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Subtrochanteric
- 1. AOTrauma Principles Course Subtrochantericfractures Martin van der Elst, NL
- 2. Subtrochanteric fractures • Fractures •Patients • Therapeutic options • Tips and tricks • Conclusions
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- 5. Biomechanical problems • Shortproximal segment • Long lever-arm • Strong musculature • Eccentric load
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- 7. Gluteal muscles →abduction Iliopsoas muscle → flexion + external rotation
- 8. Two separate populations •High-energy trauma—often seen in polytrauma • Elderly—usually with osteoporosis and co-morbidities
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- 11. Therapeutic option 1 •Traction? - Very difficult to obtain and maintain reduction due to strong muscular deforming forces • Conventional plating Therapeutic option 2
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- 13. 17-year-old women Cons: • Approach •Cosmetic • Devascularization • Bone-grafting • Demanding surgery • Plate removal • Refracture after plate removal
- 14. Therapeutic option 3 •Biological plating 0 Postop3 m
- 15. Biology and biomechanics •Preservation of viability is more important than restoration of stability
- 16. Therapeutic option 4 Intramedullarynailing (IM), antegrade or retrograde Gerhard Küntscher 1900–1972 Accurate fitting Reaming medullary canal
- 17. Conventional nailing Simple/stable fracture Narrowpart medullary canal Isthmus
- 18. Reamed nailing ofshaft fractures Cons: • Massive interruption to endosteal blood supply • Adds to the trauma by the fracuture
- 19. Nailing of subtrochantericfractures The solid femoral nail 1 2 2 3 1 2 3
- 20. Nailing of subtrochantericfractures • Essential in unreamed femoral nailing: • Sufficient reduction • Correct entry point
- 21. Nailing of subtrochantericfractures • Poor reduction • Wrong entry point
- 22. Therapeutic option 5 •Proximal femoral nail (PFN, standard size)
- 23. Long PFN • LongPFN - proximal angle - oval locking hole - hip screw for locking
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- 27. Fracture fragments aredevitalized by Trauma Surgery Impaired healing Risk of infection
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- 29. Typical dislocation ofproximal fragment Patient positioning abduction nail introduction is problematic ! leg in strong adduction
- 30. Nailing UFN Insertion point Fossa piriformis LongPFN Insertion point Trochanter tip
- 31. Nailing Open reduction Temporaryfixation - forceps, cerclage wires
- 32. Use of IMnail as a reduction tool
- 33. Conclusion Option 1: IMnail • Closed reduction will be difficult • Don’t be afraid to open fracture to obtain a reduction • Correct entry point is crucial • Long PFN has some advantages
- 34. Summary • Good reductionis essential • Correct entry point • Open reduction is often required • Plating is better than poor nailing