badly comminuted fracture femoral head, dislocation, shattered trochanter and sub-trochanter region and infection, in a multiple fracture case

1. A case of shattered proximal femur
Vinod Naneria
Girish Yeotikar
Arjun Wadhwani
Choithram Hospital & Research Centre,
Indore India

2. Case summary
• A 25 years old male, met with RTA,
• Sustained hip fracture - dislocation
• Comminuted neck + trochanter
• Subtrochanteric fractures.
• Fractures of lower end radius, metatarsals,
ligamentous injury at same side knee
• Contra-lateral comminuted fracture tibia
fibula.

5. Radiology
• Fracture/dislocation of hip with fracture of
head and neck
• Comminuted subtrochanteric fracture - Rt
• Comminuted fracture of Tibia/ febula Lt.
• CT scan of Rt hip was ordered.

9. Planning
• First nailing for Tibia on the other side.
• Open reduction of Hip
• Fixation of the head fragment with the
remaining head.
• A bridge plate from trochanter to shaft bye-passing
the comminuted pieces of
subtrochateric region.

10. 6/12/2011- Problems
• Split head fragment and how to fix it?
• How to reduce?
• Positioning of the pt. on table?
• Which approach?
• Traction table or not?
• Which implant?

11. 6/12/2011- Problems
• Primary replacement with cemented Bipolar?,
• How to fix the two pieces of the head with out
further damage to the vascularity?
• Intramedullary or extramedullary implant and
their purchase in the neck fragment?
• How to avoid the rotation of neck fragment if
a DCS/PFN or DHS is chosen?

12. 14/12/2011
Surgical notes
• Lateral position , posterior approach, blunt
dissection
• Identification of the dislocated head fragment.
• There was a capsular rent in the inferior aspect
through which the dislocated head was popping
out.
• The capsular rent was not wide enough.
• We failed to manipulate the head fragment back
in to acetabulum by direct pushing the head.

13. 14/12/2011
Surgical notes
• A gap was developed in the trochanteric area and
trochanter was reflected upward(like we do in
trochanteric osteotomy), through which the neck
of the femur was caught by a patellar clamp and
distraction was done. The head was now
manipulated and deposited in the acetabulum
and the reduction was checked by C-arm.
• A trochateric plate was chosen as a fixation
device with out opening the subtroch fracture
site.

14. 14/12/2011
Surgical notes
• I could not imaging the how to fix the two pieces of the
head when the other was not visible. To expose means
complete capsulotomy! I did not dare. So, I left it
without fixation but in good alignment.
• The chance of AVN is much more than normal and I
had to reconstruct the anatomy as near normal
as possible.
• The case here presented with an idea of reporting a
situation which is most unpleasant for any surgeon -
who was forced to enter the theatre with out a clear
pre-op planning due to bad comminution of the
fractured bones.

15. 10/12/2011
Immediate
Post op

16. 31/1/2012
Infection
• Unfortunately patient had deep wound
infection which was explored and washed. The
plate was holding well and I had no other
choice hence was left in place.
• He was on antibiotics and now wound has
nearly healed.
• He has difficulty in sitting upright.
• He was developing bedsores.

17. 31/1/2012
• He was again taken to OT for hip examination.
His c-arm pictures are attached here with.
• The lateral view showing marked anterior
rotation/displacement of proximal fragment.
• I have to wait for at least 3 months for
re-exploration + bone grafting.

18. Examination under C-arm

19. Examination under C-arm

20. Surgery .....
• In lateral position – Hip exposed.
• The external rotators were gentaly elevated
from the posterior acetabular side and the
head was reduced in the socket.
• Reduction was confirmed by C – arm.
• A long screw was tighten through a
trochnateric plate into the fragment under
vision through the capsular rent.

21. 20/5/2012
Infection + Bony Ankylosis
• Six months passed
• This patient now have bony ankylosis of hip
with occasional dischage.
• Painless. Mobilized with walker.
• Planning to do hip excision once
subtrochanteric fracture consolidates.

23. 23/5/2012
Problems & Choices
• For a stable painless hip,
• Debridement
• Control of infection antibiotic beads
• Excision of the Hip and/or Antibiotic spacer.
• At present I am concentrating of mobilisation.
The infection (low grade) is probably in the hip
joint that caused ankylosis.
• There is no loosening seen on x-rays at any screw
tracts.

24. 7/11/2012
Plate removal
• Patient had persistent problem in ADL and
specially sitting due to stiff hip.
• Discharge was persisting.
• Trochanteric plate was removed.
• Excision of hip was done.
• There was movement at proximal femur fracture.
• Temporary immobilization in Thomas’s splint.
• Mobilization continued with walker.

25. 7/11/2012
Plate removed
Head excision done
Screws tracts
curetted

26. 13/8/2013
• No infection.
• Mobility at proximal femur.
• Better mobilized due to movements at hip and
proximal femur.
• Fracture exposed.
• Fragments mobilized
• Re-plating and bone grafting done.
• Reactivation of infection, which continued till the
plate was removed on May 2014.

27. 23/8/2013
Sub-troch
Fracture Exposed
Bone ends cleared
Re-plating
Bone grafting

28. 25/9/2013

29. 15/1/2014
Discharge
Persisting
Screw getting
Loose
Fracture healing
Mobilized
Full wt. bearing

30. 5/3/2014

31. 18/6/2014
Fracture
Consolidated
Plate removed
Screw tracts
curetted

32. 23/6/2014

33. Finally
• Shortening of 2”
• Limited knee movements
• Walks without support with shoe raise
• No infection
• No pain
• No future planning for any hip replacement as
there is no medullary canal in proximal femur.

34. DISCLAIMER
Information contained and transmitted by this presentation is
based on personal experience and collection of cases at
Choithram Hospital & Research centre, Indore, India. It is
intended for use only by the students of orthopaedic surgery.
Views and opinion expressed in this presentation are
personal. Depending upon the x-rays and clinical
presentations viewers can make their own opinion. For any
confusion please contact the sole author for clarification.
Every body is allowed to copy or download and use the
material best suited to him. I am not responsible for any
controversies arise out of this presentation. For any
correction or suggestion please contact naneria@yahoo.com