This document provides surgical tips and tricks for fractures of the femur, including the neck and intertrochanteric regions. For femoral neck fractures, it discusses anatomy, classifications, reduction techniques, fixation methods, and considerations for blood supply. Intertrochanteric fractures are discussed in terms of classification, reduction methods, implant options, and the importance of screw position. Subtrochanteric fractures are also addressed, emphasizing biomechanical advantages of intramedullary nailing and tips for achieving reduction. Throughout, the importance of anatomical reduction and screw positioning is stressed for optimal outcomes.
Screw and plates are most common used devices in orthopedics. However, sometimes we forget their principles, so this presentation hopes to review most their problems. Thank you for your attention!
Screw and plates are most common used devices in orthopedics. However, sometimes we forget their principles, so this presentation hopes to review most their problems. Thank you for your attention!
Can read freely here
https://sethiortho.blogspot.com/
Challenges and Solutions in
Management of Distal Humerus Fractures
Epidemiology
Anatomy
Classification
Controversies and Recent studies
Approach
Implants selection
Plate configuration
Ulnar nerve transposition
Role of total elbow arthroplasty in DHF
Role of hemiarthroplasty in DHF
Metaphyseal comminution –
Anatomic complexity of the distal humerus
Positioning of the plates
TBW –
Skin closure
Osteoporotic nature of the bone –
Less BMD/Thin metaphysis
Screw Pullout strength is low
DHF account for 2% of all adult fractures
The common pattern of fracture
Intraarticular and involves both columns
Bimodal distribution
Peak incidence in young male and in older female patients
Young male – High-velocity injury
Older female - Osteoporosis
The distal humerus is flattened and expanded bony structure
It is composed of lateral and medial columns with the trochlea situated between these columns.
The location of the trochlea is central rather than medial
Formed by Medial SCR + M/Epicondyle
The distal end has 450 angulation with humeral shaft
M/ Epicondyle gives attachment for MCL & Common Flexor Origin
The MCL originates from the undersurface of the medial epicondyle where it is vulnerable to excessive dissection
Ulnar nerve
Formed by Lateral SCR and L/Epicondyle and Capitulum
Distal end has 200 with humeral shaft
L/ epicondyle gives attachment for LCL & common extensor origin
Its posterior surface is non articular and can be used as a site for a plate fixation
The lateral column curves anteriorly
Placement of a straight plate on the posterolateral surface of the humerus risks straightening of distal humerus.
The medial column including the medial epicondyle is in line with the humeral shaft.
It forms the center of the triangle
It has 30 - 80 – external rotation & 250 anterior divergent with the shaft
It forms a 40 - 80 degree valgus direction
X-ray -
Anterior-posterior view
lateral View
Traction View – This can help to define articular fragments and aid in pre-operative classification of the fracture.
NCCT – Elbow
Articular surfaces
Position of the fracture fragments
useful for identifying impacted fracture fragments that make reduction challenging
Olecranon Osteotomy Approach – 52-57%
Triceps sparing VS Olecranon osteotomy approach
The lateral column was often the first to fail as a result of excessive varus forces acting on the elbow during normal activities of daily living. Small anterior-posterior diameter
Smaller diameter of the humerus, permitting only one or two short screws for fixation.
Interruption of blood supply to the lateral column
blood supply to the lateral column is also derived from posterior segmental vessels. Sagittal plane plating has less risk of injuring these structures, which may improve the chances of union
Defined as fracture occurring at or proximal to the surgical neck
It is the commonest fracture affecting the shoulder girdle in adults.
Proximal humeral fracture 80% of all humeral fractures.
In pts above the age of 65 years, proximal humeral fractures are the 2nd most frequent upper extremity fractures
ANATOMY -
The proximal humerus is retroverted 35 to 40 degrees relative to the epicondylar axis.
Most common is fall onto outstretched upper extremity from a standing height, in older & osteoporotic woman.
Younger pts present following high energy trauma with significant soft tissue injury.
Less common with excessive shoulder abduction, direct trauma, electric shock and seizures r seizures
Can read freely here
https://sethiortho.blogspot.com/
Challenges and Solutions in
Management of Distal Humerus Fractures
Epidemiology
Anatomy
Classification
Controversies and Recent studies
Approach
Implants selection
Plate configuration
Ulnar nerve transposition
Role of total elbow arthroplasty in DHF
Role of hemiarthroplasty in DHF
Metaphyseal comminution –
Anatomic complexity of the distal humerus
Positioning of the plates
TBW –
Skin closure
Osteoporotic nature of the bone –
Less BMD/Thin metaphysis
Screw Pullout strength is low
DHF account for 2% of all adult fractures
The common pattern of fracture
Intraarticular and involves both columns
Bimodal distribution
Peak incidence in young male and in older female patients
Young male – High-velocity injury
Older female - Osteoporosis
The distal humerus is flattened and expanded bony structure
It is composed of lateral and medial columns with the trochlea situated between these columns.
The location of the trochlea is central rather than medial
Formed by Medial SCR + M/Epicondyle
The distal end has 450 angulation with humeral shaft
M/ Epicondyle gives attachment for MCL & Common Flexor Origin
The MCL originates from the undersurface of the medial epicondyle where it is vulnerable to excessive dissection
Ulnar nerve
Formed by Lateral SCR and L/Epicondyle and Capitulum
Distal end has 200 with humeral shaft
L/ epicondyle gives attachment for LCL & common extensor origin
Its posterior surface is non articular and can be used as a site for a plate fixation
The lateral column curves anteriorly
Placement of a straight plate on the posterolateral surface of the humerus risks straightening of distal humerus.
The medial column including the medial epicondyle is in line with the humeral shaft.
It forms the center of the triangle
It has 30 - 80 – external rotation & 250 anterior divergent with the shaft
It forms a 40 - 80 degree valgus direction
X-ray -
Anterior-posterior view
lateral View
Traction View – This can help to define articular fragments and aid in pre-operative classification of the fracture.
NCCT – Elbow
Articular surfaces
Position of the fracture fragments
useful for identifying impacted fracture fragments that make reduction challenging
Olecranon Osteotomy Approach – 52-57%
Triceps sparing VS Olecranon osteotomy approach
The lateral column was often the first to fail as a result of excessive varus forces acting on the elbow during normal activities of daily living. Small anterior-posterior diameter
Smaller diameter of the humerus, permitting only one or two short screws for fixation.
Interruption of blood supply to the lateral column
blood supply to the lateral column is also derived from posterior segmental vessels. Sagittal plane plating has less risk of injuring these structures, which may improve the chances of union
Defined as fracture occurring at or proximal to the surgical neck
It is the commonest fracture affecting the shoulder girdle in adults.
Proximal humeral fracture 80% of all humeral fractures.
In pts above the age of 65 years, proximal humeral fractures are the 2nd most frequent upper extremity fractures
ANATOMY -
The proximal humerus is retroverted 35 to 40 degrees relative to the epicondylar axis.
Most common is fall onto outstretched upper extremity from a standing height, in older & osteoporotic woman.
Younger pts present following high energy trauma with significant soft tissue injury.
Less common with excessive shoulder abduction, direct trauma, electric shock and seizures r seizures
Imaging anatomy fractures of the femurAkram Jaffar
After completion of this session, students should be able to discuss, identify, and describe:
The anatomical factors predisposing to the etiology of a fracture or dislocation.
The anatomy of displacement or deformity.
Imaging anatomy features and how to differentiate from epiphyseal lines.
Anatomy related to correct relocation and alignment.
Anatomical complications of a fracture or dislocation.
Young adult with primary fixation cutting through was treated after six months of initial injury.
Head viability was confirmed by MRI and to have bio mechanical advantage, abduction or valgus osteotmy was carried out resulting in good functional result at the end of 10 months when last seen
Intertrochanteric Fractures: Ten Commandments for How to Get Good Results wit...Vivek Jadawala
Shivashankar, B., Keshkar, S. Intertrochanteric Fractures: Ten Commandments for How to Get Good Results with Proximal Femoral Nailing. JOIO 55, 521–524 (2021). https://doi.org/10.1007/s43465-021-00373-x
The hip joint is a ball and socket joint consisting of the femoral head and acetabulum. This articulation provides multiple planes of movement and is highly congruent. Articular cartilage, consisting of type II collagen, covers the majority of the femoral head. The acetabulum peripherally consists of articular cartilage while the central floor is non-articular and filled with a fatty layer termed the pulvinar. The ligamentum teres arises from both the transverse acetabular ligament and the central non-articular layer of the acetabulum and attaches to the central femoral head. It may play a role in stabilizing the hip joint.
Similar to Surgical tips and tricks in fractures of femur (20)
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
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The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Maxilla, Mandible & Hyoid Bone & Clinical Correlations by Dr. RIG.pptx
Surgical tips and tricks in fractures of femur
1. SURGICAL TIPS AND TRICKS IN
FRACTURES OF FEMUR
DR. Praveen Mehar. J
DNB ORTHO
2. FRACTURE NECK OF FEMUR
ANATOMY :
• Cross section anatomy of femoral head in adult shows that the trabecular
pattern becomes becomes more and more concentrated towards centre with
age.
• This is the reason for central placement of screws or implants in fractures of
femur neck.
3. • Normally the tip of the greater trochanter is at or just above the center of
rotation of head.
• The distance from the center of the femoral head to the tip of the greater
trochanter is normally two to two and a half times the radius of the femoral
head.
• When the proximal femur is viewed from above, it can be seen that the
greater trochanter is not centered on the neck but flares posteriorly some
30°–40°.
• So, the more proximal the point of entry of a fixation device, the more
anterior it must be in order to come into line with the axis of the neck.
• A 90° or 95° device must be inserted in the anterior half of the trochanter,
and any device which is inserted through the shaft into the neck and head
must be inserted into the middle of the lateral surface of the femur.
4. • Any posterior placement along the lateral surface of the shaft results in the
device entering the anterior half of the head, and any anterior insertion results
in the device entering the posterior half of the head.
• Such errors of insertion cannot be corrected by changing the angle of insertion
of the device.
• The angle of insertion of a screw or of an angled device that is to traverse the
neck and enter the head is also given by the anteversion of the neck. Such
devices must be inserted parallel to the plane of anteversion.
5. • The specific configuration of the arterial blood supply of the head is
responsible for its interruption in fractures of the neck.
• The posterior superior and the posterior inferior retinacular vessels arise
from medial circumflex femoral artery. They give epiphyseal arteries through
sub synovial ring to supply head. Lateral femoral circumflex femoral artery
gives branches anteriorly and supply neck.
• So, very very important…..
Posterior vessels --------> supply only head( mainly posterosuperior) and
some neck
Anterior vessels ------- --- > supply only neck.
• This configuration of the vessels must be kept in mind whenever surgically
approaching the neck and head of the femur, and the surgeon must be very
careful not to place retractors around the posterior aspect of the neck, as this
could seriously interfere with the blood supply of the head.
6.
7. FRACTURE NECK OF FEMUR
• CLASSIFICATIONS :
1. Pauwel based on fracture angle
2. Garden based on trabeclar pattern
3. Anatomic –a. subcapital
b. transcervical
c. basicervical
8.
9. METHODS OF REDUCTION OF FRACTURE
• CLOSED
• OPEN
• CLOSED REDUCTION MANEUVRES :
A : IN HIP FLEXION : 1. LEADBETTER
2. SMITH PETERSON
3. FLYNN
B : IN HIP EXTENSION : 1: WHITMAN
2: Mc EVELENNY
3: DEYERLE
10. 1. WHITMAN’S METHOD : TRACTION INTERNAL ROTATION
ABDUCTION
2. LEADBETTER’S METHOD : TRACTION HIP FLEXION 90 DEGREES 45
DEGREE INTERNAL ROTATION FULL FLEXION + ADDUCTION
ABDUCTION+EXTERNAL ROTATION
MOST SUCCESSFUL.
REDUCTION TESTED BY HEEL PALM TEST
3. FLYNN METHOD : MOST ATRAUMATIC.
BASED ON SPIRAL CONFIGURATION OF CAPSULE FIBRES.
HIP FLEXION AND SLIGHT ABDUCTION LATERAL TRACTION
OF NECK INTERNAL ROTATION EXTENSION.
11. IN GENERAL : The mechanism of displacement is simple.
• The femoral head displaces into varus and retroversion as the leg shortens
and the femoral shaft externally rotates.
• The gentlest manipulation under anesthesia with full relaxation, which often
brings about a reduction, consists of applying longitudinal traction and then
gentle internal rotation.
• This is usually done with an image intensifier in place, which allows for an
immediate check of the reduction obtained.
• The traction brings the head out of varus and the internal rotation corrects
the retroversion.
• If this maneuver fails, it can be repeated, but it must be remembered that
any further manipulation increases the risk of rendering the head avascular
14. WHAT IS ADEQUATE REDUCTION ???
• Aim is for an anatomical reduction or one with the head in slight valgus
and with the head in neutral version or minimally anteverted.
• Any degree of residual varus or retroversion is unacceptable, because it
leads to an unacceptable incidence of failure as a result of loss of fixation
and redisplacement.
• Therefore, proper reduction is one of the most essential factors for the
successful treatment of neck fractures.
15.
16. METHODS OF FIXATION
• CANNULATED SCREW FIXATION
• DYNAMIC HIP SCREW
• HEMIARTHROPLASTY
• TOTAL HIP ARTHROPLASTY
17. CANNULATED SCREW FIXATION PEARLS :
•The screws should be inserted parallel to the axis of the neck and parallel to
each other.
•They must be parallel to each other not only to act together as lag screws, but
more importantly, if there is any resorption at the fracture, they must not block
the head from settling down on the neck.
• If the screws are not parallel they can block the shortening, and instead of
backing out they can advance through the head and perforate into the joint.
18. The cancellous screws used for fixation of a subcapital fracture must be parallel to one
another. If the neck should resorb, the screws must be able to back out. If the screws
were not parallel they could penetrate through the head instead
19. TIPS :
• Check for spurt of blood coming from lateral cortex just one finger breadth
above the insertion of gluteus maximus.This is the entry for inferior screw
insertion.
• Screw should be placed at 45 degrees to shaft or parallel to neck or in the
direction of opposire ASIS under c arm visualisation.
• Direction of neck can be checked by putting guidewire directly in the anterior
aspect of neck.
• Palpate for ridge of vastus lateralis and put second wire parallel to first wire.
This passes along the superior border of neck.
• Third wire can be inserted either centre or slight anterosuperior.
20. DECISION MAKING
• Undisplaced Fractures : CC Screw fixation
• Displaced Fractures : ORIF with CC Screws,DHS,
Hemiarthroplasty
• Age : less than 65 years : preserve head with ORIF
More than 65 years : Hemiarthroplasty.
21. INTERTROCHANTERIC FRACTURES
• Intertrochanteric fractures, more correctly referred to as pertrochanteric
fractures, are fractures that occur in the region joining the greater and
lesser trochanters.
• This is the insertion site of large muscle masses and is therefore a region
with a very abundant blood supply.
• Nonunion of these fractures is rare, and if completely neglected these
fractures usually heal with varus shortening and external rotation.
22. • The displacement of fracture fragments depends on the musculotendinous
attachments of the respective fragments.
• The greater trochanter is abducted and externally rotated by gluteus medius
and short external rotators.
• The shaft is displaced posteriorly and medially by adductors and hamstrings.
This results in shortening and varus deformities.
• Dorr classified the morphological anatomy of proximal femur as
Type A Narrow canal, narrow isthmus, thick cortex
Type B Wide canal, wide isthmus but good cortex
Type C Wide canal,wide isthmus, weak cortex.
• The choice of implant has been selected based on the morphological pattern
of proximal femur.
23. CLASSIFICATION
• While several classification systems exist for these fractures, they are all
based on the concept of stability.
• A stable fracture is a simple one that, once reduced and fixed, is
compressed and minimally impacted by the nearly perpendicular weight-
bearing force of single leg stance.
• Unstable fractures due either to comminution, ‘reverse oblique’
orientation, or both, are associated with collapse on axial loading.
• Both the posteromedial cortex and the lateral cortical buttress beneath
the vastus ridge contribute to the stability of these fractures. The
instability increases with the degree of comminution of the posteromedial
cortex. Increased comminution implies less support for axial loading
through cortical contact.
• The lateral cortex beneath the vastus ridge provides the final buttress to
impaction of the fracture after fixation, further contributing to its stability
and avoiding collapse. Incompetence of either of these cortical regions
therefore renders a fracture unstable.
24. REDUCTION OF FRACTURE
CLOSED REDUCTION :
• The reduction of these fractures is carried out on the fracture table with
the aid of image intensification.
• The limb is placed in traction and in slight abduction and internal rotation.
This is usually sufficient to align the femoral head and neck fragment with
the shaft and recreate the patient’s normal neck shaft angle.
• It is important to check on the lateral projection that the shaft has not
sagged posteriorly. If this happens, it must be corrected. Frequently, this
deformity cannot be corrected by simply externally rotating the limb,
although this maneuver will help to realign the fragments.
• Because the shaft has sagged, it must be lifted upwards and held there to
secure reduction.
25. Implant options for the treatment Of intertrochanteric
fractures of the hip
RATIONALE, EVIDENCE, AND RECOMMENDATIONS
A. R. Socci,N. E. Casemyr,M. P. Leslie,M. R. Baumgaertner, From Yale University School of
Medicine,Connecticut, United States
• Stable intertrochanteric fractures : There is currently little evidence of the
superiority of one device over another in the management of these
fractures. The quality of reduction remains paramount, with stable
fractures having direct cortical contact following accurate reduction. There
is a preference for SHS fixation after careful reduction.
• Subtrochanteric and reverse oblique fractures : There is strong evidence
to support the use of intramedullary fixation in subtrochanteric and
reverse oblique fractures. The biomechanics of these fractures are such
that fixation with a SHS is inappropriate, as the line of collapse is not
perpendicular to the fracture line and the lateral cortical buttress cannot
resist collapse.
26. Importance of screw position in intertrochanteric femoral
fractures treated by dynamic hip screw
M. Guvena,∗, U. Yavuzb, B. Kadıo˘glu c, B. Akmand,
V. Kılınc,o˘glu e, K. Unayc, F. Altıntas
Measurement of the distance between the tip of the lag screw to the apex of the
femoral head (X) and the diameter of
the lag screw (D) on the (a) anteroposterior and (b) lateral radiographs. (Tip-apex
index = X anteroposterior x [True diameter / D
anteroposterior] + X lateral x [True diameter / D lateral]).
27. Determination of the screw position in the femoral head according to the Parker’s ratio method
on the (a) anteroposterior and (b) lateral radiographs (Parker’s ratio = ab / ac).
28. • Cut-out of the lag screw has been shown to be the most common cause of
failure and is related to the position of the screw in the femoral head .
• There have been two published methods in the literature, which quantify the
screw position, including tip-apex distance (TAD) and the Parker’s ratio method.
•TAD is the sum of the distance from the tip of the lag screw to the apex of the
femoral head on anteroposterior and lateral radiographs after controlling
for magnification. Baumgaertner and Solberg concluded that the distance
greater than 25mm was a strong predictor of cut-out.
• Parker described a ratio method and reported that cut-out was more frequent
when the screw was placed superiorly and posteriorly on the anteroposterior
and lateral radiographs.
• Femoral head was divided into thirds on the anteroposterior and lateral
radiographs . The ratio of the screw position gave a range of zero to 100 and a
ratio greater than 66 was accepted as a superior and posterior position of the
lag screw on the anteroposterior and lateral radiographs.
29. • On the contrary, Kaufer advised to place the implant more posteriorly and inferiorly .
He concluded that this position placed the tip of the implant into the bone formed by
decussation of tension and compression trabeculae, thus assuring maximum proximal
fragment control.
• Peripheral placement of the lag screw in the femoral head inherently increases TAD.
•However, the placement of the screw in posterior and inferior locations of the femoral
head supports the comminuted posteromedial cortex and the device allows impaction
of the fracture surfaces, shortening the lever arm, decreasing the bending moment, as
well as avoiding cut-out of the screw from the femoral head, consequently.
•The DHS construct allows mechanical load transmission. In stable fracture patterns, it
acts as a tension band producing more force transmission through the medial cortex,
stressing the implant more in tension and less in bending.
• But, in unstable fractures, the lesser trochanter and the part of the calcar femoral are
missing from the mechanical load transmission system because of the lack of bony
support over the medial aspect of the femur.
30. Intertrochanteric Fractures:
Ten Tips to Improve Results
1. Use the tip to apex distance
2. No lateral wall, no hip screw
3. Know the unstable intertrochanteric fracture patterns and nail them
4. Beware of anterior bow of femur during nailing( ideal radius is 1.5-2.2m)
5. When using PFN, start slight medial to exact tip of GT.
6. Be cautious about nail insertion trajectory, and do not use a hammer
to seat the nail.
7. Avoid varus angulation of the proximal fragment. Use the relationship
between the tip of the trochanter and the center of femoral head.
8. Do not ream an unreduced fracture.
9. When nailing, lock the nail distally if the fracture is axially or
rotationally unstable.
10. Avoid fracture ditraction during nailing.
31.
32. Straight nail inserted into a bowed femur. Vigorous impaction or
a bow mismatch may lead to perforation of the distal anterior
femoral cortex
33. The ideal starting point is slightly medial to the exact tip of the
greater trochanter. Note the good position of the guidewire distally
34. A fracture locked in distraction. Note the typical lateral starting
point and the high hip-screw placement.
37. Characteristic appearance of a subtrochanteric femur fracture with (A) varus and
external rotation deformity of the proximal fragment because of the pull of the
abductors and external rotators; the distal fragment is pulled medially
because of the adductors, and (B) flexion is caused by the pull of the iliopsoas.
38. • Implant selection for definitive fixation ends up as a choice between using a blade-plate,
locking-plate, or an IMN construct.
• Overall, one should avoid the use of screw- and side-plate constructs, because outcomes
and high rates of cutout have caused it to fall out of favor.
• Biomechanically, IMN fixation is superior for several reasons.
• First, its increased rigidity, stiffness, and shorter moment arm allows for a
biomechanically stronger construct with decreased strain placed on the implant.
• Spanning the entire length of the femur, IMN allows for a more efficient and shared load
transfer and resists greatly, the deforming forces that occur, primarily, by preventing
excessive medialization of the femoral shaft caused by the pull of the adductors.
• Superior stiffness is inherent in IMN, because of its closed-section design, which yields
bending stiffness similar to that of an intact femur.
• These biomechanical advantages translate into the clinical realm, with primary benefits,
including less softtissue dissection, potentially less blood loss, restoration of the
mechanical axis, and arguably, most importantly, allowance for immediate weight bearing
after fixation as per surgeon’s recommendations.
39. Tips and Tricks in Achieving Reduction Before IMN Placement :
• Supine position >>> Lateral position ( obese patients)
• Percutaneous joysticks
• Femoral distractor
• Finger reduction Tool
• Blocking screws
• Clamp-assisted reduction
• Schanz pins