Subtrochanteric femur fractures are challenging to treat due to deforming forces. Intramedullary nails are the gold standard treatment as they provide better biomechanical stability compared to plates. Multiple reduction techniques such as clamps, joysticks, and blocking wires may be needed to achieve and maintain anatomical alignment given the typical fracture deformity of varus and procurvatum. Complications include malunion, nonunion, infection, and implant failure, with early mortality rates around 10%. Proper surgical technique and implant selection are important to optimize outcomes for these difficult fractures.
Distal femur fractures what makes it complex ,dr mohamed ashraf,hod orthopae...drashraf369
distal femur fractures are notorious for post operative complications due to malreduction and improper fixation.unless plan and execute a sound and stable fixation,this injury will lead to undesirable results.dr mohamed ashraf HOD orthopaedics govt TD medical college is presenting how to avoid complications in surgical management of these fractures..
Hip resurfacing has emerged as a viable alternative to replacement for arthritis in young patients. Selected individuals will benefit by Hip resurfacing arthroplasty offered by the Madras Joint replacement center in India. See if you qualify for this procedure.
Can read freely here
https://sethiortho.blogspot.com/
Damage control &
Early Appropriate care in Orthopedics
ContentsEvolution of poly trauma management
Early total care
Damage control orthopedic care
Early appropriate care
Introduction
Trauma is the leading cause of death in young populatio
Immediate death – 50%- minutes
Lethal head injury
Hemorrhagic shock
Early death - 30%- hrs
Secondary brain injury
Hemorrhagic shock
Late death – 20% - days to weeks
ARDS
Pneumonia
MODS
Damage control surgery
Evolution of Polytrauma Management
Management concept - Delayed management
Splints, casts and traction
Definite surgery delayed for 10 -14 days
Prolonged bed rest and hospital stay
Damage control surgery
Decubitus ulcer
Disuse atrophy
Early definitely stabilization long bone fracture reduced incidence of fat embolism syndrome
Early Total Care
Damage control surgery
Usually within the first 24hrs
Early Total Care - Advantages
Early fixation favors skin and soft tissue healing
Prevent ongoing tissue damage
Pain relief
Improve joint function
Early mobilization
Respiratory distress
Pneumonia
Early stabilisation of hemodynamically unstable or/and had concomitant chest or head injury patients develop high mortality
mainly by ARDS and MODs
Reasons for the high mortality ?
Two hit phenomena
These findings indicated that
ETC is not appropriate for unstable poly trauma patients
Damage control surgery
Damage control is a new term first used by the US Navy during World War II to describe emergency measures for control of flooding that threatens to sink a ship.
Goal is to ensure survival of the ship until it reaches a port where definitive repairs can be safely performed.
Basic strategies of DCO -
Control of haemorrhage
Damage control surgery
Minimize the second hit
Immediate and rapid stabilization of long bone fractures - EF
Release of tight soft tissue compartments
Reductions of dislocations
Surgical debridement of open wounds
Amputation, in cases of unsalvageable extremities
Definitive fixation is later
Immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected polytrauma patients.
Which patient need DCO approach ?
Patients who have sustained orthopedic trauma have been divided into four groups:
Damage control surgery
Patient categorization
Limitations of DCO
Axial skeleton and femoral fractures
No external fixation
Even ex fix , patient mobilization is poor - bed ridden condition
Anatomical reduction favours pain relief, soft tissue healing and muscle function
Limitations of DCO
Classification of patient condition is not static, dynamic and changed with resuscitation
DCO recommended for those patients who are unstable or in extremis however the optimal time and type of treatment, who are in border line remain controversial
Distal femur fractures what makes it complex ,dr mohamed ashraf,hod orthopae...drashraf369
distal femur fractures are notorious for post operative complications due to malreduction and improper fixation.unless plan and execute a sound and stable fixation,this injury will lead to undesirable results.dr mohamed ashraf HOD orthopaedics govt TD medical college is presenting how to avoid complications in surgical management of these fractures..
Hip resurfacing has emerged as a viable alternative to replacement for arthritis in young patients. Selected individuals will benefit by Hip resurfacing arthroplasty offered by the Madras Joint replacement center in India. See if you qualify for this procedure.
Can read freely here
https://sethiortho.blogspot.com/
Damage control &
Early Appropriate care in Orthopedics
ContentsEvolution of poly trauma management
Early total care
Damage control orthopedic care
Early appropriate care
Introduction
Trauma is the leading cause of death in young populatio
Immediate death – 50%- minutes
Lethal head injury
Hemorrhagic shock
Early death - 30%- hrs
Secondary brain injury
Hemorrhagic shock
Late death – 20% - days to weeks
ARDS
Pneumonia
MODS
Damage control surgery
Evolution of Polytrauma Management
Management concept - Delayed management
Splints, casts and traction
Definite surgery delayed for 10 -14 days
Prolonged bed rest and hospital stay
Damage control surgery
Decubitus ulcer
Disuse atrophy
Early definitely stabilization long bone fracture reduced incidence of fat embolism syndrome
Early Total Care
Damage control surgery
Usually within the first 24hrs
Early Total Care - Advantages
Early fixation favors skin and soft tissue healing
Prevent ongoing tissue damage
Pain relief
Improve joint function
Early mobilization
Respiratory distress
Pneumonia
Early stabilisation of hemodynamically unstable or/and had concomitant chest or head injury patients develop high mortality
mainly by ARDS and MODs
Reasons for the high mortality ?
Two hit phenomena
These findings indicated that
ETC is not appropriate for unstable poly trauma patients
Damage control surgery
Damage control is a new term first used by the US Navy during World War II to describe emergency measures for control of flooding that threatens to sink a ship.
Goal is to ensure survival of the ship until it reaches a port where definitive repairs can be safely performed.
Basic strategies of DCO -
Control of haemorrhage
Damage control surgery
Minimize the second hit
Immediate and rapid stabilization of long bone fractures - EF
Release of tight soft tissue compartments
Reductions of dislocations
Surgical debridement of open wounds
Amputation, in cases of unsalvageable extremities
Definitive fixation is later
Immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected polytrauma patients.
Which patient need DCO approach ?
Patients who have sustained orthopedic trauma have been divided into four groups:
Damage control surgery
Patient categorization
Limitations of DCO
Axial skeleton and femoral fractures
No external fixation
Even ex fix , patient mobilization is poor - bed ridden condition
Anatomical reduction favours pain relief, soft tissue healing and muscle function
Limitations of DCO
Classification of patient condition is not static, dynamic and changed with resuscitation
DCO recommended for those patients who are unstable or in extremis however the optimal time and type of treatment, who are in border line remain controversial
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
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Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
3. OVER-VIEW
Subtrochanteric (ST) femur fractures are proximal femur fractures, which are
often difficult to manage effectively because of their deforming anatomical
forces.
Operative management of ST fractures is the mainstay of treatment, with the
two primary surgical implant options being intramedullary (IM) nails and
extramedullary plates.
4. Of these, IM nails have a biologic and biomechanical superiority,
and have become the gold standard for ST femur fractures.
The orthopaedic surgeon should become familiar and facile with
several reduction techniques to create anatomical alignment in all
unique ST fracture patterns.
This article presents a comprehensive and current review of the
epidemiology, anatomy, biomechanics, clinical presentation,
diagnosis, and management of subtrochanteric femur fractures.
5. INTRODUCTION
Definition: Subtrochanteric (ST) femur fractures are defined as fractures of the proximal femur that
occur within 5 cm of the lesser trochanter
Incidence: 15–20 per 100,000 individuals
Age distribution: bimodal distribution. Individuals younger than 40 years old account for
approximately 20% of ST fractures, while individuals older than 50 years account for over 2/3 of
ST fractures
Risk factors include:
1. Older female individuals,
2. patients undergoing treatment of osteoporosis with bisphosphonates,
3. low total bone mineral density,
4. and chronic diseases such as diabetes mellitus
6. Anatomy
The ST area comprises the meta-diaphyseal proximal femur within 5 cm distal to
the lesser trochanter.
The femoral calcar provides significant structural integrity to the proximal femur. It is the
dense posteromedial bone that extends from distal to the lesser trochanter to the
posteroinferior femoral neck.
Biomechanically, the calcar can experience greater than 1000 Newtons of force upon
standing and during gait
7. Anatomy
The subtrochanteric region also experiences secondary forces from the numerous
muscular attachments found in the area, which increase stress around the proximal
femur and hip.
These muscular attachments include the hip abductors, adductors, short external
rotators, and iliopsoas.
8. Biomechanics
On the proximal fragment,
Abduction: The gluteus medius and gluteus minimus
Flexion : The iliopsoas
External rotation: short external rotators (piriformis,
obturator internus, quadratus femoris, and the superior
and inferior gemelli)
On the distal fragment,
Adduction and shortening force: The gracilis and adductor
muscles.
9. The culmination of these forces results in the characteristic deformity seen in ST
femur fractures of abduction, external rotation, and flexion of the proximal segment
and adduction of the distal segment – overall generating a typical fracture pattern of
VARUS AND PROCURVATUM
11. Clinical evaluation/presentation
Patients with ST femur fractures present in a bimodal distribution.
Subtrochanteric fractures in young patients are typically the result of high-energy
trauma such as a motor vehicle collision or fall from height.
Subtrochanteric fractures in elderly patients are typically the result of low-energy
trauma, which often presents as an isolated injury.
These individuals should undergo a thorough history to assess for comorbid medical
conditions and medication history with specific attention to bisphosphonate usage and
duration
12. Symptoms
Hip and/or thigh pain
Inability to bear weight,
Pain with hip motion.
13. Physical examination of the affected limb
The affected limb will typically reveal a shortened and externally rotated lower extremity.
While these fractures are normally closed injuries, a skin examination should be
performed, as a high degree of flexion of the proximal segment may threaten the
overlying skin.
Neurovascular structures should be examined thoroughly
After ruling out other ipsilateral lower extremity injuries, patients may be placed into
traction, as this will restore fracture length and improve preoperative pain scores
14.
15. Radiographic evaluation
Suspected ST fracture should include:
1. Anteroposterior pelvis,
2. orthogonal femur
3. knee radiographs.
Contralateral femur films may be useful to estimate femoral version, particularly with comminuted
fractures that lack cortical reads to judge anatomical reduction
Typical radiographic findings for ST fractures include:
Abduction, external rotation, and flexion of the proximal segment,
Adduction of the distal segment.
16. Treatment
Non-operative management of ST fractures is not usually a viable option leading to
malunion/nonunion
They are unable to mobilize,resulting in a higher mortality rate.
Considerations for Non-operative treatment :
1. Unacceptably high mortality risk from anaesthesia,
2. Those who are in hospice care,
3. PatientS with Minimal hip discomfort.
17. Operative management of ST fractures
Intramedullary (IM) nailing and extramedullary plating
IM nail has become the gold standard of treatment for numerous reasons :
1. Decreased hospital length of stay,
2. Minimal blood loss,
3. overall operative time,
4. Immediate weight-bearing and
5. Improved functional outcomes
18. Intramedullary nails provide a biomechanical advantage with :
Increased stiffness,
rigidity,
Shorter moment arm, (A stronger construct and decreased strain experienced by the
implant.)
Recent data from the Swedish registry show that the overwhelming majority (1989/2288,
or 87%) of ST fractures are being treated with IM nails.
19. Nail entry point:
Nail entry point and construct design can affect fracture reduction and stability;
therefore, the surgeon should understand the modifiable variables that can improve
surgical outcomes.
Nail entry point: Piriformis or trochanteric entry point.
The incision for both entry portals should be made proximal and in line with the curved
axis of the femoral canal to avoid the superior gluteal nerve.
20. The piriformis entry portal :
Has an inherent advantage in that it is a straight nail that is in line with the coronal axis
of the femoral intramedullary canal.
This collinear advantage results in a decreased risk of varus malreduction and eccentric
medial cortex reaming.
It is more challenging in
obese patients,
There is an increased risk for anterior cortical blowout with excessive anterior
placement.
21. The greater trochanter: It is the alternative entry portal for treating ST fractures with IM nails.
Advantange: Decreased soft tissue dissection due to its more superficial location,
Disadvantage:
1. It does violate the abductor insertion.
2. Varus malreduction and presents a high degree of variability based on individual patient
trochanteric anatomy.
Overall, the entry point decision should be made on an individualized basis, taking into
relevant patient anatomy, surgeon preference, fracture characteristics, and extension of the fracture
pattern.
23. When treating ST femur fractures, the ideal nail is an antegrade, statically and distally locked.
cephalomedullary nail that allows for added proximal fixation in the femoral neck and head. A
large cephalomedullary screw or helical blade can be utilized.
However, these provide more utility in intertrochanteric fractures by providing compression at
the fracture site.
Alternatively, using two smaller diameter reconstruction-style screws decreases the bone
removal in the femoral neck and head, while still providing adequate proximal fixation.
24. Additional advantageous nail characteristics are a larger proximal diameter and full
length nails.
This strengthens the construct by improving rotational and axial stability and decreases
the risk of post-implant fractures when compared to the use of short nails.
The use of two distal interlocking screws has been demonstrated to provide greater
rotational and axial stability than one.
25. The second major category of operative fixation for ST fractures is the use of locking or
fixed-angle extramedullary plates.
Disadvantages of fixed-angle blade plates :
1. presents a high degree of technical difficulty.
2. Decreased rates of union,
3. Increased operative time,
4. Increased time until weight-bearing, and
5. Increased infection rates
26. Using a locking plate compared to a fixed-angle blade plate has demonstrated better
biomechanical properties.
However, this construct was shown by Collinge et al to result in failed fixation,
malalignment/malunion, deep infection, or a combination of these factors in over 40% of patients.
Of these patients, over 1/3 underwent a secondary revision surgery.
However, in extramedullary plating, particularly when using a small fragment plate for provision
fixation when open reduction is required, Malunion rates have been reported to drop from 27% to
0% when using this provisional plating technique
27. Reduction strategies and techniques
Due to the deforming forces in ST fractures, several techniques can be considered to achieve
proper anatomic reduction which include :
1. The use of clamps,
2. A ball spike pusher with a bone hook,
3. Percutaneous Schanz pin joysticks,
4. A femoral distractor,
5. A finger reduction tool,
6. Blocking wires or screws,
7. And cerclage wiring.
28. Positioning of the patient prior to
reduction :
Lateral decubitus position can allow for easier entry portal access via adduction of the
ipsilateral leg in more obese patients. This position also allows for easier reduction of the
distal fragment.
The supine position is familiar to most surgeons, is superior in the case of polytrauma by
providing access to other extremities, and is protective of an injured spine.
29. Use of a ball spike pusher to medialize the distal fracture
fragment while simultaneously pulling the proximal fragment
with a bone hook to address the varus fracture deformity.
a) After the guide wire was
placed, a clamp was utilized
to maintain the reduction in
the coronal
b), c) nd saggital planes
d) Anatomical reduction was
acheived and the
subtrochanteric femur
fracture was fixed with a
trochanteric entry
reconstruction nail.
30. For many ST fractures, the use of clamps can be considered to assist in maintaining reduction.The
use of this technique has demonstrated excellent reductions and a high union rate.
For simpler two-segment ST fractures, devices such as percutaneous Schanz pin, joysticks or the
ball spike pusher and bone hook can be utilized to align the fragments and allow for proper
placement of a guide wire.
Schanz pins can also be coupled with a femoral distractor to establish length and to lock the
reduction into place once proper alignment has been achieved.
Another tool that can be of significant use for two-segment ST fractures is the finger reduction tool
31. Multiple reduction techniques were used to
address this complex subtrochanteric femur
fracture with intertrochanteric extension.
A) The finger reduction tool was placed into the piriform
fossa entry portal to gain control on proximal fragment.
B) Cobb periosteal elevator and a posterior blocking wire
were utilized to correct the sagittal plane deformity
C) The finger reduction tool was then passed to the level of
the distal fragment to allow for passage of the guidewire
D) Anatomical reduction was acheived and maintained with
a piriformis entry reconstruction nail.
32. While length is typically improved with longitudinal traction, varus malalignment typically persists despite
traction due to the proximal insertion of the abductors and the distal insertion of the adductors.
In this case, passing a finger reduction tool can be utilized to gain control of the proximal fragment and
correct the varus malalignment.
Improper starting point or path of the guide wire can result in eccentric reaming, potentially resulting in
cortical blowout or malreduction of a previously aligned reduction.
For more complex fracture patterns with comminution or those with distal extension, blocking wires or
screws can be placed on the concavity of the deformity in the proximal segment to maintain reduction
and stiffen the construct.
Although there is concern for disruption of the femoral blood supply, the use of percutaneous cerclage
wiring has also been shown to be an effective and safe reduction method.
33. A) A blocking wire was placed in the concavity of
the deformity in the proximal fracture fragment
just medial to the guidewire and was left in
place during reaming to guide the Reaming of
proximal fragment
B) As the nail was passed
C) The blocking wire effectively lateralized the
distal segment
D) And created an anatomical reduction that was
maintained with a piriformis entry
reconstruction nail.
34. Complications:
Malunion,
nonunion,
infection,
implant breakage, and
Mortality
Mortality rates for ST fractures have been shown at 30 days, one year, and four years to be
approximately 9.5%, 27%, and 60%, respectively
35. Malunion, in particular, can be associated with rotational errors which may result in gait
abnormalities and hip pain.
Rotational malalignment is particularly prevalent with the use of a traction table, as
excessive internal rotation is often used for attempted fracture reduction. This is
especially concerning in severely comminuted fractures.
When healed in the typical ST malreduction pattern, excessive varus angation and
flexion of the proximal fragment can negatively alter the patient’s gait mechanics.
36. Symptomatic malunion may require a corrective osteotomy with instrumentation, and
nonunion can be effectively managed with exchange of the implants with or without use of
bone grafting.As with all surgical procedures, infection is a potential risk.
Superficial infections can typically be managed with antibiotics alone. However, deep
infections require surgical irrigation and debridement and possible implant removal.
In the setting of an infected nonunion, the implants are removed and replaced with an
antibiotic intramedullary implant, along with long-term intravenous (IV) or oral antibiotics.
37. Conclusion
Subtrochanteric femur fractures are challenging orthopaedic injuries due to their
complex and powerful deforming forces, which create significant difficulty in fracture
reduction and implant fixation.
As operative management remains the definitive treatment of choice for ST femur
fractures, it is imperative to understand these forces and the techniques to properly
reduce these fractures in order to improve alignment, stability, and patient outcomes.