A presentation created and delivered by me in the weekly meeting of our unit in the orthopedic surgery department in National Ribat Teaching Hospital (Khartoum, Sudan) on the 28th of August 2018. In it I present the content of a scientific paper from 2010. The paper is titled "“Intertrochanteric Fractures:Ten Tips to Improve Results”". It is composed of the following parts:
- The author, journal and article
- The 10 tips
The paper can be found here:
https://www.ncbi.nlm.nih.gov/pubmed/20415401
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Ten tips presentation
1. Abdalla Mutwakil Gamal
Medical Officer
Mr Mohammed Babiker Unit
Department of Orthopedic Surgery
National Ribat Teaching Hospital
Khartoum, Sudan
2.
3. An Instructional Course Lecture,
American Academy of Orthopaedic
Surgeons
Trained at the Mayo Clinic
Director of orthopedic trauma
Academic chairman for the
Orthopedic Faculty Practice
Professor at the University of Central
Florida College of Medicine
Award-winning researcher
100+ peer reviewed publications and
book chapters
20+ patents and has developed
multiple innovative implants for
fracture fixation and joint
replacement.
4. 1948-present
The journal is the official
publication of the:
• British Orthopaedic Association
• Canadian Orthopaedic
Association
• New Zealand Orthopaedic
Association
• Australian Orthopaedic
Association, and
• Sociedade Brasileira de
Orthopedia e raumatologia.
Impact factor: 3.581 (2017)
5.
6.
7.
8. Tip 1: Use the Tip-to-Apex Distance
Tip 2: ‘‘No Lateral Wall, No Hip Screw’’
Tip 3: Know the Unstable Intertrochanteric
Fracture Patterns, and Nail Them
Tip 4: Beware of the Anterior Bow of the
Femoral Shaft
Tip 5: When Using a Trochanteric Entry Nail,
Start Slightly Medial to the Exact Tip of the
Greater Trochanter
Tip 6: Do Not Ream an Unreduced Fracture
9. Tip 7: Be Cautious About the Nail Insertion
Trajectory, and Do Not Use a Hammer to
Seat the Nail
Tip 8: Avoid Varus Angulation of the Proximal
Fragment—Use the Relationship Between the
Tip of the Trochanter and the Center of the
Femoral Head
Tip 9: When Nailing, Lock the Nail Distally if
the Fracture Is Axially or Rotationally
Unstable
Tip 10: Avoid Fracture Distraction
When Nailing
10. Planning:
• Nail or Screw?
• Nail or screw properties
Execution:
• Open
• Reduce
• Fix
• Close
11. Planning:
• Nail or Screw? (Tip 2 & 3)
• Nail or screw properties? (Tip 4)
Execution:
• Open
• Reduce (Tip 6)
• Fix (Tip 5, 7 & 10 when nailing)(Tips 1 & 8 for
position)(Tip 9 for locking)
• Close
31. Planning:
• Nail or Screw?
• Nail or screw properties
Execution:
• Open
• Reduce
• Fix
• Close
Tip 2: ‘‘No Lateral Wall,
No Hip Screw’’
Tip 3: Know the Unstable
Intertrochanteric Fracture
Patterns, and Nail Them
32. Planning:
• Nail or Screw?
• Nail or screw properties
Execution:
• Open
• Reduce
• Fix
• Close
Tip 4: Beware of the
Anterior Bow of the
Femoral Shaft
33. Planning:
• Nail or Screw?
• Nail or screw properties
Execution:
• Open
• Reduce
• Fix
• Close
Nothing
34. Planning:
• Nail or Screw?
• Nail or screw properties
Execution:
• Open
• Reduce
• Fix
• Close
Tip 6: Do Not Ream an
Unreduced Fracture
35. Planning:
• Nail or Screw?
• Nail or screw properties
Execution:
• Open
• Reduce
• Fix - Nailing
• Close
Tip 5: When Using a
Trochanteric Entry Nail,
Start Slightly Medial to
the Exact Tip of the
Greater Trochanter
Tip 7: Be Cautious
About the Nail Insertion
Trajectory, and Do Not
Use a Hammer to Seat
the Nail
Tip 10: Avoid Fracture
Distraction
When Nailing
36. Planning:
• Nail or Screw?
• Nail or screw properties
Execution:
• Open
• Reduce
• Fix - position
• Close
Tip 1: Use the Tip-to-Apex
Distance
Tip 8: Avoid Varus
Angulation of the Proximal
Fragment—Use the
Relationship Between the
Tip of the Trochanter and
the Center of the Femoral
Head
37. Planning:
• Nail or Screw?
• Nail or screw properties
Execution:
• Open
• Reduce
• Fix - Locking
• Close
Tip 9: When Nailing, Lock
the Nail Distally if the
Fracture Is Axially or
Rotationally Unstable
Editor's Notes
Varus angulation of the proximal fragment increases the lever arm on the fixation since it makes the femoral neck more horizontal and therefore functionally longer when body weight is applied. This also results in the femoral head fixation being placed more superiorly in the head than is ideal and increases the risk of the device cutting out of the femoral head. It can be difficult to determine the appropriate femoral neck-shaft angle in a patient
with an intertrochanteric fracture. When using an intramedullary nail for fixation of an intertrochanteric fracture, most surgeons choose a nail with a 130
neck-shaft configuration (Figs. 13 and 14). It is important to know the neckshaft angle of the device that is being used. One way to assess varus or valgus
position during surgery is to look at the relationship between the tip of the greater trochanter and the center of the femoral head. These two points should
be coplanar. If the center of the femoral head is distal to the tip of the greater trochanter, the reduction is in varus. If the center of the head is proximal to the greater trochanter, the reduction is in valgus. Preoperative plain radiographs of the uninjured hip can be used to assess the patient’s normal neck-shaft
angle as the two sides are normally symmetric. Varus and high lag-screw placement are associated with an increased frequency of failure of fixation
with an intramedullary nail and sliding hip screw20,21.
(Fig. 13 A well-aligned fracture. Note the central position of the lag screw in the femoral head. Fig. 14 Radiograph
showing the relationship between the tip of the greater trochanter and the center of the femoral head. Normally, this
relationship is coplanar. Here, the proximal fragment is in varus, the starting point is lateral, and the screw is high
in the head.)
The unstable patterns include reverse obliquity fractures, transtrochanteric fractures, fractures with a large posteromedial fragment implying loss of the calcar buttress, and fractures with subtrochanteric extension (Figs. 4 through 7)3-5,9,12-16.