchase. I've found anything >45mm in the plateau in young ppl is enough (6/-)

COVID happened and missed some follow-ups but here's 4.5mo out. 3/4 cortices healed in the femur. Full WB, no pain. (7/-)

Bonus bent nail souvenir and learning point- metal cutting burr >>> diamond cutting wheel (8/end)