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Average 4.2 of 50 Ratings
Which of the following methods accurately describes the measurement of tip-apex-distance as it relates to placement of a lag screw in the femoral head?
Summation of the distance between the end of the screw and the apex of the femoral head on AP and lateral radiographs
Distance from the acetabular teardrop to the tip of the screw on an AP radiograph of the hip
Multiplication of the distance between the end of the screw and the apex of the femoral head on AP and lateral radiographs
Distance from the center of the lesser trochanter to the tip of the screw on an AP hip radiograph
Summation of the distance between the tip of the greater trochanter and end of the screw on AP and lateral hip radiographs
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TIp-apex distance (TAD) as it relates to a lag screw in the femoral head is the summation of the distance between the end of the screw and the apex of the femoral head on AP and lateral radiographs. This is shown in Illustration A.
TAD is a useful intraoperative indicator of deep and central placement of the lag screw in the femoral head, regardless of whether a nail or a plate is chosen to fix a fracture. A TAD of <25mm has been shown to minimize the risk of fixation cut-out in stable and unstable intertrochanteric hip fractures.
Baumgaertner et al examined factors leading to the failure of sliding hip screws (SHS) in the treatment of 198 intertrochanteric fractures. They determined that the tip-apex distance (TAD) is a reproducible, standard measurement to predict SHS failure. The average TAD for successful fractures was 24mm while the average TAD for failures was 38mm. No screw with a TAD <25mm failed. Calculation of the TAD is shown in Illustration B.
Kyle et al reviewed 622 intertrochanteric fractures. For unstable patterns, a SHS was superior to a fixed angle nail. Early ambulation and weight bearing contributed to improved results.
Illustrations B and C show a lag screw with an excessive TAD, and subsequent failure of fixation.
Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM.
J Bone Joint Surg Am. 1995 Jul;77(7):1058-64. PMID: 7608228 (Link to Abstract)
Kyle RF, Gustilo RB, Premer RF.
J Bone Joint Surg Am. 1979 Mar;61(2):216-21. PMID: 422605 (Link to Abstract)
Please rate question.
Average 3.0 of 28 Ratings
Which of the following deformities is most likely to occur with dynamic hip screw fixation of unstable left sided standard obliquity hip fractures?
Posterior spike displacement of the proximal fragment
Anterior spike displacement of the proximal fragment
Lateral displacement of the proximal fragment relative to the distal fragment
Shortening of the proximal fragment relative to the distal fragment
Medial displacement of the proximal fragment in relation to the distal fragment
Left-sided unstable intertrochanteric hip fractures are at increased risk of malreduction compared to unstable right-sided fractures fixed with dynamic hip screws. In left-sided fractures the rotational torque imparted to the proximal head and neck fragment can cause loss of reduction leading to potential failures of fixation. With these left sided injuries, the rotational torque can cause an anterior spike, whereas with right-sided injuries the rotational torque causes compression and reduction of the fracture. In addition, if a nail is used for these injuries and the proximal fracture fragment is not being held by the nail itself, this phenomenon can be seen as well.
Mohan et al conducted a study to assess the effect of clockwise rotational torque onto the fracture configuration in unstable and stable intertrochanteric fractures fixed with a dynamic hip screw construct. They found that 11 out of 30 unstable fractures showed an anterior spike (flexion malreduction) in left-sided fixations due to clockwise torque. This malreduction was not present in right-sided or stable fractures.
Illustrations A and B are images from Mohan et al's study showing the rotational affect on the fracture with placement of a dynamic hip screw.
Mohan R, Karthikeyan R, Sonanis SV.
Injury. 2000 Nov;31(9):697-9. PMID: 11084157 (Link to Abstract)
Average 3.0 of 52 Ratings
A 74-year-old female falls from a standing height and sustains the fracture shown in Figure A. The occurrence of this injury most increases her risk of sustaining which of the following fractures?
Distal radius fracture
Distal fibula fracture
Distal humerus fracture
Clinton et al performed a Level 2 study of 8049 women that demonstrated that proximal humeral fractures independently increased the risk of a subsequent hip fracture. The risk was more than five times in the first year after the humeral fracture but was not associated with a significant increase in the hip fracture risk in subsequent years.
Johnell et al performed a Level 4 review that found that men and women had an increased risk of hip, forearm and spine fractures following a prior spine, hip or shoulder fracture.
Schousboe et al performed a Level 2 investigation of 9516 community-dwelling elderly women and found that 521 hip fractures occurred after 10 years of follow-up. They found that prior non-spine fractures, non-hip fractures, and prevalent moderate to severe radiographic vertebral fractures were modestly associated with incident hip fracture.
Clinton J, Franta A, Polissar NL, Neradilek B, Mounce D, Fink HA, Schousboe JT, Matsen FA 3rd.
J Bone Joint Surg Am. 2009 Mar 1;91(3):503-11. PMID: 19255209 (Link to Abstract)
Johnell O, Kanis JA, Odén A, Sernbo I, Redlund-Johnell I, Petterson C, De Laet C, Jönsson B.
Osteoporos Int. 2004 Mar;15(3):175-9. Epub 2003 Dec 23. PMID: 14691617 (Link to Abstract)
Schousboe JT, Fink HA, Lui LY, Taylor BC, Ensrud KE.
J Bone Miner Res. 2006 Oct;21(10):1557-64. PMID: 16995810 (Link to Abstract)
Average 1.0 of 88 Ratings
Which of the following factors has been shown to be the strongest predictor of screw cutout of a dynamic compression hip screw used for an intertrochanteric femur fracture?
Age of the patient
Intrinsic stability of the fracture
Quality of reduction
Angle of the sideplate
Illustration A found below depicts the method to calculate Tip-apex distance (TAD). The tip-apex distance is the sum of the distances from the tip of the lag screw to the apex of the femoral head as seen on the AP and lateral radiographs.
Baumgaertner et al reported that he had no screws cut out if the tip-apex distance was less than 25mm. Tip-apex distance was the strongest predictor of cutout. Increasing age of the patient, poor reduction, use of a high angle sideplate, and unstable fracture were weaker predictors of cutout.
Kyle et al demonstrated that obtaining an anatomic reduction when using a sliding hip screw with intertrochanteric fractures leads to the best radiographic and clinical outcomes.
Average 4.0 of 16 Ratings
A patient with an intertrochanteric hip fracture undergoes reduction and dynamic hip screw application. The post-operative radiographs demonstrate that the lag screw is superior in the femoral head with a tip-apex distance of 40 millimeters. This patient is at increased risk of what complication?
lag screw cutout
lag screw breakage
Baumgaertner et al in their classic study in 1995 determined that the position of the lag screw in the femoral head influenced the risk of cutout of a dynamic hip screw construct in treatment of intertrochanteric fractures. They had no cutouts if the tip-apex distance on the combined AP and lateral radiographs was less than 25 millimeters. Subsequent studies demonstrated a decreased cutout rate once people were aware of the tip-apex distance importance.
Baumgaertner MR, Solberg BD
J Bone Joint Surg Br. 1997 Nov;79(6):969-71. PMID: 9393914 (Link to Abstract)
Templeman D, Baumgaertner MR, Leighton RK, Lindsey RW, Moed BR.
Instr Course Lect. 2005;54:409-15. PMID: 15948470 (Link to Abstract)
Average 4.0 of 20 Ratings
Which of the following statements is true regarding treatment of intertrochanteric hip fractures with an intramedullary nail versus a sliding hip screw?
The use of intramedullary nail has increased in the last ten years
The use of sliding hip screws has increased in the last ten years
Medicare reimbursement is more for a sliding hip screw
Intramedullary nails have demonstrated superior outcomes in randomized-controlled studies
Sliding hip screw is superior for treatment of reverse obliquity intertrochanteric fractures
The use of intramedullary (cephalomedullary) devices has increased in the last ten years despite a lack of evidence to support superiority over extramedullary implants (sliding hip screws)
Intertrochanteric hip fractures remain one of the most common injuries managed by Orthopaedic surgeons. The optimal form of surgical stabilization for these injuries has been a topic of debate, however several recent studies have demonstrated equivalent outcomes with long cephalomedullary nails and sliding hip screws.
Anglen et al. reviewed the database of orthopaedic surgeons taking their oral board examination. The authors found that the use of intramedullary nails for intertrochanteric hip fractures dramatically increased from 3% in 1999 to 67% in 2006. The authors calls attention to the fact that reimbursement was higher until 2010 for intramedullary nails despite a lack of evidence demonstrating superiority.
Forte et al. evaluated geographic variation in the use of intramedullary nails to treat intertrochanteric hip fractures. The authors found significant regional variation in the use of these devices despite similarities in the treatment populations.
Barton et al. conducted a Level 1 prospective randomized controlled study comparing long cephalomedullary nails with sliding hips screws in the treatment of unstable intertrochanteric fractures (AO/OTA 31-A2). The authors found no significant difference in any of the measured variables when comparing the two devices.
Answer 2: The use of the sliding hip screw has decreased despite equivalence with cephalomedullary nails
Answer 3: Until 2010 Medicare reimbursement was more for cephalomedullary nails.
Answer 4: Intramedullary nails have not been shown to have superior outcomes in multiple studies
Answer 5: Sliding screws have been shown to have worse outcomes for reverse obliquity fractures
Anglen JO, Weinstein JN.
J Bone Joint Surg Am. 2008 Apr;90(4):700-7. PMID: 18381305 (Link to Abstract)
Forte ML, Virnig BA, Kane RL, Durham S, Bhandari M, Feldman R, Swiontkowski MF.
J Bone Joint Surg Am. 2008 Apr;90(4):691-9. PMID: 18381304 (Link to Abstract)
Barton TM, Gleeson R, Topliss C, Greenwood R, Harries WJ, Chesser TJ.
J Bone Joint Surg Am. 2010 Apr;92(4):792-8. PMID: 20360500 (Link to Abstract)
Average 2.0 of 25 Ratings
An 82-year-old female sustains an intertrochanteric hip fracture and is treated with a sliding hip screw. What is the most appropriate definitive step in treating the failure seen in figure A?
Valgus proximal femoral osteotomy
Total hip arthroplasty
Revision open reduction and internal fixation
Proximal femoral resection
Figure A shows superior cutout of the lag screw from the sliding hip screw as well as the superior cannulated screw used for an "antirotation" device.
In the referenced review article by Haidukewych and Berry, salvage of failed treatment of hip fractures in the elderly is limited by bone quality and comorbidities. They recommend total hip arthroplasty in this instance to restore function, decrease pain, and limit periods of immobilization. They mention that the major challenges for arthroplasty are: assessing the need for acetabular resurfacing, selecting the femoral implant, and managing the greater trochanter.
Haidukewych GJ, Berry DJ.
J Am Acad Orthop Surg. 2005 Mar-Apr;13(2):101-9. PMID: 15850367 (Link to Abstract)
Average 3.0 of 19 Ratings
Which of the following is not an appropriate implant for treatment of the fracture seen in Figure A?
Proximal femoral locking plate
95 degree blade plate
Sliding hip screw
The image shows a reverse obliquity intertrochanteric hip fracture.
According to the referenced article by Haidukewych et al, unstable peritrochanteric hip fractures have a worse outcome (failed in 9/16 cases) if treated with a sliding hip screw. Two additional factors that were found to have a strong correlation with postoperative failure (nonunion, loss of reduction) were poor reduction and poor implant placement. In this study, fixed angle devices were superior. Intramedullary fixation has the added advantage of a shorter lever arm and less potential for fracture collapse and limb shortening. The IMN also acts as a medial buttress.
According to Sanders et al, the dynamic condylar screw (DCS) can also be used in subtrochanteric models, but should not be used if extensive comminution is seen, as they reported a high failure rate with DCS in these fractures if highly comminuted. They report a 77% overall union rate with this device.
Haidukewych GJ, Israel TA, Berry DJ.
J Bone Joint Surg Am. 2001 May;83-A(5):643-50. PMID: 11379732 (Link to Abstract)
Sanders R, Regazzoni P.
J Orthop Trauma. 1989;3(3):206-13. PMID: 2809821 (Link to Abstract)
Average 2.0 of 39 Ratings
Anterior perforation of the distal femur from antegrade femoral nailing has been attributed to what factor?
Mismatch of the radius of curvature of implant and bone
Usage of too large an implant
Lateral patient positioning
Lateral proximal starting point
Anterior perforation of the femur has been attributed to a simple mismatch in the radius of curvature of implants and the apex anterior bowed femur.
The radius of curvature is generally smaller (114-120 cm) than many earlier generation femoral nails (up to 300 cm), and the referenced article by Ostrum et al describes a case series of 3 such patients with subtrochanteric fractures. He noted that the difference in femoral anteroposterior bow between the bone and the implant is a contributing factor to distal femoral anterior cortex penetration in intramedullary nailing of subtrochanteric fractures.
Illustration A shows an example of a nail penetrating the anterior femoral cortex.
Ostrum RF, Levy MS
J Orthop Trauma. 2005 Oct;19(9):656-60. PMID: 16247312 (Link to Abstract)
Average 3.0 of 14 Ratings
A 72-year-old male sustains the injury shown in Figure A as a result of a fall from a ladder. Following internal fixation for this fracture with a sliding hip screw, which of the following factors has been shown to be associated with increased collapse or sliding displacement?
Use of a long intramedullary device
Use of a short intramedullary device
Use of external fixation
Post operative weight bearing status
Intraoperative fracture of the lateral femoral wall
Intertrochanteric hip fractures with lateral wall fractures should be treated with an intramedullary device as opposed to a sliding hip screw, as the intact lateral wall provides a buttress for the proximal fragment facilitating fracture impaction as well as rotational and varus stability.
Palm et al showed that 22% of patients with a fractured lateral femoral wall underwent reoperation for collapse of fracture compared to 3% with an intact lateral femoral wall. Interestingly, 74% of the lateral proximal femoral wall fractures were iatrogenic during the procedure itself.
Gotfried et al reported on 24 patients with postoperative intertrochanteric hip fracture collapse and noted that this complication followed fracture of the lateral wall in every instance and resulted in a protracted period of disability until fracture healing. They recommend care when drilling at the base of the lateral wall intraoperatively.
Lindskog et al review the diagnosis, treatment, as well as biomechanical reviews of treatment options for unstable intertrochanteric hip fractures.
Answer 1, 2, and 3: No difference in collapse has been shown between long or short intramedullary devices and a sliding hip screw in stable intertrochanteric hip fractures.
Answer 4: Early postoperative weightbearing is the goal after repair, and no differences have been shown in collapse rates with different weight bearing protocols.
Palm H, Jacobsen S, Sonne-Holm S, Gebuhr P.
J Bone Joint Surg Am. 2007 Mar;89(3):470-5. PMID: 17332094 (Link to Abstract)
Clin. Orthop. Relat. Res.. 2004 Aug;(425):82-6. PMID: 15292791 (Link to Abstract)
Lindskog DM, Baumgaertner MR.
J Am Acad Orthop Surg. 2004 May-Jun;12(3):179-90. PMID: 15161171 (Link to Abstract)
Which of the following is a recognized predictor of mortality after hip fracture?
American Society of Anesthesiologist (ASA) classification
Post-operative weight bearing status
Fixation device used
Type of anesthetic used
American Society of Anesthesiologist (ASA) classification is predictive of post-surgical mortality in hip fracture patients.
The ASA classification (detailed in Illustration A) was initially developed in 1963 and has been shown to be predictive of post-surgical mortality in hip fracture patients. Basic categories are as follows: 1= normal, healthy; 2= mild systemic disease; 3= severe systemic disease, not incapacitating; 4= severe incapacitating systemic condition, constant threat to life; 5= moribund patient; 6 = brain dead, organs being donated.
Richmond et al. looked at 836 patients treated for a hip fracture and found that this injury is not associated with significant excess mortality among patients older than age 85. However, in younger patients, those with ASA classifications of 3 or 4 have significant excess mortality following hip fracture that persists up to 2 years after injury.
Holt et al. investigated the relationship between a number of patient and management variables and mortality after surgery for fracture of the hip. Data relating to 18,817 patients were obtained from the Scottish Hip Fracture Audit database. They found that type of anesthetic did not adversely affect the 30 or 120 day mortality rate.
Richmond J, Aharonoff GB, Zuckerman JD, Koval KJ.
J Orthop Trauma. 2003 Jan;17(1):53-6. PMID: 12499968 (Link to Abstract)
Holt G, Smith R, Duncan K, Finlayson DF, Gregori A.
J Bone Joint Surg Br. 2008 Oct;90(10):1357-63. PMID: 18827248 (Link to Abstract)
Average 3.0 of 13 Ratings
A 55-year-old male is involved in a motor vehicle accident and sustains the injury seen in Figure A. What is the most appropriate treatment for this type of injury?
Percutaneous screw fixation
Cephalomedullary nail fixation
The radiographs demonstrate a reverse obliquity intertrochanteric femur fracture. Compared to the more stable intertrochanteric femur fracture, a reverse oblique intertrochanteric hip fracture is not optimally treated with a sliding hip screw. Compression along a sliding hip screw is designed to create compression along the plane of the fracture, however in a reverse obliquity fracture pattern as seen here, shear force is created causing medial displacement of the femoral shaft and screw cutout.
Haidukewych et al showed in their retrospective review of 55 consecutively treated reverse obliquity intertrochanteric fractures, that patients treated with a sliding hip screw had nearly a 56% failure rate (9/16). The failure rate of patients treated with a blade plate was only 13%.
Sadowski et al showed in their prospective randomized trial in patients with a reverse obliquity or transverse intertrochanteric fracture who were randomized to either a 95 degree screw-plate or cephalomedullary nail a much higher failure rate for the plate-screw implant. Implant failure was seen in 7/19 patients treated with the 95 degree screw plate and only 1/30 in the intramedullary nail group. Both articles support the use of a blade plate or cephalomedullary nail for reverse obliquity fractures.
An example of screw cutout and medial displacement is seen in Illustration A.
Sadowski C, Labbeke A, Saudan M, Riand N, Stern R, Hoffmeyer P
J Bone Joint Surg Am. 2002 Mar;84-A(3):372-81. PMID: 11886906 (Link to Abstract)
Average 4.0 of 17 Ratings
All of the following implants offer adequate fracture fixation of the injury shown in Figure A EXCEPT:
Trochanteric entry point cephalomedullary nail
Piriformis fossa entry point cephalomedullary nail
Dynamic hip screw
Fixed angle blade plate
95 degree dynamic condylar screw
Currently, cephalomedullary nails are used widely for reverse obliquity fractures because they limit medialization of the shaft fragment unlike sliding hip screws.
The Haidukewych et al study quoted demonstrated the superiority of fixed angle devices such as blade-plates or dynamic condylar screws over the sliding (or dynamic) hip screws. Reverse obliquity intertrochanteric fractures of the femur are recognized as biomechanically different from standard intertrochanteric fractures. The rate of failure of internal fixation for this fracture pattern was higher than the rates in most reports of internal fixation of intertrochanteric fractures devices.
Average 4.0 of 24 Ratings
When treating a stable 2-part intertrochanteric hip fracture with a sliding hip screw construct, what is the minimum number of screw holes that are needed in the side plate for successful fixation?
A two part stable intertrochanteric femur fracture can be treated with a sliding hip screw, with good biomechanical and clinical results.
The referenced article by Bolhofner et al reviews a series of 69 patients with a sliding hip screw and two hole side plate and notes that they did not have any failure of the side plate construct.
The referenced article by McLoughlin et al is a biomechanical evaluation of 2 versus 4 hole plates and found that peak load in the failure test was not found to be statistically different between the two-hole and four-hole designs. In cyclic testing, the two-hole configuration exhibited statistically smaller fragment migration in both shear and distraction than the four-hole design.
Bolhofner BR, Russo PR, Carmen B.
J Orthop Trauma. 1999 Jan;13(1):5-8. PMID: 9892117 (Link to Abstract)
McLoughlin SW, Wheeler DL, Rider J, Bolhofner B.
J Orthop Trauma. 2000 Jun-Jul;14(5):318-23. PMID: 10926237 (Link to Abstract)
Average 3.0 of 32 Ratings
HPI - • 88 year old woman presented to the ER with chief complaint of left hip pain
- Patient denied any hip pain prior to this fall
• Symptoms began after a mechanical fall directly onto her hip
• Independent community ambulator
• CT head done due to left hand weakness and stroke ruled out
• Cleared by medicine and anesthesia to undergo surgery
Are the xrays above adequate to proceed with treatment?
HPI - pedestrian hit by a car 4 days earlier. Isolated orthopaedic injury. Has solid organ lacerations. Currently day one post op.
IT DHS performed an no GT fx noticed intra-op.
Now post op xrays show a displaced GT fx.
How would you treat the postop displaced GT fx (seen in Post-procedure P1 films below) given the patients abdominal injuries?
HPI - CA and head truma
Would you obtain additional imaging?
HPI - 63 yo male with fall onto right hip
How would you treat this case?
HPI - 69-y/o male status-post 10-foot fall from the roof. He has a history of CABG 3 years ago, and minimal intermittent pre-existing left hip discomfort but not inhibitive to daily activites and is currently not requiring any treatments for DJD of the hips.
Would you attempt to fix (cephalomedullary nail) or proceed with total hip arthroplasty with calcar replacing femoral stem?
HPI - History of fall at home 24 hours back leading to fracture proximal end femur
What are the treatment option
HPI - patient was playing beach volleyball and experienced a sudden pain and fall after a minor twist while playing
How would you treat this patient's injury?
HPI - felt home
How to treat this fracture?
HPI - Walker-assisted low-level community ambulator, mildly demented 79 y/o female who had non-syncopal fall while walking to bathroom.
What would you do with this fracture?
HPI - case of fall 2 mths ago operated elsewhere for hip fracture.post surgery 2 mths complaining of pain increasing on weight bearing(on walker support)
Would you continue with observation or revise at this time.
HPI - Had MVC 2 year ago. Operated with DHS twice leading to failure.
Best procedure for revision
HPI - Slip and Fall on the ice
What implant would you use to fix this fracture?
HPI - had a fall 2 days ago on her left hip,
How would you classify this fracture?
HPI - Fracture of the proximal end of femur 1.5 yrs ago. The patient underwent an ORIF with a DHS.
What option would be next in your treatment plan?
HPI - fall from height.injury rt hip.pain.inabilty to stand
How would you treat this comminuted peri-trochanteric hip fracture
HPI - inability to stand after a fall at home.pain in the left hip
What would be your preferred treatment plan
HPI - SImple Fall in nursing home patient
How would you treat this fracture
HPI - RTA
How would you treat this peri-trochanteric hip fracture
HPI - IT # on 23.6.13 , operated else where on 25.6.13 and discharged after 5 days.post op xray was satisfactory.came to me on 5.7.13 for pain ipsilateral knee for 3 days.physio knee had been done 3 days ago.o/e knee effusion was seen.xray was taken.
What next? Reasons for fracture?
HPI - Fall from a standing height 1 day ago
How would you treat this fracture?
HPI - The patient sliped on floor.
How would you treat this patient?
HPI - Fall from standing height 2 days ago
What is your preferred treatment?
HPI - Intertrochanteric fracture 10.2013 , intramedullary nailing with 1 distal screw.
No pain relieve until today 05.2013
What is your treatment?
HPI - Road side accident JUNE 2012 resulting in fracture proximal end femur
Closed reduction and internal fixation with proximal femoral nail
What should be the treatment option of this eight month old nonunion
HPI - A 40-year-old female with h/o gun shot injury to left gluteal region.
What fixation method would you use for this fracture?
HPI - h/o fall at home
HPI - Pain hip. Original surgery performed 4 years ago. Mobility poor with frame.On labs no infection.nothing obvious in pagient biology which can lead to nonunion.
What do you think is the cause of failure of this fixation by short gamma3 nail.
HPI - c/o pain in hip since 15 days. h/o hit by a bike.
what would be further treatment options
HPI - pt s/p mva last night with left segmental femur, right distal femur left proximal humerus, right ulna. looking for opinion on best way to fix left femur
how would you treat left segmental femur
HPI - 4 months back operated with pfn for fracture subtrochanter. no h/o fall or trauma post op. post op un eventful
HPI - 69 yr old obese female with left hip basicervical fx after fall. Patient has hx of multiple falls including healing pubic rami fx on same side. Also has r ankle fx that was in a cast. Osteoporosis workup done. Taken to the OR within 48 hours. Decided to use long cephomedullary device because of her hx of multiple fractures I wanted to protect the femur.
What would you do next?
HPI - History of trauma
Susan Harding, MD, Clin. Associate Professor of Orthopaedic Surgery, Drexel Univ...
This is an example of an intertrochanteric femur fracture being treated with a s...