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GRAND ROUND Dr. Yasir Jameel Clinical Fellow Orthopadic Trauma
25

Fracture grand jameel

Jul 16, 2015

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Yasir Jameel
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Page 1: Fracture grand  jameel

GRAND ROUND

Dr. Yasir JameelClinical Fellow Orthopadic Trauma

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• 80 year old male sustaind fall at home and presented with hip pain to A&E

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• History

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• Age, sex, occupation• Presenting complain• History of PC• Past medical history• Past surgical history • Drugs, Allergies• Social history

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Investigations

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X-rays

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X-rays

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X-rays

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Subtrochenteric femur fracture

• Subtrochanteric area typically defined as area from lesser trochanter to 5cm distal.

• fractures with an associated intertrochanteric component may be called intertrochanteric fracture with subtrochanteric extension or peritrochanteric fracture

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Epidemiology

• Younger patients with a high-energy mechanism RTA

• may occur in elderly patients from a low-energy mechanism

• Pathologic or atypical femur fracture • Bisphosphonate use, particularly alendronate,

can be risk factor • Preveious neck fixation with screws placed

with entry below lesser trochenter

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Anatomy

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Pathoanatomy• Deforming forces on the proximal fragment • Abduction gluteus medius and gluteus minimus • Flexion iliopsoas • External rotation short external rotators • deforming forces on distal fragment • Adduction hip adductors • Shortening quads and hamstrings

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Pathoanatomy

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Biomechanics

• Posteriomedial femur undergoes compressive forces

• Lateral femur undergoes tensile forces

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Russell-Taylor Classification

• Based on integrity of the piriformis fossa.• Designed to guide treatment of intramedullary nails

using a piriformis fossa starting point.

Type I - intact piriformis fossaA - lesser trochanter attached to proximal fragmentB - lesser trochanter detached from proximal fragment

Type II - fracture extends into piriformis fossaA - stable posterior-medial buttressB - comminution of lesser trochanter

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Russell-Taylor Classification

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RT Type 2 B

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Treatment

• Nonoperative – observation with pain management • indications

– non-ambulatory patients with medical co-morbidities not fit for surgery

– limited role due to strong muscular forces displacing fracture and inability to mobilize patients without surgical intervention

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Treatment

• Operative – intramedullary nailing (usually cephalomedullary)

• indications – historically Russel-Taylor type I fractures– newer design of intramedullary nails has expanded indications– most subtrochanteric fractures treated with IM nail

– fixed angle plate • indications

– surgeon preference– associated femoral neck fracture– narrow medullary canal– pre-existing femoral shaft deformity

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Complications

• Varus/ procurvatum malunion

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Complications

• Nonunion

Incidence of 0-8% , continued inability to bear weight at 4-6 months and continued pain. Varus malreduction is an important predictor of nonunion accompanied by implant failure.

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Complications

• Malunion: Coxa varus: Caused by uncorrected abduction

deformity, nail entry point that is too lateral, and migration of hardware proximally in the femoral head and neck

Shortening: Due to uncorrected shortening intraoperatively and premature dynamization.

Rotational deformity: Do to uncorrected external rotation of proximal fragment. This can be assessed intraoperatively with visualization of the lesser trochanter

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Complications

• Fixation failure: Most common in osteoporotic bone. Screw cutout in the femoral head; backing out of locking screws.

• Failure of implant: Excessive motion at fracture site leads to implant fatigue

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• Do you have any question??????????????????

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THANK YOU