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Ten tips presentation
Dr. Abdalla Mutwakil Gamal, a medical officer and orthopedic trauma director with extensive training and over 100 publications, outlines key tips for intertrochanteric fracture management, emphasizing the importance of planning and execution in surgical procedures. Notable instructions include avoiding lateral wall screws, proper placement of nails, and careful attention to fracture stability during treatment. The document serves as a guideline for orthopedic surgeons in optimizing fracture fixation techniques.
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Ten tips presentation
- 1. Abdalla Mutwakil Gamal MedicalOfficer Mr Mohammed Babiker Unit Department of Orthopedic Surgery National Ribat Teaching Hospital Khartoum, Sudan
- 3. An InstructionalCourse Lecture, American Academy of Orthopaedic Surgeons Trained at the Mayo Clinic Director of orthopedic trauma Academic chairman for the Orthopedic Faculty Practice Professor at the University of Central Florida College of Medicine Award-winning researcher 100+ peer reviewed publications and book chapters 20+ patents and has developed multiple innovative implants for fracture fixation and joint replacement.
- 4. 1948-present Thejournal is the official publication of the: • British Orthopaedic Association • Canadian Orthopaedic Association • New Zealand Orthopaedic Association • Australian Orthopaedic Association, and • Sociedade Brasileira de Orthopedia e raumatologia. Impact factor: 3.581 (2017)
- 8. Tip 1:Use the Tip-to-Apex Distance Tip 2: ‘‘No Lateral Wall, No Hip Screw’’ Tip 3: Know the Unstable Intertrochanteric Fracture Patterns, and Nail Them Tip 4: Beware of the Anterior Bow of the Femoral Shaft Tip 5: When Using a Trochanteric Entry Nail, Start Slightly Medial to the Exact Tip of the Greater Trochanter Tip 6: Do Not Ream an Unreduced Fracture
- 9. Tip 7:Be Cautious About the Nail Insertion Trajectory, and Do Not Use a Hammer to Seat the Nail Tip 8: Avoid Varus Angulation of the Proximal Fragment—Use the Relationship Between the Tip of the Trochanter and the Center of the Femoral Head Tip 9: When Nailing, Lock the Nail Distally if the Fracture Is Axially or Rotationally Unstable Tip 10: Avoid Fracture Distraction When Nailing
- 10. Planning: • Nail orScrew? • Nail or screw properties Execution: • Open • Reduce • Fix • Close
- 11. Planning: • Nail orScrew? (Tip 2 & 3) • Nail or screw properties? (Tip 4) Execution: • Open • Reduce (Tip 6) • Fix (Tip 5, 7 & 10 when nailing)(Tips 1 & 8 for position)(Tip 9 for locking) • Close
- 15. A REVERSE OBLIQUITY FRACTURE. ATRANSTROCHANTERIC FRACTURE
- 16. A FOUR-PART FRACTUREWITH A LARGE POSTEROMEDIAL FRAGMENT A FRACTURE WITH SUBTROCHANTERIC EXTENSION.
- 19.
- 23. Nailing: Tip5, 7 & 10 Position: Tips 1 & 8 Locking: Tip 9
- 31. Planning: • Nailor Screw? • Nail or screw properties Execution: • Open • Reduce • Fix • Close Tip 2: ‘‘No Lateral Wall, No Hip Screw’’ Tip 3: Know the Unstable Intertrochanteric Fracture Patterns, and Nail Them
- 32. Planning: • Nailor Screw? • Nail or screw properties Execution: • Open • Reduce • Fix • Close Tip 4: Beware of the Anterior Bow of the Femoral Shaft
- 33. Planning: • Nailor Screw? • Nail or screw properties Execution: • Open • Reduce • Fix • Close Nothing
- 34. Planning: • Nailor Screw? • Nail or screw properties Execution: • Open • Reduce • Fix • Close Tip 6: Do Not Ream an Unreduced Fracture
- 35. Planning: • Nailor Screw? • Nail or screw properties Execution: • Open • Reduce • Fix - Nailing • Close Tip 5: When Using a Trochanteric Entry Nail, Start Slightly Medial to the Exact Tip of the Greater Trochanter Tip 7: Be Cautious About the Nail Insertion Trajectory, and Do Not Use a Hammer to Seat the Nail Tip 10: Avoid Fracture Distraction When Nailing
- 36. Planning: • Nailor Screw? • Nail or screw properties Execution: • Open • Reduce • Fix - position • Close Tip 1: Use the Tip-to-Apex Distance Tip 8: Avoid Varus Angulation of the Proximal Fragment—Use the Relationship Between the Tip of the Trochanter and the Center of the Femoral Head
- 37. Planning: • Nailor Screw? • Nail or screw properties Execution: • Open • Reduce • Fix - Locking • Close Tip 9: When Nailing, Lock the Nail Distally if the Fracture Is Axially or Rotationally Unstable
Editor's Notes
- #30 Varus angulation of the proximal fragment increases the lever arm on the fixation since it makes the femoral neck more horizontal and therefore functionally longer when body weight is applied. This also results in the femoral head fixation being placed more superiorly in the head than is ideal and increases the risk of the device cutting out of the femoral head. It can be difficult to determine the appropriate femoral neck-shaft angle in a patient with an intertrochanteric fracture. When using an intramedullary nail for fixation of an intertrochanteric fracture, most surgeons choose a nail with a 130 neck-shaft configuration (Figs. 13 and 14). It is important to know the neckshaft angle of the device that is being used. One way to assess varus or valgus position during surgery is to look at the relationship between the tip of the greater trochanter and the center of the femoral head. These two points should be coplanar. If the center of the femoral head is distal to the tip of the greater trochanter, the reduction is in varus. If the center of the head is proximal to the greater trochanter, the reduction is in valgus. Preoperative plain radiographs of the uninjured hip can be used to assess the patient’s normal neck-shaft angle as the two sides are normally symmetric. Varus and high lag-screw placement are associated with an increased frequency of failure of fixation with an intramedullary nail and sliding hip screw20,21. (Fig. 13 A well-aligned fracture. Note the central position of the lag screw in the femoral head. Fig. 14 Radiograph showing the relationship between the tip of the greater trochanter and the center of the femoral head. Normally, this relationship is coplanar. Here, the proximal fragment is in varus, the starting point is lateral, and the screw is high in the head.)
- #32 The unstable patterns include reverse obliquity fractures, transtrochanteric fractures, fractures with a large posteromedial fragment implying loss of the calcar buttress, and fractures with subtrochanteric extension (Figs. 4 through 7)3-5,9,12-16.