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 MRI useful to evaluate intertrochanteric extension with isolated greater trochanteric fracture patterns 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 no violation of hip abductors 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 periprosthetic fracture higher cost than sliding hip screw requires violation of hip abductors for insertion 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
Technique Guide 10/9/2017 Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Intertrochanteric Fracture ORIF with Cephalomedullary Nail Orthobullets Team Trauma - Intertrochanteric Fractures Technique Guide 10/9/2017 Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Femoral Neck Fracture ORIF with Dynamic Hip Screw Orthobullets Team Trauma - Femoral Neck Fractures
QUESTIONS 1 of 19 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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 73% (429/589) 2 Post-operative weight bearing status 23% (137/589) 3 Fracture comminution 2% (10/589) 4 Fixation device used 0% (2/589) 5 Type of anesthetic used 2% (9/589) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (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 95% (2782/2939) 2 Distance from the acetabular teardrop to the tip of the screw on an AP radiograph of the hip 1% (43/2939) 3 Multiplication of the distance between the end of the screw and the apex of the femoral head on AP and lateral radiographs 1% (35/2939) 4 Distance from the center of the lesser trochanter to the tip of the screw on an AP hip radiograph 1% (27/2939) 5 Summation of the distance between the tip of the greater trochanter and end of the screw on AP and lateral hip radiographs 1% (35/2939) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 1 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ07.246) A 72-year-old male sustains the injury shown in Figure A as a result of a fall from a ladder. Which of the following factors has been shown to be associated with increased collapse or sliding displacement? Review Topic QID: 907 FIGURES: A 1 Use of a long intramedullary device 1% (7/540) 2 Use of a short intramedullary device 7% (37/540) 3 Use of external fixation 3% (16/540) 4 Postoperative weight bearing status 6% (33/540) 5 Intraoperative fracture of the lateral femoral wall 83% (447/540) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 5 (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% (5/569) 2 Two 79% (452/569) 3 Three 15% (86/569) 4 Four 4% (22/569) 5 Five 0% (0/569) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (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% (452/501) 2 The use of sliding hip screws has increased in the last ten years 3% (14/501) 3 Medicare reimbursement is more for a sliding hip screw 1% (6/501) 4 Intramedullary nails have demonstrated superior outcomes in randomized-controlled studies 3% (17/501) 5 Sliding hip screw is superior for treatment of reverse obliquity intertrochanteric fractures 2% (12/501) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (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% (1090/1133) 2 osteonecrosis 1% (7/1133) 3 osteoarthritis 1% (8/1133) 4 peri-prosthetic fracture 1% (9/1133) 5 lag screw breakage 1% (15/1133) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (OBQ05.210) All of the following implants offer adequate fracture fixation of the injury shown in Figure A EXCEPT: Review Topic QID: 1096 FIGURES: A 1 Trochanteric entry point cephalomedullary nail 2% (47/1938) 2 Piriformis fossa entry point cephalomedullary nail 3% (53/1938) 3 Dynamic hip screw 87% (1683/1938) 4 Fixed angle blade plate 1% (26/1938) 5 95 degree dynamic condylar screw 7% (126/1938) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 3 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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: A 1 Non-weight bearing 1% (3/549) 2 Valgus proximal femoral osteotomy 7% (40/549) 3 Total hip arthroplasty 81% (444/549) 4 Revision open reduction and internal fixation 11% (58/549) 5 Proximal femoral resection 0% (2/549) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (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: A 1 Total hip arthroplasty 1% (10/1149) 2 Bipolar hemi-arthroplasty 0% (5/1149) 3 Sliding hip screw 2% (27/1149) 4 Percutaneous screw fixation 1% (6/1149) 5 Cephalomedullary nail fixation 95% (1096/1149) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 5 (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 8% (144/1801) 2 Anterior spike displacement of the proximal fragment 66% (1193/1801) 3 Lateral displacement of the proximal fragment relative to the distal fragment 8% (140/1801) 4 Shortening of the proximal fragment relative to the distal fragment 3% (52/1801) 5 Medial displacement of the proximal fragment in relation to the distal fragment 15% (264/1801) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (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: A 1 Sacral fracture 2% (29/1437) 2 Hip fracture 60% (859/1437) 3 Distal radius fracture 15% (214/1437) 4 Distal fibula fracture 1% (10/1437) 5 Distal humerus fracture 22% (322/1437) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (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% (41/2372) 2 Mismatch of the radius of curvature of implant and bone 92% (2192/2372) 3 Usage of too large an implant 2% (38/2372) 4 Lateral patient positioning 1% (12/2372) 5 Lateral proximal starting point 3% (80/2372) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (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: A 1 Cephalomedullary nail 7% (136/2002) 2 External fixation 7% (143/2002) 3 Proximal femoral locking plate 3% (52/2002) 4 95 degree blade plate 1% (27/2002) 5 Sliding hip screw 82% (1641/2002) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 5 (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% (21/2620) 2 Intrinsic stability of the fracture 4% (99/2620) 3 Tip-apex distance 93% (2428/2620) 4 Quality of reduction 2% (57/2620) 5 Angle of the sideplate 0% (9/2620) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 3
Case - Failed Intertrochanteric Fx - Justin Greisberg, MD - (NYT #9 - S2-5 - 2017) Trauma - Intertrochanteric Fractures - Treatment Consult Title: Intertrochanteric Presenter: Justin Greisberg, MDColumbia University Orth... 10/3/2017 412 views Unstable Intertrochanteric Fracture - What Works? - Roy Sanders, MD - (NYT #6- S2-1 - 2017) Trauma - Intertrochanteric Fractures - Surgical Techniques Title: Unstable Intertrochanteric Fracture - What Works? Presenter: Roy Sanders,... 10/3/2017 2152 views Fixation of intertrochanteric femur fractures: SHS vs nail - Debate Trauma - Intertrochanteric Fractures - Treatment Consult Susan Harding, MD, Clin. Associate Professor of Orthopaedic Surgery, Drexel Univ... 9/5/2016 1245 views See More See Less
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