Kamal, a healthy 20-year-old Afghan male, got caught in cross fire after an improvised explosive device (IED) detonated in his neighborhood. He was brought to a level II field hospital in Southeastern Afghanistan with a gun shot wound through his right anterolateral thigh and multiple exit wounds in his right buttock. Amazingly, Kamal is neurovascularly intact. Although there is an exit wound near his rectum, it does not penetrate it. Kamal is hemodynamically stable and has no other injuries.
Radiographs show a segmentally comminuted subtrochantric femur fracture. The fracture includes some of the anterior cortex at the level of the lesser trochanter.
General surgery clears him of a rectal injury and irrigates and debrides his right buttock of secondary shrapnel.
When I saw Kamal, I had the brief thought that would be nice to call in the rep for a trochanteric entry third generation cephalomedullary nail. Then I remembered I was Afghanistan.
What would you suggest as the next steps in treatment in this less than ideal environment?