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Intertrochanteric Fractures
Posted: Jan 12 2021 #(C101695)
A

Subacute Hip Fracture in 85F

HPI

An 85-year-old female patient presents with complaints of left lower extremity pain and extremity swelling after a fall two weeks prior. She did not come in earlier because of COVID. The patient had just recovered from an ipsilateral femoral condyle fracture that healed with nonoperative treatment and was just beginning to walk independently.

PMH

Healthy and relatively active prior to fracture.

PE

Focused physical examination of her left lower extremity reveals her hip to be short and externally rotated. Admits to pain with logrolling of the hip. She is neurovascularly intact.

Poll
1 of 12
1. In addition to AP and LAT radiographs of the injured hip, what additional imaging would you get to guide management?
None - AP and LAT radiographs are sufficient
54%
279/509
Additional xrays (aXR)
9%
50/509
Hip CT (CT)
30%
153/509
Hip MRI (MRI)
0%
4/509
aXR + CT
3%
16/509
aXR + MRI
0%
0/509
CT + MRI
0%
1/509
aXR + CT + MRI
0%
2/509
Outside my area of expertise - best if I don't vote
0%
4/509
2. If you choose Operative management, what surgical technique would you use?
I would not choose Operative management
2%
10/475
Fracture reduction internal fixation (FIX)
79%
376/475
Total hip arthoplasty (THA)
6%
31/475
Hemiarthroplasty (Hemi)
11%
53/475
Outside my area of expertise - best if I don't vote
1%
5/475
3. If you choose Fracture reduction internal fixation (FIX), and the patient arrived in the ER at 8:30 pm, with their last full meal at 2 pm, and is medically optimized, when would you perform surgery?
I would not choose Fracture reduction internal fixation (FIX)
5%
24/453
Same night (within 6 hours of arrival to ER)
7%
36/453
Following morning first case, Bump elective cases, Cancel clinic if scheduled (12-24 hours)
29%
135/453
Following day after elective cases, After clinic (24 - 32 hours)
39%
181/453
When convenient within 3 days from admission (OR available, don't change clinic, start before 5 pm)
13%
62/453
When convenient within 5 days from admission (OR available, don't change clinic, start before 5 pm)
2%
10/453
Outside my area of expertise - best if I don't vote
1%
5/453
4. If you choose Fracture reduction internal fixation (FIX), what Reduction technique would you use?
I would not choose Fracture reduction internal fixation (FIX)
8%
36/446
Closed Reduction - Fluoro + Fx Table
71%
318/446
Closed Reduction - Percutaneous K-wires (joystick technique)
3%
17/446
Open Reduction - Watson Jones Approach
3%
17/446
Open Reduction - Direct Anterior Approach
1%
6/446
Open Reduction - Direct Lateral Approach
9%
44/446
Outside my area of expertise - best if I don't vote
1%
8/446
5. If you choose Fracture reduction internal fixation (FIX), what Fixation construct would you use?
I would not choose Fracture reduction internal fixation (FIX)
6%
28/433
Cephalomedullary nail
77%
336/433
Dynamic/sliding hip screw (DHS/SHS)
12%
55/433
Cannulated screws only
0%
2/433
Divergent Screw Plate System (e.g., FNS)
0%
3/433
Proximal Femoral Locking Plate
0%
3/433
Outside my area of expertise - best if I don't vote
1%
6/433
6. If you choose Cephalomedullary nail (CMN), how would you position the patient and what table would you use?
I would not choose CMN
7%
34/438
Lateral - Fracture table
4%
18/438
Lateral - Radiolucent flattop table
2%
10/438
Supine - Fracture table
76%
334/438
Supine - Radiolucent flattop table
7%
34/438
Outside my area of expertise - best if I don't vote
1%
8/438
7. If you choose Cephalomedullary nail (CMN), what length nail would you select?
I would not choose CMN
7%
32/434
Short
40%
175/434
Intermediate
14%
62/434
Long
36%
158/434
Outside my area of expertise - best if I don't vote
1%
7/434
8. If you choose Cephalomedullary nail (CMN), what type of fixation would you use in the femoral neck?
I would not choose CMN
7%
32/428
Helical blade
18%
81/428
Single head lag screw
33%
143/428
Single head lag screw + anti-rotational head screw
31%
133/428
Dual screws (recon nail)
7%
34/428
Outside my area of expertise - best if I don't vote
1%
5/428
9. If you choose Cephalomedullary nail fixation (CMN) with a single head lag screw, where would you position the implant within the femoral head and neck on the AP view?
I would not choose CMN
7%
32/429
Centered within the neck
41%
178/429
As low as possible, hugging the inferior calcar
49%
211/429
Outside my area of expertise - best if I don't vote
1%
8/429
10. If you choose Cephalomedullary nail (CMN), would you augment your construct with cables?
I would not choose CMN
7%
32/422
No - I would not use cables
85%
359/422
Yes - I would supplement with cables
5%
25/422
Outside my area of expertise - best if I don't vote
1%
6/422
11. If you choose Cephalomedullary nail (CMN), what would be your PRIMARY (most valuable) method to get your femoral ROTATION correct?
I would not choose CMN
6%
28/419
Preop Templating - Nail-screw angle vs. Contralateral
1%
6/419
Intraop Open - Direct visualization of Fx reduction
6%
29/419
Intraop Fluoro - Cortical Thickness
25%
105/419
Intraop Fluoro - Lesser trochanter profile (LTP)
20%
84/419
Intraop Fluoro - Femoral neck horizontal angle (NHA)
7%
31/419
Intraop Fluoro - True lateral technique (TLT)
14%
59/419
Clinical Inspection - Look at direction foot is pointing vs. contralateral side
14%
61/419
Clinical Inspection - Look at skin wrinkling
0%
2/419
Outside my area of expertise - best if I don't vote
3%
14/419
12. If you choose Cephalomedullary nail (CMN), would you use distal interlocking screw(s)?
I would not choose CMN
6%
28/419
No
3%
13/419
Yes - 1
58%
244/419
Yes - 2
29%
124/419
Outside my area of expertise - best if I don't vote
2%
10/419
PROCEDURE #1

Left short cephalomedullary nail fixation

Intra-procedure P1
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OUTCOMES
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