1. Pertrochanteric fracture
Case for small group discussion: Management principles for the treatment of articular fractures
Hiroaki Minehara, JP
Discussion points:
Differentiate between high-energy and low-energy injury
Fracture classification (stable/unstable fracture)
Tip-apex distance
Pros and cons of DHS vs IM device
Timing of surgery
Entry point vs type of nail
Preoperative planning/nail length
Patient positioning
Fracture reduction
Intraoperative imaging and assessment of reduction
Aftertreatment
AO Trauma Advanced Principles Course

2. 74-year-old woman, fall from a 3-meter height
Vital sign stable
Closed
Associated injuries: Stable pelvic ring fracture, left blow-out fracture, zygomatic fracture
Discussion points:
How do you classify this fracture?
Is this a stable or unstable fracture?
Is further imaging required: CT scan, better x-rays?
What would be your initial management?
Day 0

3. Other X-rays and CT Discussion points:
Discuss operative management: DHS vs IM device.
When is the best timing of surgery?
How to manage the pelvic fracture? Try to prioritize.
Any comments on initial management in this highly displaced fracture?
What would your reduction strategy be?

4. Operative reduction technique
Schanz screw used as a joystick to control the fragment
Discussion points:
Other reduction techniques?

5. Discussion points:
Nail entry point
Position of the implant in the femoral head (tip-apex distance)
Acceptable reduction?
Aftertreatment

6. 1 month postoperative

7. 1 year postoperative

8. Summary and take-home message
Immediate operative treatment should be considered for an unstable proximal femoral fracture if the status of the patient allows.
Intramedullary nailing is the treatment of choice for unstable proximal femoral fractures.
Good fracture reduction is very important and can be obtained by using non invasive operative reduction techniques.
Fracture reduction starts in the emergency room!
Moderator should ask participants to summarize what else they have learned from this case.