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Subtrochanteric Fractures
Posted: Feb 19 2022 #(C102003)
A

Open Subtrochanteric Femur Fx s/p GSW in 48M

HPI

A 48-year-old male presents after a GSW to the left thigh. He reports being in his auto shop when he was assaulted by unknown individuals. He was shot in the left thigh and sustained blunt trauma to his head. He denies any loss of consciousness. Denies blood thinner use. The patient denies any numbness or tingling to the ipsilateral lower extremity. The remainder of the exam is unremarkable.

PMH

Obesity, HTN, HLD

PE

A focused physical exam of the left lower extremity demonstrates external rotation positioning of the left leg. There is an open wound to the anterior proximal thigh with oozing blood present. He has pain with logrolling of the hip and has TTP to proximal femur, traveling down into the distal thigh. Compartments are soft to palpation. He is neurovascularly intact.

Poll
1 of 12
1. In addition to the plain film radiographs, would you obtain any other imaging to guide management?
No - current radiographs are sufficient
60%
613/1017
Yes - additional radiographic views (XR)
3%
36/1017
Yes - CT scan of the hip/femur (CT)
28%
287/1017
Yes - MRI scan of the hip/femur (MRI)
0%
8/1017
Yes - CT + XR
3%
38/1017
Yes - MRI + XR
0%
5/1017
Yes - MRI + CT
0%
4/1017
Yes - MRI + CT + XR
0%
4/1017
Outside my area of expertise - best if I don't vote
2%
22/1017
2. Would you use a classification system to guide management of this injury?
No - a classification system would not help me
65%
643/975
Yes - Russel-Taylor
6%
67/975
Yes - AO/OTA
21%
207/975
Yes - Other
1%
18/975
Outside my area of expertise - best if I don't vote
4%
40/975
3. How would you manage this injury?
Nonoperative
0%
3/982
Operative
98%
971/982
Outside my area of expertise - best if I don't vote
0%
8/982
4. If you choose Operative management, assuming the patient arrived in the ER at 7 pm, when would you perform surgery?
I would not choose Operative management
0%
0/995
Emergently (within 2-3 hours)
25%
257/995
Urgently (within 4-6 hours, I would NOT wait until following morning)
29%
297/995
Semi-urgently (within 7-12hrs, first case following morning)
34%
340/995
Routinely, within 13-24 hours
7%
74/995
25-48 hours
1%
14/995
Outside my area of expertise - best if I don't vote
1%
13/995
5. If you choose Operative management, would you temporize this patient prior to definitive fixation?
I would not choose Operative management
0%
8/976
No - I would operate acutely
41%
401/976
Yes - temporize short-term with Buck's external traction
19%
194/976
Yes - temporize short-term with Skeletal traction
21%
210/976
Yes - temporize short term with external fixation
14%
140/976
Outside my area of expertise - best if I don't vote
2%
23/976
6. If you choose Operative management and choose to temporize with Skeletal Traction, what type would you use?
I would not temporize with Skeletal Traction
36%
342/936
Distal Femoral Traction Pin
29%
277/936
Proximal Tibial Traction Pin
30%
290/936
Calcaneal Traction Pin
0%
4/936
Outside my area of expertise - best if I don't vote
2%
23/936
7. If you choose Operative management, what definitive fixation would you perform?
I would not choose Operative management
0%
1/951
External fixation (ExFix) (includes monoplane, circular fixation)
3%
36/951
Open reduction and internal fixation (ORIF) with plates, pins and screws
7%
73/951
Intramedullary nail (IMN)
66%
629/951
IMN + ORIF
20%
198/951
Outside my area of expertise - best if I don't vote
1%
14/951
8. If you choose Intramedullary nail fixation (IMN), how would you position this patient?
I would not choose IMN
0%
8/931
Supine, radiolucent flattop
16%
149/931
Supine, fracture table
67%
632/931
Lateral, radiolucent flattop
8%
83/931
Lateral, fracture table
4%
40/931
Outside my area of expertise - best if I don't vote
2%
19/931
9. If you choose IMN, would you perform open reduction of the fracture site?
I would not choose IMN
1%
16/919
No
48%
446/919
Yes
47%
441/919
Outside my area of expertise - best if I don't vote
1%
16/919
10. If you choose IMN and perform an open reduction of the fracture site, would you use any provisional fixation?
I would not choose IMN
1%
13/885
I would not choose open reduction
15%
139/885
No
24%
213/885
Yes - cerclage cables
48%
426/885
Yes - plate(s) and screws
7%
65/885
Yes - screw fixation alone
1%
12/885
Outside my area of expertise - best if I don't vote
1%
17/885
11. If you choose IMN, what approach would you use?
I would not choose IMN
0%
6/892
Antegrade - Trochanteric entry
68%
609/892
Antegrade - Piriformis entry
28%
251/892
Retrograde
1%
12/892
Outside my area of expertise - best if I don't vote
1%
14/892
12. If you choose Intramedullary nail fixation (IMN), what type of implant would you use?
I would not choose IMN
0%
4/878
Cephallomedullary nail - single lag screw
33%
296/878
Cephallomedullary nail - dual lag screw (recon nail)
58%
510/878
Intramedullary nail (no head/neck fixation)
5%
47/878
Outside my area of expertise - best if I don't vote
2%
21/878
PROCEDURE #1

Recon intramedullary nail left femur

Intra-procedure P1
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