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Introduction
  • Extracapsular fractures of the proximal femur between the greater and lesser trochanters
  • Epidemiology
    • incidence
      • roughly the same as femoral neck fractures
    • demographics
      • female:male ratio between 2:1 and 8:1
      • typically older age than patients with femoral neck fractures
    • risk factors
      • proximal humerus fractures increase risk of hip fracture for 1 year
  • Pathophysiology
    • mechanism
      • elderly
        • low energy falls in osteoporotic patients
      • young
        • high energy trauma
  • Prognosis
    • nonunion and malunion rates are low
    • 20-30% mortality risk in the first year following fracture
    • factors that increase mortality
      • male gender (25-30% mortality) vs female (20% mortality)
      • higher in intertrochanteric fracture (vs femoral neck fracture)
      • operative delay of >2 days 
      • age >85 years
      • 2 or more pre-existing medical conditions
      • ASA classification (ASA III and IV increases mortality) 
    • surgery within 48 hours decreases 1 year mortality
    • early medical optimization and co-management with medical hospitalists or geriatricians can improve outcomes 
Anatomy
  • Osteology
    • intertrochanteric area exists between greater and lesser trochanters
    • made of dense trabecular bone
    • calcar femorale
      • vertical wall of dense bone that extends from posteromedial aspect of femoral shaft to posterior portion of femoral neck
      • helps determine stable versus unstable fracture patterns
Classification
  • Stability of fracture pattern is arguably the most reliable method of classification
    • stable
      • definition
        • intact posteromedial cortex
      • clinical significance
        • will resist medial compressive loads once reduced
    • unstable
      • definition
        • comminution of the posteromedial cortex
      • clinical significance
        • fracture will collapse into varus and retroversion when loaded
      • examples
        • fractures with a large posteromedial fragment
          • i.e., lesser trochanter is displaced
        • subtrochanteric extension
        • reverse obliquity
          • oblique fracture line extending from medial cortex both laterally and distally
Presentation
  • Physical Exam
    • painful, shortened, externally rotated lower extremity
Imaging
  • Radiographs
    • recommended views
      • AP pelvis
      • AP of hip, cross table lateral
      • full length femur radiographs
  • CT or MRI
    • useful if radiographs are negative but physical exam consistent with fracture
Treatment
  • Nonoperative
    • nonweightbearing with early out of bed to chair
      • indications
        • nonambulatory patients
        • patients at high risk for perioperative mortality
      • outcomes
        • high rates of pneumonia, urinary tract infections, decubiti, and DVT
  • Operative
    • sliding hip compression screw
      • indications
        • stable intertrochanteric fractures
      • outcomes
        • equal outcomes when compared to intramedullary hip screws for stable fracture patterns
    • intramedullary hip screw (cephalomedullary nail)
      • indications
        • stable fracture patterns
        • unstable fracture patterns 
        • reverse obliquity fractures
          • 56% failure when treated with sliding hip screw
        • subtrochanteric extension
        • lack of integrity of femoral wall
          • associated with increased displacement and collapse when treated with sliding hip screw
      • outcomes
        • equivalent outcomes to sliding hip screw for stable fracture patterns
        • use has significantly increased in last decade
    • arthroplasty
      • indications
        • severely comminuted fractures
        • preexisting symptomatic degenerative arthritis
        • osteoporotic bone that is unlikely to hold internal fixation
        • salvage for failed internal fixation
Techniques
  • Sliding hip compression screw
    • technique
      • must obtain correct neck-shaft relationship
      • lag screw with tip-apex distance >25 mm is associated with increased failure rates
      • 4 hole plates show no benefit clinically or biomechanically over 2 hole plates
    • pros
      • allows dynamic interfragmentary compression
      • low cost
    • cons
      • open technique
      • increased blood loss
      • not advisable in unstable fracture patterns 
        • may result in
          • collapse
          • limb shortening
          • medialization of shaft
      • can cause anterior spike malreduction in left-sided, unstable fractures due to screw torque
  • Intramedullary hip screw
    • technique
      • short implants with optional distal locking
        • standard obliquity fractures
      • long implants
        • standard obliquity fractures
        • reverse obliquity fractures
        • subtrochanteric extension
    • pros
      • percutaneous approach
      • minimal blood loss
      • may be used in unstable fracture patterns
    • cons
      • increased incidence of screw cutout
      • periprosthetic fracture
      • higher cost than sliding hip screw
  • Arthroplasty
    • technique
      • calcar-replacing prosthesis often needed
      • must attempt fixation of greater trochanter to shaft
    • pros
      • possible earlier return for full weight bearing
    • cons
      • increased blood loss
      • may require prosthesis that some surgeons are unfamiliar with
Complications
  • Implant failure and cutout
    • incidence
      • most common complication
      • usually occurs within first 3 months
    • cause
      • tip-apex distance >45 mm associated with 60% failure rate
    • treatment
      • young
        • corrective osteotomy and/or revision open reduction and internal fixation
      • elderly
        • total hip arthroplasty
  • Anterior perforation of the distal femur
    • incidence
      • can occur following intramedullary screw fixation
    • cause
      • mismatch of the radius of curvature of the femur (shorter) and implant (longer)
  • Nonunion
    • incidence
      • <2%
    • treatment
      • revision ORIF with bone grafting
      • proximal femoral replacement
  • Malunion
    • incidence
      • varus and rotational deformities are common
    • treatment
      • corrective osteotomies
 

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Questions (14)

(OBQ11.172) 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? Review Topic

QID:3595
1

Summation of the distance between the end of the screw and the apex of the femoral head on AP and lateral radiographs

94%

(1521/1617)

2

Distance from the acetabular teardrop to the tip of the screw on an AP radiograph of the hip

2%

(28/1617)

3

Multiplication of the distance between the end of the screw and the apex of the femoral head on AP and lateral radiographs

1%

(17/1617)

4

Distance from the center of the lesser trochanter to the tip of the screw on an AP hip radiograph

1%

(18/1617)

5

Summation of the distance between the tip of the greater trochanter and end of the screw on AP and lateral hip radiographs

2%

(25/1617)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

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, corrected for radiographic magnification of the image. 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.

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(OBQ11.189) Which of the following deformities is most likely to occur with dynamic hip screw fixation of unstable left sided standard obliquity hip fractures? Review Topic

QID:3612
1

Posterior spike displacement of the proximal fragment

9%

(135/1504)

2

Anterior spike displacement of the proximal fragment

68%

(1024/1504)

3

Lateral displacement of the proximal fragment relative to the distal fragment

6%

(85/1504)

4

Shortening of the proximal fragment relative to the distal fragment

2%

(26/1504)

5

Medial displacement of the proximal fragment in relation to the distal fragment

15%

(232/1504)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

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.

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(OBQ10.17) 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? Review Topic

QID:3105
FIGURES:
1

Sacral fracture

2%

(22/949)

2

Hip fracture

51%

(486/949)

3

Distal radius fracture

12%

(114/949)

4

Distal fibula fracture

1%

(10/949)

5

Distal humerus fracture

33%

(316/949)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

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.


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(OBQ09.3) 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? Review Topic

QID:2816
1

Age of the patient

1%

(11/1512)

2

Intrinsic stability of the fracture

4%

(57/1512)

3

Tip-apex distance

93%

(1407/1512)

4

Quality of reduction

2%

(29/1512)

5

Angle of the sideplate

0%

(6/1512)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

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.

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(OBQ09.222) 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? Review Topic

QID:3035
1

lag screw cutout

96%

(877/909)

2

osteonecrosis

1%

(5/909)

3

osteoarthritis

1%

(5/909)

4

peri-prosthetic fracture

1%

(8/909)

5

lag screw breakage

1%

(12/909)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

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.


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(OBQ09.233) Which of the following statements is true regarding treatment of intertrochanteric hip fractures with an intramedullary nail versus a sliding hip screw? Review Topic

QID:3046
1

The use of intramedullary nail has increased in the last ten years

90%

(277/308)

2

The use of sliding hip screws has increased in the last ten years

3%

(9/308)

3

Medicare reimbursement is more for a sliding hip screw

1%

(3/308)

4

Intramedullary nails have demonstrated superior outcomes in randomized-controlled studies

3%

(10/308)

5

Sliding hip screw is superior for treatment of reverse obliquity intertrochanteric fractures

3%

(9/308)

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PREFERRED RESPONSE 1

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.

Incorrect Answers:
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


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(OBQ08.138) 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? Review Topic

QID:524
FIGURES:
1

Non-weight bearing

1%

(2/342)

2

Valgus proximal femoral osteotomy

8%

(27/342)

3

Total hip arthroplasty

77%

(265/342)

4

Revision open reduction and internal fixation

13%

(45/342)

5

Proximal femoral resection

1%

(2/342)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

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.


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(OBQ07.86) Which of the following is not an appropriate implant for treatment of the fracture seen in Figure A? Review Topic

QID:747
FIGURES:
1

Cephalomedullary nail

6%

(105/1706)

2

External fixation

8%

(128/1706)

3

Proximal femoral locking plate

3%

(48/1706)

4

95 degree blade plate

1%

(25/1706)

5

Sliding hip screw

82%

(1397/1706)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

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.


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(OBQ07.153) Anterior perforation of the distal femur from antegrade femoral nailing has been attributed to what factor? Review Topic

QID:814
1

Non-anatomic reduction

2%

(31/1946)

2

Mismatch of the radius of curvature of implant and bone

93%

(1805/1946)

3

Usage of too large an implant

2%

(30/1946)

4

Lateral patient positioning

1%

(11/1946)

5

Lateral proximal starting point

3%

(62/1946)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

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.

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(OBQ07.246) 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? Review Topic

QID:907
FIGURES:
1

Use of a long intramedullary device

1%

(4/354)

2

Use of a short intramedullary device

6%

(23/354)

3

Use of external fixation

3%

(9/354)

4

Post operative weight bearing status

6%

(23/354)

5

Intraoperative fracture of the lateral femoral wall

83%

(295/354)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

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.

Incorrect Answers:
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.


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(OBQ06.157) Which of the following is a recognized predictor of mortality after hip fracture? Review Topic

QID:343
1

American Society of Anesthesiologist (ASA) classification

72%

(297/411)

2

Post-operative weight bearing status

23%

(96/411)

3

Fracture comminution

1%

(6/411)

4

Fixation device used

0%

(2/411)

5

Type of anesthetic used

2%

(9/411)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

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.

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(OBQ05.161) 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? Review Topic

QID:1047
FIGURES:
1

Total hip arthroplasty

1%

(5/908)

2

Bipolar hemi-arthroplasty

0%

(3/908)

3

Sliding hip screw

2%

(22/908)

4

Percutaneous screw fixation

0%

(4/908)

5

Cephalomedullary nail fixation

96%

(871/908)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

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.

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(OBQ05.210) All of the following implants offer adequate fracture fixation of the injury shown in Figure A EXCEPT: Review Topic

QID:1096
FIGURES:
1

Trochanteric entry point cephalomedullary nail

3%

(42/1660)

2

Piriformis fossa entry point cephalomedullary nail

3%

(47/1660)

3

Dynamic hip screw

88%

(1456/1660)

4

Fixed angle blade plate

1%

(21/1660)

5

95 degree dynamic condylar screw

5%

(91/1660)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

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.


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(OBQ05.262) 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? Review Topic

QID:1148
1

One

1%

(3/430)

2

Two

78%

(334/430)

3

Three

17%

(72/430)

4

Four

4%

(18/430)

5

Five

0%

(0/430)

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PREFERRED RESPONSE 2

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.


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