1 / 20

Subtrochanteric Fractures

Subtrochanteric Fractures. Mitch Armstrong PGY-1 . The Case. HPI- 81 F, from RH. Tripped on carpet walking to breakfast. Landed face first onto floor. Laceration sustained to forehead. Unable to ambulate, C/O sore neck as well. Normally ambulates without gait aids

mairi
Download Presentation

Subtrochanteric Fractures

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Subtrochanteric Fractures Mitch Armstrong PGY-1

  2. The Case • HPI- 81 F, from RH. Tripped on carpet walking to breakfast. Landed face first onto floor. Laceration sustained to forehead. Unable to ambulate, C/O sore neck as well. • Normally ambulates without gait aids • PMHx- HTN, new onset Afib (in Emerg), GERD, Depression, 50 pack year smoking history • All- NKDA • Meds- Escitalopram, HCTZ, Lansoprazole, MV, Vit D, Calcium Carb

  3. Background • # between the LT and a point 5 cm distal • In young patient results from high energy mechanism - often polytraumatized (MVAs, gun shot, falls from a height) • In elderly osteopenic patients, results from low energy mechanism - falls from standing height

  4. Anatomy • Composed mainly of cortical bone, less vascularity, diminished capacity for healing compared with intertrochanteric #’s • Medial and posterio-medial cortices experiences high compressive forces - can exceed upwards of 1000 ppsi in > 200lb person • Lateral cortex experiences high tensile forces • Proximal fragment experiences deforming forces from hip flexors and abductors • Distal fragment experiences deforming forces from adductor muscles

  5. Fielding Classification

  6. Seinsheimer Classification

  7. Russell-Taylor Classification

  8. Operative Treatments • IM Nail- Gold Standard • Can chose piriformis or trochanteric starting point - most important factor is quality of reduction • Proximal locking choices of ‘greater to lesser’ with single locking screw OR • Reconstruction or cephomedullary locking screw into femoral head -decision of Gamma type nail vs. Recon nail

  9. Operative Treatments • With IM nailing, imperative that reaming carried out with appropriate reduction • Avoid varus malreduction and flexion deformity of proximal fragment • Nail path should parallel along the anterior lateral cortex of proximal femur (Russell et al.) • Techniques such as blocking screws, clamp reduction, cable cerclage (can lead to significant soft tissue damage), ball-spiked pusher inserted through small stab incisions can be useful aids (Rhorer AS, Seyhan et al). • Most common complication of blocking screwis occurrence of # at BS site

  10. Complications • Malunion- relatively common • Limp, leg length discrepancy, or rotational deformity. • Varus deformity - uncorrected abduction deformity of proximal segment caused by hip abductors. • Leg length discrepancy- complex problem usually related to extensive comminution, dynamically locked distal screws • Malrotation

  11. Complications • Loss of fixation- femoral head cutout, entry portal comminution, screws breakage (related to mal-alignment) • Nonunion- rare • Unable to resume FWB by 6 months, pain in proximal thigh. • If alignment appropriate consider exchange nailing with larger diameter nail • If hardware failure, malalignment, proximal fragment shortening, requires non-union take down • Infection- Difficult to treat, associated with nonunions

  12. References • Russell T., Hassan R., Stoneback BS., Cohen J. Avoidance of Malreduction of Proximal Femoral Shaft Fractures With the Use of a Minimally Invasive Nail Insertion Technique. 2008. JOT:22(6). • Seyhan M., Koray U., Sener N. Comparison of reduction methods in intramedullary nailing of subtrochanteric femoral fractures. 2012. ActaOrthopTraumatolTurc. 46(2). • Rhorer AS. Percutaneous/Minimally Invasive Techniques in Treatment of Femoral Shaft Fractures With an Intramedullary Nail. 2009. JOT:23(5). • Bucholz RW., Heckman JD. Subtrochanteric Fractures. 2010. Rockwood and Green’s Fractures in Adults.

More Related