Pearls & Pitfalls of Managing Intertrochanteric Fractures with SHS
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PEARLS & PITFALLS OF MANAGINGINTERTROCHANTERIC FRACTURES
WITH D.H.S
DR. ZAKRIA TARIQPGR, ORTHOPEDICS
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INTERTROCHANTERIC FRACTURES
Intertrochanteric or Pertrochanteric orPeritrochanteric
Accounts for nearly 50% of all proximal femurfractures
Average patient age of incidence is 66-76yrs
In females, annual incidence is 63/100,000population per year while it is 34/100,000 in
males (USA) Female to male ratio 2:1 to 8:1, likely because of
postmenopausal metabolic changes in bone
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Some factors found to be associated with
intertrochanteric rather than femoral neckfractures
Advancing age
Increased number of comorbidities
Increased dependency in activities of daily living
A history of other osteoporosis related (fragility)
fractures
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ANATOMY Intertrochanteric fracture occurs in the region between G.T
and L.T of proximal femur Occasionally extend into subtrochanteric area
Extracapsular fractures
Occur in cancellous bone with an abundant blood supply
Nonunion and osteonecrosis are not major problems Deforming forces produce shortening, ER and varus
position at the fracture. Abductorsdisplace GT laterally & proximally
Iliopsoasdisplace LT medially & proximally
Hip Flexors, Extensors & Adductors- pull distal fragment proximally
Fracture stability determined by presence of posteromedialbony contact, which acts as a buttress against fracturecollapse
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MECHNISM OF INJURY
IN YOUNGER INDIVIDUALS
Usually high energy trauma such as RTA or fall
from height
IN ELDERLY
90%result from a simple fall
Most fractures from a direct impact to GT area
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MECHNISM OF INJURY
The tendency to fall increases with patient age and is
exacerbated by several factors including
poor vision,
decreased muscle power, labile blood pressure,
decreased reflexes,
vascular disease, and
coexisting musculoskeletal pathology.
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CLINICAL EVALUATION
Patients presentation vary depending upon
displacement
Displaced fractures are non ambulatory on
presentation, with shortening and ER of lower
extremity
Pain is evident on attempted range of hip
motion
Nondisplaced fractures may go unnoticed
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CLINICAL EVALUATION
Patient may experience delay beforepresentation at hospital
Mostly are dehydrated with nutrition
depletion at presentation Potential for VTE, pressure ulceration as well
as hemodynamic instability
Intertrochanteric fractures may be associatedwith as much as a full unit of hemorrhage intothe thigh.
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RADIOGRAPHIC EVALUATION AP view of Pelvis
Allows comparison of involved with contralateral side
Can help to identify nondisplaced fractures
Lateral view
Assess posterior communition of proximal femur AP & Cross Table View of the involved proximal femur
Preferred over frog leg lateral as latter requires FABERof
the affected leg and involves risk of fracture displacement
Physician assisted IR view of injured hip (10-15 degree)
IR offsets the anteversion of femoral neck
Provides true AP view of the Proximal femur
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RADIOGRAPHIC EVALUATION
MRI imaging study of choice
Delineates nondisplaced or occult fractures that are not
apparent on plain radiographs
Reveals fracture within 24 hours of injury
CT Scan & Bone Scan
where MRI contraindicated
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BOYD AND GRIFFIN CLASSIFICATION
Type I:A single fracture along the intertrochanteric line, stable and easily reducible.
Type II:
Major fracture line along the intertrochanteric line with comminution in thecoronal plane.
Type III:Fracture at the level of the lesser trochanter with variable comminution and
extension into the subtrochanteric region (reverse obliquity).
Type IV:Fracture extending into the proximal femoral shaft in at least two planes.
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TYPE I TYPE II
TYPE III TYPE IV
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EVANS CLASSIFICATIONType I:
(A) Stable:
- Undisplaced fractures.
- Displaced but after reduction overlap of the medial cortical
buttress make the fracture stable.
(B) Unstable:
- Displaced and the medial cortical buttress is not restored by
reduction of fracture.
- Displaced and comminuted fractures in which the medial corticalbuttress is not restored by reduction of the fracture.
Type II: Reverse obliquity fractures.
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UNDISPLACED
DISPLACED
but reduced
DISPLACED
not Reduced
REVERSEDOBLIQUITY
COMMUNITED
Trochanteric fractures. (Reproduced with permission and copyright of the British Editorial Society
of Bone and Joint Surgery. Ewans EM. The treatment of trochanteric fractures of the femur.J Bone
Joint Surg 1949;31-B:190
203.)
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OTA CLASSIFICATION31-A Femur, proximal trochanteric
31-A1 Peritrochanteric simple
31-A1.1 Along intertrochanteric line
31-A1.2 Through greater trochanter
31-A1.3 Below lesser trochanter
31-A2 Peritrochanteric multifragmentary
31-A2.1 With one intermediate fragment
31-A2.2 With several intermediate fragments
31-A2.3 Extending more than 1 cm below lesser trochanter
31-A3 Intertrochanteric
31-A3.1 Simple oblique
31-A3.2 Simple transverse
31-A3.3 Multifragmentary
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Otota CLASSIFICATION
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UNUSUAL FRACTURE PATTERNS
BASICERVICAL FRACTURES located just proximal to or along the intertrochanteric
line
Anatomically included in femoral neck fractures
Usually extracapsular Behave and treated as intertrochanteric fractures
At greater risk for AVN than the more distalintertrochanteric fractures
Lack the cancellous interdigitation seen with fracturesthrough intertrochanteric region
More likely to sustain rotation of femoral head duringimplant
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UNUSUAL FRACTURE PATTERNS
REVERSE OBLIQUITY FRACTURES
Unstable fractures.
An oblique fracture line extending from medial
cortex proximally to lateral cortex distally.
Location and direction of fracture line results in a
tendency to medial displacement from the pull of
adductors. Treated as subtrochanteric fractures.
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TREATMENT
NONOPERATIVE INDICATIONS
Patients who are at extreme medical risk for surgery
Demented nonambulatory patients with mild hip pain
Nondisplaced fractures can be considered for nonoperative
because displacement changes neither operation type nor
outcome
Early bed to chair mobilization
Avoid complications like poor pulmonary toilet,
atelectasis, venous stasis, pressure sores.
Resultant hip deformity is both expected and accepted in
cases of displacement
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TREATMENT
OPERATIVE GOAL
Stable internal fixation to allow early mobilization and fullweight bearing ambulation.
STABILITY OF FRACTURE FIXATIONdepends on Bone quality Fracture pattern
Fracture reduction
Implant design
Implant placement
TIMING OF SURGERY Should be performed in timely fashion once the patient is
medically stabilized
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OPTIONS
Available options for treating intertrochanteric
fractures include -
SLIDING HIP SCREW
INTRAMEDULLARY HIP SCREW NAIL
EXTERNAL FIXATION
PROSTHETIC REPLACEMENT
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EVOLUTION OF SLIDING HIP SCREW
Fixed-Angle Nail-Plate Devices First successful implants were fixed-angle nail-plate devices (e.g., Jewett nail, Holt nail)
Consisting of a tri-flanged nail fixed to a plate at an angle of 130 to 150 degrees
While these devices provided stabilization of the femoral head and neck fragment to the
femoral shaft,
They did not allow fracture impaction.
Sliding-nail-plate Devices
Experience with fixed-angle nail-plate devices indicated the need for a device that
would allow controlled fracture impaction.
This gave rise to sliding nail-plate devices (e.g., Massie nail, Ken-Pugh nail),
Massie nail ,Ken-Pugh nail consisting of a nail that provided proximal fragment fixation
and a side plate that allowed the nail to telescopewithin a barrel allowing bone on
bone contact
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The sliding nail-plate devices gave rise to
Sliding Hip Screw Devices
The sliding hip screw is the most widely used implant for
stabilization of both stable and unstable intertrochanteric
fractures.
Sliding hip screwside plate angles are available in 5 degree
increments from 130 to 150 degrees.
The 135 degree plate is most commonly utilized
this angle is easier to insert in the desired central position of thefemoral head and neck than higher angle devices and creates less
of a stress riser in the subtrochanteric region.
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SLIDING HIP SCREW
The most important technical aspect of screw
insertion are
Placement within 1 cm of subchondral bone to
provide secure fixation
Central position in the femoral head (Tip ApexDistance)
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TIP-APEX DISTANCE
This can be used to determine lag screw position
within femoral head.
This measurement, expressed in millimeters, is the
sum of distance from the tip of lag screw to the apexof femoral head on both AP and lateral radiographic
views (after controlling for radiographic
magnification).
The sum should be
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SURGICAL PEARLS FOR INSERTION OF A SLIDING HIP
SCREW
Ascertain that there is no impingement of the labia orscrotum from the fracture table
Assess the fracture reduction before prepping the patient and
ensure that non-obstructive biplanar radiographic
visualization of the entire proximal femur, including the hipjoint, is obtainable
Check for residual varus angulation, posterior sag, or
malrotation prior to starting the procedure
Use a 135 degree angle guide to insert the guide pin Position the guide pin in the center of the femoral head and
neck on both the AP and lateral planes within 1 cm of the
subchondral bone
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SURGICAL PEARLS FOR INSERTION OF A SLIDING HIP
SCREW
Ream the femoral neck and head under image
intensification to detect guide pin advancement
Tap the entire screw path to prevent femoral head
rotation during lag screw insertion Confirm a minimum of 20 mm available for lag
screw/barrel slide
Impact the fracture before insertion of the plate holding
screws Use a compression screw if the lag screw cannot be
visualized within the plate barrel
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PITFALLS WITH USE OF A SLIDING HIP SCREW
Misinterpretation of the fracture pattern. This pitfall can be avoided by obtaining both AP and cross-
table lateral x-rays when evaluating proximal femurfractures. If these x-rays do not clarify the nature of thefracture pattern, an x-ray taken with the extremity internally
rotated should be taken. Use a sliding screw for the reverse obliquity type pattern.
Place the lag screw away from the center-center positionand farther than 1 cm from the subchondral bone.
Bending the guide pin during reaming. Bending the guide pin within the reamer resulting in intra-
articular or intra-pelvic penetration.
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PITFALLS WITH USE OF A SLIDING HIP SCREW
Loss of reduction during lag screw insertion. During reaming or lag screw insertion, rotation of the proximal
fragment with loss of fracture reduction can occur. To preventrotation of the proximal fragment, the authors routinely tap thefemoral head and neck prior to lag screw insertion.
Improper lag screw-plate barrel relationship. When a sliding hip screw loses its capacity to slide, it behaves as
a fixed-angle device and is at risk for multiple complications.
Disengagement of the lag screw from the barrel. This uncommon complication results from inadequate lag
screw-plate barrel engagement secondary to use of either ashort lag screw or short barrel side plate.
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VARIATIONS ON THE SLIDING HIP SCREW DESIGNNAME CHARACTERISTICS ADVANTAGES DISADVANTAGES
Conventional Sliding
Hip screw
(SHS)
Lag screw and side
plate
1. Controlled
fracture collapse
2. Well established
device
3. Cost effective
1. Limb shortening
2. Fracture deformity
Variable Angle SlidingHip Screw (VHS)
Angular adjustment ofside plate barrel
1. Reduced inventory2. Allows free hand
guide pin insertion
3. Allow fracture
adjustment one
implant inserted
Beefed up proximalwidth of plate
Talon compression Hip
screw
Prongs protrude from
lag screw
Increased purchase in
femoral head
Difficulty with
hardware removal
NAME CHARACTERISTICS ADVANTAGES DISADVANTAGES
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C C S CS G S S G S
Trochanteric stabilizing
plates
Plate attaches to
conventional 4-hole side
plate to buttress the GT
1. Limits the amount of
fracture collapse
2. Allows screw fixation
of GT
1. Compromise fracture
union
2. Trochanteric bursitis
3. Requires additional
exposure
4. expensive
Medoff plate Biaxial loading plate 1. Limits the amount of
facture collapse
2. Expands use of SHSto S/T and Reverse
obliquity fractures
1. Expensive
2. Learning curve
3. Only available in 135degree angle
Percutaneous
compression plate
(PCCP)
1. Two smaller
diameter lag screw
2. Designed for
percutaneous
insertion
1. Less exposure
2. Less blood loss
3. Limited fracture
collapse
4. Better rotational
control of femoral
head
1. Expensive
2. Learning curve
3. Only available in 135
degree angle
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Talon compression hip screw Trochanteric Stabilizing Plates
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Percutaneous Compression Plate Medoff plate Biaxial Sliding Hip Screw
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INTRAMEDULLARY HIP SCREW NAIL
Combines features of sliding hip screw and intramedullary nail Indicated in unstable fractures
intertrochanteric fracture with subtrochanteric extension
reverse obliquity fractures
Advantages Theoretically, these implants can be inserted in a closed
manner with limited fracture exposure, decreased bloodloss, less tissue damage than sliding hip screw.
Subjected to a lower bending movements than sliding hipscrew owing to their intramedullary location.
Limits the amount of fracture collapse, compared withsliding hip screw.
No clinical advantage of intramedullary hip screwcompared with sliding hip screw in stable fracture pattern.
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EXTERNAL FIXATION Not commonly considered for treatment of intertrochanteric fractures
Early experiences with external fixator for intertrochanteric fracturesassociated withpin loosening, infection and varus collapse.
Indicated in patients at unacceptably high risk for complication related togeneral or regional anesthesia
One or two half pins placed into femoral neck within 10 mm of subchondralbone.
Two or three half pins placed in proximal femur. Satisfactory healing rates 95-100%
Advantages Shorter operative time,
minimal blood loss and
application with local anesthetic with adjuvant analgesia
Duration of external fixation averages 90 days
Complications Malalignment in varus - 12%
Pin tract complication 7% to 44 %
Progression to osteomyelitis - rare
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PROSTHETIC REPLACEMENT INDICATIONS
Elderly, debilitated patient with a communited, unstableintertrochanteric fracture in severely osteoporotic bone
Unsuitable candidates for repeated Internal Fixation
Disadvantages Greater implant cost
More extensive procedure than ORIF Greater blood loss
Longer surgical and anesthetic time
Potential for more frequent complications
Complications
Hip dislocation (3% Hemiarthoplasty; 45% THR) Pressure sores
Pulmonary infections, atelectasis
Periprosthetic fracture
Femoral nonunion
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IMPLANT CHOICE FOR INTERTROCHANTERIC
FRACTURE STABILIZATION (ROCKWOOD)
STABLE FRACTURE PATTERN Sliding hip screw with a two hole side plate
UNSTABLE FRACTURE PATTERN
Intramedullary-type hip screw
BASICERVICAL FRACTURE Sliding hip screw with two hole side plate and anti-rotation
screw
REVERSE OBLIQUITY AND INTERTROCHANTERICFRACTURE WITH SUBTROCHNATERIC EXTENSION Intramedullary-type hip screw
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POSTOPERATIVE CARE Mobilization of hip fracture patients out of bed and ambulation training
should be initiated on post-op day 1 Allow weight bearing as tolerated
Often difficult for elderly patients with decreased upper extremity
strength to comply with partial weight bearing protocol
Restricted WB after hip fracture has little biomechanical justification
Moving around in bed and use of bedpan generates force across the hip
Foot and ankle ROM exercises produce substantial load on femoral head
secondary to muscle contraction
Ecker et al., Unrestricted WB does not increase complication rates
following fixation of intertrochanteric fractures
62 cases with #P/T treated with DHS
early WB-22, non WB for 6 weeks-33, no ambulation-7. Follow up 15 months
3 required revision surgery secondary to nonunion, all three occurred in
unstable fractures
No effect of WBon need for revision surgery.
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COMPLICATIONS
LOSS OF FIXATION
NONUNION
MALROTATION DEFORMITY
OTHER Complications
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LOSS OF FIXATION Commonly result from varus collapse of proximal fragment with
cutout of lag screw from the femoral head Incidence - 20%in unstable fractures
Lag screw cutout from femoral head occurs within 3 months ofsurgery
Causes of lag screw cutout
Eccentric placement of lag screw within femoral head - most common
Improper reamingsecond channel created
Inability to attain a stable reduction
Excessive fracture collapse such that sliding capacity of device isexceeded.
Inadequate screw-barrel engagement, which prevents sliding Severe osteopenia, which precludes secure fixation.
Management
Acceptance of deformity
Revision ORIF with bone cement
Conversion to prosthetic replacement
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NONUNION
Rare as fracture occurs through well vascularized bone
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MALROTATION DEFORMITY
Results from Internal Rotation of distal fragment at thetime of internal fixation.
In unstable fractures, distal and proximal fragments
may move independently
Place distal fragment in neutral to slight external rotation
during fixation of plate to the shaft
When severe and interferes with ambulation, revision
surgery with plate removal and rotational osteotomy offemoral shaft is done.
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OTHER COMPLICATIONS With full length IMnails, impingement or perforation of
distal aspect of nail on the anterior femoral cortex canoccur, secondary to a mismatch of nail curvature andfemoral bow.
Z-effect- most common with dual screw CMTN proximal screw penetrating hip joint
distal screw backing out of femoral head
Osteonecrosis
Rare No association between location of implant within femoral head
and development of ON
Side plate separation and lag screw migration into pelvis
Use compression screw if inadequate screw-barrel engagement
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OTHER COMPLICATIONS
Traumatic laceration of superficial femoral artery by adisplaced LT fragment
Binding of guide pin within reamer intra-articular or intrapelvic penetration
Periprosthetic fractures first generation short trochanteric gamma nails
Due to large distal diameter , large proximal bend and largedistal screws
Nail breakage either short or long trochanteric nails
Typically occur at lag screw site area of maximal stress andthinnest metal
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THANK YOU !!
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