Presentation is loading. Please wait.

Presentation is loading. Please wait.

Multifragmentary intertrochanteric fracture (treated with a nail)

Similar presentations


Presentation on theme: "Multifragmentary intertrochanteric fracture (treated with a nail)"— Presentation transcript:

1 Multifragmentary intertrochanteric fracture (treated with a nail)
Case for small group discussion: Fractures of the femur Ernest Kwek, SG Discussion points (overview): Imaging Fracture classification Deforming forces Treatment options Preoperative planning Surgical approach Entry point Reduction Tip-apex distance Aftertreatment Complications Haidukewych GJ. Intertrochanteric fractures: ten tips to improve results. J Bone Joint Surg Am Mar 1;91(3):712–719. Use the tip-to-apex distance No lateral wall, NO HIP SCREW Know the unstable patterns, and NAIL THEM Beware the anterior femoral bow Start slightly medial to tip of GT Do not ream an unreduced fracture Be cautious about nail trajectory Avoid varus angulation Lock nail distally if axially or rotationally unstable Avoid distraction when nailing AO Trauma Advanced Principles Course

2 Case description 76-year-old lady
Premorbid ADL-independent, ambulant using walking stick Past medical history: Diabetes mellitus Hypertension Hyperlipidemia Hyperthyroidism, on carbomazole Chronic renal disease, not requiring dialysis Gout Stumbled on a curb and fell onto left hip

3 Plain X-rays Day 0

4 Classification A2.1 A2.2 A2.3 Can you classify based on plain x-rays? Is this stable or unstable? Does this help you with choice of implant? Can you classify this fracture based on plain X-rays?

5 CT Is this fracture classifiable? How does CT help you?

6 How would you treat this fracture?
Nonoperative treatment DHS +/- TSP Angled blade plate/ DCS Proximal Femur Locking Plate Intramedullary nail

7 Intraoperative views on traction table
Is reduction adequate? How can it be improved? What to do about the trochanteric fragment? Ideal nail entry point?

8 Postoperative X-rays Your comments on the postoperative result?
What is the ideal implant position? Would you have used a long nail?

9 Full weight bearing as tolerated immediately
3 months

10 At 1 year: ambulates with walking stick

11 Is there an ideal trochanteric nail entry point?
There is no ideal lateral entry point Variable depending on Patient trochanteric profile Patient neck-shaft angle Implant geometry Too lateral = varus malreduction

12 Influence of nail geometry
The tip of the trochanter, or even slightly medial, is recommended as the universal starting point for these nails. Holland 10 degrees TAN 5 degrees Gamma 3 4 degrees TFN 6 degrees Ostrum RF, Marcantonio A, Marburger R. A critical analysis of the eccentric starting point for trochanteric intramedullary femoral nailing. J Orthop Trauma Nov-Dec;19(10):681–686. Trochanteric entry point: Trochanteric tip is only ideal in a minority of cases 70% of patients: ideal entry point was medial 23% lateral Streubel PN, Wong AH, Ricci WM, et al. Is there a standard trochanteric entry site for nailing of subtrochanteric femur fractures? J Orthop Trauma Apr;25(4):202–207. Ostrum RF et al (J Orthop Trauma. 2005;19:681–686)

13 Regardless of trochanteric or piriformis entry, the ideal portal is collinear with the long axis of the femur on the lateral

14 Summary and take-home message
Getting the entry point right is essential for IM nailing of an intertrochanteric fracture. Respect the tip-to-apex distance. IM nailing is ideal in elderly patients with unstable intertrochanteric fractures. The priority in such patients is stable fixation for early mobilization. Moderator should ask participants to summarize what else they have learned from this case. Haidukewych GJ. Intertrochanteric fractures: ten tips to improve results. J Bone Joint Surg Am Mar 1;91(3):712–719. Use the tip-to-apex distance No lateral wall, NO HIP SCREW Know the unstable patterns, and NAIL THEM Beware the anterior femoral bow Start slightly medial to tip of GT Do not ream an unreduced fracture Be cautious about nail trajectory Avoid varus angulation Lock nail distally if axially or rotationally unstable Avoid distraction when nailing


Download ppt "Multifragmentary intertrochanteric fracture (treated with a nail)"

Similar presentations


Ads by Google