Intertrochanteric Fractures - Ten Tips To Improve Results
Intertrochanteric Fractures - Ten Tips To Improve Results
Intertrochanteric Fractures - Ten Tips To Improve Results
T H E J O U R N A L O F B O N E & J O I N T S U R G E RY J B J S . O R G
V O LU M E 91 -A N U M B E R 3 M A R C H 2 009
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IN T E RT RO C H A N T E R I C FR AC T U R E S :
T E N T I P S T O I M P R O V E R E S U LT S
Intertrochanteric Fractures:
Ten Tips to Improve Results
By George J. Haidukewych, MD
An Instructional Course Lecture, American Academy of Orthopaedic Surgeons
Intertrochanteric fractures are becoming increasingly common as our population ages. These fractures typically
occur in frail patients with multiple
medical comorbidities and often result
in the end of the patients functional
independence. The all-too-often problematic dispositions and prolonged
hospital stays result in a tremendous
cost to patients, their families, and
society. Effective treatment strategies
that result in high rates of union of these
fractures and low rates of complications
are important. As orthopaedic surgeons,
we cannot control the quality of the
bone, patient compliance, or comorbidities, but we should be able to
minimize the morbidity associated with
the fracture. This requires choosing the
appropriate fixation device for the
fracture pattern, recognizing the problem fracture patterns, and performing
accurate reductions with ideal implant
placement while being conscious of
implant costs. If we treat these fractures
expeditiously, minimize fixation failures, and recognize underlying osteoporosis and treat it accordingly, we will
improve our patients outcomes and
Disclosure: The author did not receive any outside funding or grants in support of his research for or preparation of this work. The author or a member of
his immediate family received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits
from a commercial entity (DePuy Trauma). Also, a commercial entity (DePuy Trauma) paid or directed in any one year, or agreed to pay or direct, benefits in
excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or
a member of his immediate family, is affiliated or associated.
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T H E J O U R N A L O F B O N E & J O I N T S U R G E RY J B J S . O R G
V O LU M E 91 -A N U M B E R 3 M A R C H 2 009
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IN T E RT RO C H A N T E R I C FR AC T U R E S :
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Fig. 1
Fig. 2
Fig. 3
Fig. 2 Excellent reduction and deep, central placement of the lag screw in the femoral head. Fig. 3 Failed fixation of a reverse obliquity
fracture with lateralization of the proximal fragment and screw cutout.
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IN T E RT RO C H A N T E R I C FR AC T U R E S :
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Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 6 A four-part fracture with a large posteromedial fragment. Fig. 7 A fracture with subtrochanteric extension.
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T H E J O U R N A L O F B O N E & J O I N T S U R G E RY J B J S . O R G
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IN T E RT RO C H A N T E R I C FR AC T U R E S :
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Fig. 8
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Fig. 9
IN T E RT RO C H A N T E R I C FR AC T U R E S :
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Fig. 10
Fig. 9 The ideal starting point is slightly medial to the exact tip of the greater trochanter. Note the good position of the guidewire distally.
Fig. 10 An unreduced fracture will not reduce with nail passage because of the capacious metaphysis in most patients with osteopenia.
Fig. 11
Fig. 12
Fig. 11 Reduction has been achieved with a clamp placed through a small lateral incision. Fig. 12 Use of a clamp to reduce a
fracture with a subtrochanteric extension. Clamps can be inserted without evacuation of the fracture hematoma and with
minimal soft-tissue disruption.
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T H E J O U R N A L O F B O N E & J O I N T S U R G E RY J B J S . O R G
V O LU M E 91 -A N U M B E R 3 M A R C H 2 009
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Fig. 13
IN T E RT RO C H A N T E R I C FR AC T U R E S :
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Fig. 14
Fig. 13 A well-aligned fracture. Note the central position of the lag screw in the femoral head. Fig. 14 Radiograph
showing the relationship between the tip of the greater trochanter and the center of the femoral head. Normally, this
relationship is coplanar. Here, the proximal fragment is in varus, the starting point is lateral, and the screw is high
in the head.
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Fig. 15
IN T E RT RO C H A N T E R I C FR AC T U R E S :
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Fig. 16
Fig. 15 A fracture locked in distraction. Note the typical lateral starting point and the high hip-screw placement.
Fig. 16 Distracted fractures in varus can result in high loads on the implant, causing nail fracture, typically through
the aperture for the lag screw.
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T H E J O U R N A L O F B O N E & J O I N T S U R G E RY J B J S . O R G
V O LU M E 91 -A N U M B E R 3 M A R C H 2 009
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IN T E RT RO C H A N T E R I C FR AC T U R E S :
T E N T I P S T O I M P R O V E R E S U LT S
George J. Haidukewych, MD
Florida Orthopaedic Institute, 13020 Telecom
Parkway, Temple Terrace, FL 33637.
E-mail address: DocGJH@aol.com
References
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