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unstable trochanteric fracture

unstable trochanteric fracture

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Unstable trochanteric fractures:
Issues and avoiding pitfalls
Sushrut Babhulkar (2017)
Introduction :-
• Factors essential for pre-operative planning prior to re-construction of these
fractures includes :
i. Fracture geometry
ii. Bone quality
iii. Amount of comminution
iv. Fracture extension in nearby areas like neck femur or subtrochentric extension
• AIM :
Factors contributing to inherent instability and failure of fixation :-
i. Loss of posteromedial support
ii. Severe comminution at Greater trochanter leading to difficulty in passing an
intramedullary nail
iii. Reverse oblique #
iv. Burst lateral wall
v. Posterior wall fracture/Coronal split
vi. Extension into femoral neck area/piriformis fossa / subtroch
vii. Poor bone quality
Review of literature
Evans (1948) -
• Key to stable fracture reduction is restoration of posteromedial cortical
continuity .
• Reverse oblique fractures are inherently unstable because of tendency for
medial displacement of the femur shaft.
• Cortical buttessing of bone on inner side of femoral neck and shaft increase
fixation stability.
Dimon and hughston technique (1967) -
•leaves a posteromedial defect and thereby stability is not achieved.
Baumgaertner et al. (1997) –
D true = known diameter of lag screw

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unstable trochanteric fracture

  • 1. Unstable trochanteric fractures: Issues and avoiding pitfalls Sushrut Babhulkar (2017)
  • 2. Introduction :- • Factors essential for pre-operative planning prior to re-construction of these fractures includes : i. Fracture geometry ii. Bone quality iii. Amount of comminution iv. Fracture extension in nearby areas like neck femur or subtrochentric extension • AIM :
  • 3. Factors contributing to inherent instability and failure of fixation :- i. Loss of posteromedial support ii. Severe comminution at Greater trochanter leading to difficulty in passing an intramedullary nail iii. Reverse oblique # iv. Burst lateral wall v. Posterior wall fracture/Coronal split vi. Extension into femoral neck area/piriformis fossa / subtroch vii. Poor bone quality
  • 4. Review of literature Evans (1948) - • Key to stable fracture reduction is restoration of posteromedial cortical continuity . • Reverse oblique fractures are inherently unstable because of tendency for medial displacement of the femur shaft. • Cortical buttessing of bone on inner side of femoral neck and shaft increase fixation stability.
  • 5. Dimon and hughston technique (1967) - •leaves a posteromedial defect and thereby stability is not achieved.
  • 6. Baumgaertner et al. (1997) – D true = known diameter of lag screw
  • 7. Madsen et al. – • CHS vs Gamma nail for unstable per- and sub-trochentric fractures ; Trochenteric stabilising plate (TSP) may aid in treatment of these difficult fractures. Haidukewych et al. (2001) – • Reverse oblique fractures when treated with cephalomedullary implant :- • advantage - shorter lever arm for fixation device , -less potential for fracture collapse and limb shortening
  • 8. Kim et al. (2001)- • Unstable IT# with osteoporosis : DHS shouldn’t be the first choice of treatent . Sadowki et al. (2002) – • Use of an intramedullary nail rather than a 95° screw plate for fixation of reverse oblique and transverse intertrochentric fractures in elderly patients . Zickel et al. (2002) – • Use of cephalomedullary implant in Fracture extending from intertrochentric region to subtrochentric region without comminution of proximal fragment.
  • 9. Lorich et al. (2004) – • Cephalomedullary implant advantage :- inhibition of excessive sliding - early patient mobility Babhulkar et al. (2006) – • Stable fractures : DHS • Unstable trochanteric fractures : cephalomedullary implant to prevent rotational instability. Kulkarni et al. (2006) – • DHS -> gold standard for treatment of stable trochanteric fractures • cephalomedullary implant -> unstable trochanteric fractures
  • 10. Haidukewych et al. (2009) – 1. Measurement of tip to apex distance 2. No lateral wall 3. No use of hip screw 4. Knowledge of unstable fracture pattern and nail them 5. Beware of anterior bow of femoral shaft 6. When nailing , start slightely medial to medial to exact tip of greater trochanter 7. Don’t ream an unreduced fracture 8. Be cautious about nail insertion trajectory, don’t use hammer to seal the nail 9. Avoid varus angulation of proximal fragment 10. When nailing , lock the nail distally if fracture is axially or rotationally unstable.
  • 11. Gupta et al. (2010) – • Combination of DHS and TSP is better option than DHS alone in treatment of unstable trochentric fractures with burst lateral wall . Knobe et al. (2012) -- • Unstable pertrochanteric fractures may be fixed either with locked extramedullary small diameter screw systems to avoid lateral wall fractures or with the new intramedullary systems to avoid potential mechanical complications of a broken lateral wall.
  • 12. Hsu et al. (2013) – i. lateral wall thickness is a reliable predictor of post-operative lateral wall fracture ii. Intertrochanteric fracture with a lateral wall thickness < 20.5 mm should not be treated with a DHS alone
  • 13. Bryan Tan et al. (2015) – • Loss of superolateral support rather than the medial calcar buttress is the main contributing factor to mechanical failure. • CT is important in preoperative planning. • Intramedullary nailing is more appropriate than extramedullary plating for unstable fractures
  • 17. Babhulkar’s Modified OTA Classification Type A- Lateral trochanteric wall fracture as seen on lateral CT. Type B- Posterior wall fracture as seen on Posterior and Oblique CT. Type C- Burst Lateral wall with posterior wall fracture with Medial column (Lesser Trochanter) dissociation and overall Comminution.
  • 19. DISCUSSION Factors influencing treatment outcome :- 1. Age of patient 2. Pt. general health condition 3. Time from fracture to treatment 4. Stability of fixation • The DHS implant, initially introduced by Clawson in 1964, remains the implant of choice in all stable fractures of proximal femur. • Disadvantages of DHS :
  • 20. Intramedullary implants :- • Rotational stability • Control of axial telescoping • Less exposure/minimal invasive • Biomechanically stronger than extramedullary implants • Withstand higher static and cyclical loading than DHS  Not favoured ; in low-energy pertrochanteric fractures, specifically with its increased cost and lack of evidence to show decreased complications or improved patient outcome
  • 21. prevent the Z-effect phenomenon suggest the use of a “ring” in the lateral side of the hip pin.
  • 22. Take home message on how to avoid pitfalls :- • Unstable IT fractures : 3D-CT , Augumentation techniques • Lateral and posterior wall fractures need to be identified before planning any procedure. • Reverse oblique fractures need separate attention. • In the treatment of unstable trochanteric fractures intramedullary devices are better option than extramedullary .