A Intermediate Evaluation and Management 1 Obtains focused history and performs focused exam mechanism of injury check neurovascular status compare extremity to contralateral side impacted and stress fractures no obvious clinical deformity minor discomfort with active or passive hip range of motion, muscle spasms at extremes of motion pain with percussion over greater trochanter displaced fractures leg in external rotation and abduction, with shortening 2 Interpret AP pelvis and cross-table lateral, and full length femur film of ipsilateral side consider obtaining dedicated imaging of uninjured hip to use as template intraop traction-internal rotation AP hip is best for defining fracture type CT scan with 3-D reconstruction recommended with comminution and segmentation 3 Interacts with consultants regarding optimal patient management timing of surgery elderly patients with hip fractures should be brought to surgery as soon as medically optimal medical management the benefits of early mobilization cannot be overemphasized improved outcomes in medically fit patients if surgically treated less than 4 days from injury 4 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 5 Provides post-operative management and rehabilitation postop: 2-3 Week postoperative visit <br> wound check diagnose and management of early complications<br /> remove sutures check biplanar films of the hip postop: ~ 3 month postoperative visit <br> advance to weightbearing as tolerated check biplanar radiographs B Advanced Evaluation and Management 1 Comprehensive assessment of fracture patterns on imaging studies recognize reverse obliquity fractures 2 Garden classification Type I Incomplete, valgus impacted Type II Complete fx. nondisplaced Type III Complete, displaced < 50% Type IV Complete, displaced 3 Pauwels classification Type I < 30 deg from horizontal Type II 30 to 50 deg from horizontal Type III > 50 deg from horizontal (most unstable with highest risk of nonunion and AVN) 4 Interpretation of diagnostic studies for fragility fractures with appropriate management and/or referral 5 Arranges for long term management of geriatric patients management of bone health discharge planning to long term care 6 Completes comprehensive pre-operative planning with alternatives sliding hip screw or cephalomedullary nail hemiarthroplasty total hip arthoplasty 7 Modifies and adjusts post-operative treatment plan as needed 8 Provides prohylaxis and manages thromboemblotic disease 9 Capable of treating intraoperative and postoperative complications C Preoperative H & P 1 Obtain basic history and physical exam check neurovascular status compare extremity to uninjured side identify associated injuries and comorbidities identify patient comorbidities and ASA status (predictor of mortality) screen medical studies to identify and contraindications for surgery 2 Order basic imaging studies obtain AP pelvis and cross-table lateral, and full length femur films present of ipsilateral side 3 Perform operative consent including listing potential complications describe complications of surgery including osteonecrosis nonunion infection heterotopic bone formation thigh pain
E Preoperative Plan 1 Radiographically template the fracture identify fracture pattern 2 Template instrumentation use contralateral side to measure for instrumentation 3 Execute surgical walkthrough verbally describe steps of the procedure to the attending prior to the start of the case describe potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation Two Gelpi retractors Dental Pic Terminally threaded Shantz Pins Small Medium and large Tenaculum Clamps 130 Degree blade plate Mini fragment set 2 Room setup and equipment Fracture table C-arm 3 Patient positioning patient is placed supine with folded sheet placed under the upper buttock on the effected side G Superficial Dissection of Modified Smith Peterson Approach 1 Make the incision from ASIS curve inferiorly in the direction of the lateral patella for 8-10 cm 2 Identify gap between sartorius and tensor fasciae latae dissect through subcutaneous fat identify and avoid lateral femoral cutaneous nerve 3 Incise fascia on medial side of tensor fascia latae 4 Detach origin of tensor fasciae lata on iliac to develop internervous plane ligate the ascending branch of the lateral femoral circumflex artery (crosses gap between sartorius and tensor fascia latae) H Deep Disection 1 Identify plane between rectus femoris and gluteus medius detach rectus femoris from both its origins 2 Expose and dislocate the hip retract rectus femoris and iliopsoas medially and gluteus medius laterally expose the hip capsule adduct and externally rotate the hip to place the capsule on stretch incise capsule with a longitudinal or T-shaped capsular incision dislocate hip with external rotation after capsulotomy is complete I Fracture Reduction 1 Visual and clear fracture line use a freer elevator and dental pick along with saline irrigation to clear the fracture of infolded soft tissue and clotted blood 2 Obtain reduction use a K wire or 4mm Schantz half pin to manipulate the fracture reduction use traction to manipulate the distal segment of the fracture J Provisional Fixation 1 Obtain provisional fixation place a pointed tenaculum or K wire across the fracture for provisional fixation. for comminuted fractures use a small plate with unicortical screws 2 Check reduction with AP/Lateral views with C-arm K Cannulated Screw Placement 1 Make a separate lateral incision place incision in line with projected axis of the reduced femoral neck for definitive fixation may be single or three small incision 2 Use C-arm and a parallel drill guide to direct guidepins for the cannulated screws the first screw should directed tangential to and contiguous with the calcar at the level of the fracture on AP view the first screw should bisect the head and the neck on the lateral view starting the screws below the level of the lesser trochanter should be avoided to minimize iatrogenic subtrochanteric fracture 3 Advance screws under fluoroscopic guidance place 3 or 4 parallel cannulated screws directed from the lateral proximal femur into the head to provide good fixation. 4 Confirm position with fluoroscopy L Wound Closure 1 Irrigation, hemostasis, and drain copiuosly irrigate the surgical wound 2 Deep closure use 0-vicryl for deep fascia 3 Superficial closure use 3-0 vicryl for subcutaneous tissue use 3-0 nylon for skin 4 Dressing and immediate immobilization place soft dressings over incision
O Perioperative Inpatient Management 1 Write comprehensive admission orders IV fluids prescribe DVT prophylaxis pain control advance diet as tolerated foley out when ambulating check appropriate labs wound care remove dressings POD 2 2 Appropriately orders and interprets basic imaging studies check radiographs of the femur in post op 3 Appropriate medical management and medical consultation foley out when ambulating 4 Initiate Physical Therapy POD 1 mobilize with the weight of leg ambulation 5 Discharges patient appropriately pain meds outpatient PT schedule follow up appointment in 2 weeks R Complex Evaluation and Management 1 Develops unique, complex post-operative management plans