Review Question - QID 210706

A sliding hip compression screw device (SHS) would be appropriate for a standard obliquity intertrochanteric hip fracture with a stable lateral wall. Femoral neck stress fractures may also be treated with a SHS.

A SHS is indicated for stable intertrochanteric fractures and some basilar neck and vertical fracture patterns. A lesser trochanteric fracture is not a contraindication to a SHS as long as the medial buttress lacks comminution and subtrochanteric extension. A contraindication to a SHS is a reverse obliquity intertrochanteric fracture in which the lateral buttress is compromised, as they are associated with SHS failure and cut-out. In these circumstances, an intramedullary nail (IMN) would be more appropriate.

Palm et al. evaluated the integrity of the lateral femoral wall as a predictor of reoperation in intertrochanteric hip fractures. They looked at 214 intertrochanteric fractures treated with a 135° SHS. They found that a postoperative fracture of the lateral femoral wall was the main predictor for reoperation and therefore concluded that patients with lateral femoral wall fractures should not be treated with SHS.

Sadowski et al. performed a prospective randomized study evaluating the treatment of reverse obliquity and transverse intertrochanteric fractures with an IMN versus a 95° screw-plate. 39 elderly patients were included in the study, with 19 patients treated with fixed-angle devices and 20 patients treated with IMN. They concluded that IMN was the better option for treating reverse obliquity and transverse IT fractures in elderly patients.

Baumgaertner et al. evaluated the value of the tip-apex distance in predicting failure of fixation of peritrochanteric hip fractures with SHS. They looked at 198 peritrochanteric fractures and reported 19 failures over an average follow-up time of 13 months. They determined that fractures with a tip-apex distance of 25 mm or less did not experience cut-out, but a strong relationship existed between an increasing tip-apex distance and cut-out rate.

Figures A is a radiograph of a standard obliquity intertrochanteric hip fracture with an associated lesser trochanteric fracture. Figure B is a reverse obliquity intertrochanteric fracture. Figure C is a subcapital femoral neck fracture. Figure D is a subtrochanteric femur fracture. Figure E is a standard obliquity intertrochanteric fracture. Figure F is a tension-sided femoral neck stress fracture. Illustration A shows an intertrochanteric fracture treated with a SHS. Illustration B demonstrates how to measure the tip-apex distance, which should be less than 25 mm to prevent screw cut-out.

Incorrect Answers:
Answer 1: Figure C is a subcapital femoral neck fracture that should be treated with arthroplasty versus ORIF in younger patients.
Answer 2: Figure D is a subtrochanteric femur fracture that is typically treated with IMN.
Answer 4: Figrue B is an reverse obliquity intertrochanteric fracture that is best treated with a cephalomedullary nail.
Answer 5: See Answers 1 and 2.