24. INDICATIONS
• One Cannot Consider the Indications
for Treatment of Pelvic Fractures
Without an Understanding of:
– Pelvic Anatomy
– Pelvic Biomechanics… Stability Concept
86. EXTENDED
ILIOFEMORAL
• TRANSVERSE AND T-TYPE
– TRANSTECTAL
– SEVERE COMMINUTION
– LATE PRESENTATION
• BOTH-COLUMN
– LATE PRESENTATION
– SEVERE COMMINUTION
88. RELEVANT ANATOMY
• Blood supply to the
femoral head is derived
primarily from the medial
femoral circumflex
artery, which forms an
extracapsular ring with the
lateral femoral circumflex
artery
89. RELEVANT
ANATOMY
• Ascending arteries
follow the posterior
femoral neck and
perforate the femoral
head at the junction of
the inferior articular
surface.
91. POSTERIOR HIP
DISLOCATION
• Account for
nearly 90% of all
hip dislocations
92. POSTERIOR HIP
DISLOCATION
• Treatment
– Emergent closed reduction
– Open reduction through a Kocher-Langenbeck
approach if closed reduction is unsuccessful
93. POSTERIOR HIP
DISLOCATION
• Sciatic nerve is an at risk structure
– Initial injury
– Surgical reduction
– Occur in 8-19% of patients
94. COMPLICATIONS OF HIP
DISLOCATIONS
• Avascular necrosis of femoral head in
10% of hip dislocations
– Risk of AVN increases with associated
acetabular fracture
– Early reduction of hip dislocations is
associated with a lower rate of AVN
• Post-traumatic hip arthritis in 15% of hip
dislocations.
95. FEMORAL HEAD
FRACTURES
• Pipkin Classification-
Four types
– Type I- inferior to the
fovea
– Type II- superior to the
fovea
– Type III- associated
femoral neck fracture
– Type IV- associated
acetabular fracture
96. FEMORAL HEAD
FRACTURES
• Treatment based on:
– Fragment size
– Fragment location
– Fragment displacement
– Hip stability
97. FEMORAL HEAD
FRACTURES- treatment
• Type I (infra-foveal)
– Nondisplaced-
nonsurgical
– Small displaced
fragments- surgical
excision
– Large displaced
fragments- reduction
and surgical fixation
98. FEMORAL HEAD
FRACTURES- treatment
• Type I (infra-foveal)
– Nondisplaced-
nonsurgical
– Small displaced
fragments- surgical
excision
– Large displaced
fragments- reduction and
surgical fixation
99. FEMORAL HEAD
FRACTURES- treatment
• Type I (infra-foveal)
– Nondisplaced-
nonsurgical
– Small displaced
fragments- surgical
excision
– Large displaced
fragments- reduction
and surgical fixation
100. FEMORAL HEAD
FRACTURES- treatment
• Type II (supra-foveal)
– Requires accurate
anatomic reduction and
stable internal fixation
101. FEMORAL HEAD
FRACTURES- treatment
• Type III (associated
femoral neck frx)
– Young patient
• Anatomic reduction
and stable internal
fixation of both the
femoral neck and
femoral head
– Older patient
• Hemiarthroplasty
104. FEMORAL NECK
FRACTURES- Classification
• Pauwel s
Classification - based
on fracture verticality
– Type I- Less than 30
degress
– Type II- 30-50
degrees
– Type III- Greater
than 50 degrees
105. FEMORAL NECK
FRACTURES- Classification
• Garden Classification
– Type I and II –
nondisplaced
– Type III and IV -
displaced
106. FEMORAL NECK
FRACTURES- Nondisplaced
• Nondisplaced femoral neck fractures
– Treatment is the same regardless of the patient
age
118. FEMORAL NECK
FRACTURES- Displaced
• Young Patients (<65 years old)
– Efforts are focused on preservation of the
femoral head and avoiding arthroplasty at a
young age
– ORIF
119. FEMORAL NECK
FRACTURES- Displaced
• Young patients
– Timing is urgent
– Lower rates of AVN with early treatment
– Anatomic reduction and stable fixation
– Slight valgus acceptable
– Avoid varus reductions
125. FEMORAL NECK
FRACTURES- Displaced
• Older patients
– In North America, prosthetic replacement is
favored
126. FEMORAL NECK
FRACTURES- Displaced
• Why endoprosthesis in older patients?
– Need for rapid mobilization
– ORIF failure rate of 40%
• Osteoporotic bone
• Comminution
127. FEMORAL NECK
FRACTURES- Displaced
• Older patients- type
of prosthetic
replacement?
– Unipolar
hemiarthroplasty
– Bipolar
hemiarthroplasty
– Cemented vs.
uncemented
Unipolar Bipolar
128. FEMORAL NECK
FRACTURES- Displaced
• Older patients- type of prosthetic
replacement?
– NO difference in morbidity, mortality, or
functional outcome
129. FEMORAL NECK
FRACTURES- Displaced
• Older patients- Total Hip Arthroplasty
– Classic indication
• Displaced fracture with ipsilateral hip arthritis
– Recently indication expanded
• Displaced fracture and an active elderly patient
with no hip arthritis
131. INTERTROCHANTERIC HIP
FRACTURES- Treatment
• Intertrochanteric hip fractures are treated
the same, regardless of age
132. INTERTROCHANTERIC HIP
FRACTURES- Treatment
• Anatomic reduction and stable internal
fixation
• Choice of implant based on
– Fracture pattern
– Associated stability of the fracture
133. INTERTROCHANTERIC HIP
FRACTURES- Treatment
• Sliding hip screw
– Useful for most (avoid
in reverse oblique)
– Simple and predictable
134. INTERTROCHANTERIC HIP
FRACTURES- Treatment
• Sliding hip screw
– Do not use with reverse oblique fracture
patterns
142. INTERTROCHANTERIC HIP
FRACTURES- Treatment
• Outcomes
– No difference
between a two-
hole and four-
hole sliding hip
screw
143. INTERTROCHANTERIC HIP
FRACTURES- Treatment
• Cepholomedullary device
– No clear advantage over conventional sliding
hip screw for most fractures
– Exceptions
• Reverse oblique fractures
• Intertrochanteric fractures with subtrochanteric
extension
– More studies necessary
166. IS THERE ANOTHER
SOLUTION?
• Locking Plate fixation with
multiple fixed angle screws in the
metaphyseal segment
– Locking Condylar Plate
– Liss Plate
