Intertrochantric hip fracture

8/12/2019 Intertrochantric hip fracture.

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LESSER

TUBEROSITY

AP pelvis and AP hip of an elderly patient

with a three-part intertrochanteric hip fracture.


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LATERAL RADIOGRAPH

The set up on the fracture table does not require the uninjured leg to be

placed in hyperflexion and abduction. The legs may be scissored to

allow for good lateral radiographs of the affected side without putting the

opposite hip at risk.

ISCHIUM

LESSER

TROCHANTER

FEMUR


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This image demonstrates the position of the fracture

table with the patients affected arm over the chest

and well padded.


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SCDs ON

DURING

PROCEDURE

This image demonstrates the scissoring of the legs with the

affected side slightly flexed and the unaffected side slightly

extended. Notice that sequential compression devices remain

on the legs during the procedure.


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A view from below demonstrates the position of the arm.


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The C-arm is brought in from an angle approximately 30 degrees

distal to the patient. The AP radiograph is taken with the C-arm

slightly over rotated to give a more perfect AP view with respect

to the anatomy of the proximal femur and the lateral view.


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The incision should begin proximally at the trochanteric

ridge and need extend approximately 10 centimeters

down the thigh.


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ITB

The incision brought down to the level of the

iliotibial band and fascia lata.


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ITB

The iliotibial band is incised with a knife. A Metzenbaum

scissors is used to dissect under the band, which is divided

in line with the incision.


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The iliotibial band is incised with a knife. A Metzenbaum

scissors is used to dissect under the band, which is divided

in line with the incision.


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With retraction of the iliotibial band, the vastus

lateralis fascia is visualized.

VASTUS

LATERALIS

ITB


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A sharp rake is introduced anteriorly and is used to retract the

vastus lateralis anteriorly. An incision is then made in the

fascia just anterior to the most posterior aspect of the femur.


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A sharp rake is introduced anteriorly and is used to retract the

vastus lateralis anteriorly. An incision is then made in the

fascia just anterior to the most posterior aspect of the femur.


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A periosteal elevator can be used to elevate the lateralis

off the femur with care taken to avoid perforating branches.


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A Bennett retractor can be placed over the anterior

surface of the femur, exposing the lateral edge of

the femur.


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AP x-ray demonstrating abduction of the proximal fragment

and displacement of the posteromedial fragment.


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A bone hook can be used, as can a clamp or other

technique, to reduce the abduction in the proximal

fragment.


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Once a reduction is obtained and confirmed on the AP and

lateral radiographs, the angle guide is placed against the

lateral surface of the femur in order to place the guidewire

for the lag screw.


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The natural anteversion of the hip requires commensurate

external rotation of the jig in order to drive the wire into the

center of the head.


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X-rays demonstrating the position of the guidewire

through the jig in the AP and lateral planes.


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After the appropriate measurement for the lag screw is made,

the femur is prepared by reaming. In this case, a long barrel

was chosen and the appropriate reamer is selected.


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If the bone is of good quality, a tap may be used.


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AP radiograph of the lag screw being terminally seated.


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When using a small incision, the side plate must be slid from proximal

to distal along the femoral shaft, then drawn back up proximally such

that it is within the wound.


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In order to seat the side plate, its distal end must be held

gently off bone, such that the side plate is parallel with the

femur in order to engage the lag screw.


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Once the plate is terminally seated and tapped in place,

it is affixed to the cortex using standard screw fixation.


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AP radiograph of the lag screw and side plate in position.


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In this particular situation, the posteromedial fragment was

rather large, thus it was elected to fix it with a lag screw.

This must be done from a position anterior to the side plate.


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This is the case because the side plate must be slightly

posterior to the midline in order to direct the lag screw

into the center of the head, given the normal anteversion

of the neck.


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The posteromedial fragment cannot be lagged through the

plate because the angle of the screw through the plate

would be too great. Thus, the screw is placed from anterior

to the plate as seen in this figure.


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Lateral view of the posteromedial fragment

reduction with a clamp.


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The image shows the drill that is placed into

the lesser trochanter.


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Final AP radiograph demonstrating excellent fixation and

compression across the intertrochanteric fracture as well

as lag screw fixation of the lesser trochanter.


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ITB

The closure is then performed with a running

stitch of the vastus lateralis.


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ITB

The iliotibial band is repaired using interupted sutures;

the skin will then be closed in layers.


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Intertrochantric hip fracture