subtrochanteric femoral fractures
TRANSCRIPT
Subtrochanteric Femoral Fractures
Dr.Hisham E. Gheit
Definition Fielding (1973) Interval between lesser troch and around 5-7.5 cm below it.
Fielding JW. Subtrochantric fractures.clin orthop Relat.1973;(92):86-99
Bimodal age distribution
About 10% to 30% of all hip fractures Young patients 20-40y • High energy trauma • Associated with polytrauma, life threatening injuries.
Patients above 60y • Low energy trauma • Associated with osteoporosis and co-morbidities
Anatomy
• subtrochanteric area Composed mainly of cortical bone • Region of maximal compressive forces (medially) and tensile forces(laterally).
Image: Yoon RS and Haidukewych GJ, Subtrochanteric Fractures, Chapter 54,Figure 54-2. Rockwood and Green’s Fractures in Adults, editors Tornetta, Paul; Ricci, William. Wolters Kluwer, 2019
Image: Yoon RS and Haidukewych GJ, Subtrochanteric Fractures, Chapter 54, Figure 54-4. Rockwood and Green’s Fractures in Adults, editors Tornetta, Paul; Ricci, William. Wolters Kluwer, 2019
• Proximal segment Gluteal muscle abduction Iliopsoas muscle Flexion & external rotators.
• Distal segment Adductors Shortening and medial translation
Classification: There is no ideal classification system that guides treatment and establishes prognosis with satisfactory inter-observer reproducibility.
Fielding (1973) : anatomical location
Seinsheimer (1978) : number of fragments involvement of medial lateral cortics Russel taylor (1987) : entirety of piriformis fossa A/O (1990) : oblique, transverse, or multifragmentar
Russel Taylor ClassificationPrior to the development of a trochanteric entry nail, this was historically used to differentiate fractures amenable to intramedullary (IM) nailing versus those requiring a lateral fixed-angle device.
image: Yoon RS and Haidukewych GJ, Subtrochanteric Fractures, Chapter 54, Figure 54-3. Rockwood and Green’s Fractures in Adults, 9th edition. Editors Tornetta, Paul; Ricci, William. Wolters Kluwer, 2019
The AO/OTA classification has utility in its universality and is primarily used in the discussion of research
Bio-mechanical proplems
• Short proximal segment • Long lever arm • Strong musculature • Eccentric load
Treatment options
(Surgery is standard of care) Intramedullary nail
Extra-medullary plate
Biomechanically IMN fixation is superior for several reasons. increased rigidity stiffness shorter moment arm allows for a biomechanically stronger construct with decreased strain placed on the implant. Wang J, et al. 2014
2019Zhang et al. Randomized controlled trial 180 pt Comminuted subtrochanteric femur fracture; compare the efficacy and safety of the proximal femoral anatomical locking compression plate vs proximal femoral nail antirotation. Result Intramedullary nail resulted in better recovery of hip function good and excellent Harris hip scores (p <.05). There was no significant difference in complication rate (p > .05).
Intramedullary nailing Tips and tricks
postion: Supine Traction table hemilithotomy position adduct the affected limb and trunk to allow access to the trochanteric region Avoid excessive pelvic tilt
Reduction • Should be reduce deformity and ensure proper path of guidewire on both views prior to reaming
To Prevention varus, Rotational malreduction
Reduction techniques Traction It is rare to overcome the deforming forces of a subtrochantericfracture with the table alone
Closed reduction Depressing the proximal fragment by use of external pressure from a mallet. Use of a crutch beneath the distal fragment
Percutaneous by: ball spike pusher Shanz pins joysticks blocking wire or screws
Open by: bone hook bone Clamp reduction forceps Cerclage wire
Hoskins et al. 2015 Retrospective review 134 pt
Subtrochanteric fractures; Cerclage wire use improved fracture displacement (3.2 mm vs. 8.8 mm), angulation and quality of reduction (p < 0.05). Result Open reduction and the use of cerclage did not producea negative effect in terms of fracture union
Entery point Starting point medial to tip of greater trochanter
Too anterior entry point… final reduction in flexion
Too lateral entry point final reduction in varus
Implant positioning
Hip Screws centered in femoral head in AP/Lat view best position
Baumgaertner et al,1995
Complications
• Varus malunion
• Implant failure
• Non union
• infection
Revision fixation with poor starting point
Malreduction Note very lateral starting point/nail path
Correcting varus withanother nail in theshort proximalsegment is verydifficult
A plate is still a viable option
Summary
Closed reduction is difficult Don’t be afraid to open fracture to obtain good reduction
Correct entry point is essential to decrease complication
Thank you