A case of shattered proximal femur

Vinod Naneria

Girish Yeotikar

Arjun Wadhwani

Choithram Hospital & Research Centre, Indore India

Case summary

• A 25 years old male, met with RTA,

• Sustained hip fracture - dislocation

• Comminuted neck + trochanter

• Subtrochanteric fractures.

• Fractures of lower end radius, metatarsals, ligamentous injury at same side knee

• Contra-lateral comminuted fracture tibia fibula.

Radiology

• Fracture/dislocation of hip with fracture of head and neck

• Comminuted subtrochanteric fracture - Rt

• Comminuted fracture of Tibia/ febula Lt.

• CT scan of Rt hip was ordered.

Planning

• First nailing for Tibia on the other side.

• Open reduction of Hip

• Fixation of the head fragment with the remaining head.

• A bridge plate from trochanter to shaft bye-passing the comminuted pieces of subtrochateric region.

6/12/2011- Problems

• Split head fragment and how to fix it?

• How to reduce?

• Positioning of the pt. on table?

• Which approach?

• Traction table or not?

• Which implant?

6/12/2011- Problems

• Primary replacement with cemented Bipolar?,

• How to fix the two pieces of the head with out further damage to the vascularity?

• Intramedullary or extramedullary implant and their purchase in the neck fragment?

• How to avoid the rotation of neck fragment if a DCS/PFN or DHS is chosen?

14/12/2011Surgical notes

• Lateral position , posterior approach, blunt dissection

• Identification of the dislocated head fragment.

• There was a capsular rent in the inferior aspect through which the dislocated head was popping out.

• The capsular rent was not wide enough.

• We failed to manipulate the head fragment back in to acetabulum by direct pushing the head.

14/12/2011Surgical notes

• A gap was developed in the trochanteric area and trochanter was reflected upward(like we do in trochanteric osteotomy), through which the neck of the femur was caught by a patellar clamp and distraction was done. The head was now manipulated and deposited in the acetabulumand the reduction was checked by C-arm.

• A trochateric plate was chosen as a fixation device with out opening the subtroch fracture site.

14/12/2011Surgical notes

• I could not imaging the how to fix the two pieces of the head when the other was not visible. To expose means complete capsulotomy! I did not dare. So, I left it without fixation but in good alignment.

• The chance of AVN is much more than normal and I had to reconstruct the anatomy as near normal as possible.

• The case here presented with an idea of reporting a situation which is most unpleasant for any surgeon -who was forced to enter the theatre with out a clear pre-op planning due to bad comminution of the fractured bones.

10/12/2011

Immediate Post op

31/1/2012Infection

• Unfortunately patient had deep wound infection which was explored and washed. The plate was holding well and I had no other choice hence was left in place.

• He was on antibiotics and now wound has nearly healed.

• He has difficulty in sitting upright.

• He was developing bedsores.

31/1/2012

• He was again taken to OT for hip examination. His c-arm pictures are attached here with.

• The lateral view showing marked anterior rotation/displacement of proximal fragment.

• I have to wait for at least 3 months for re-exploration + bone grafting.

Examination under C-arm

Examination under C-arm

Surgery .....

• In lateral position – Hip exposed.

• The external rotators were gentaly elevated from the posterior acetabular side and the head was reduced in the socket.

• Reduction was confirmed by C – arm.

• A long screw was tighten through a trochnateric plate into the fragment under vision through the capsular rent.

20/5/2012Infection + Bony Ankylosis

• Six months passed

• This patient now have bony ankylosis of hip with occasional dischage.

• Painless. Mobilized with walker.

• Planning to do hip excision once subtrochanteric fracture consolidates.

23/5/2012Problems & Choices

• For a stable painless hip,

• Debridement

• Control of infection antibiotic beads

• Excision of the Hip and/or Antibiotic spacer.

• At present I am concentrating of mobilisation. The infection (low grade) is probably in the hip joint that caused ankylosis.

• There is no loosening seen on x-rays at any screw tracts.

7/11/2012Plate removal

• Patient had persistent problem in ADL and specially sitting due to stiff hip.

• Discharge was persisting.

• Trochanteric plate was removed.

• Excision of hip was done.

• There was movement at proximal femur fracture.

• Temporary immobilization in Thomas’s splint.

• Mobilization continued with walker.

7/11/2012

Plate removedHead excision doneScrews tractscuretted

13/8/2013

• No infection.

• Mobility at proximal femur.

• Better mobilized due to movements at hip and proximal femur.

• Fracture exposed.

• Fragments mobilized

• Re-plating and bone grafting done.

• Reactivation of infection, which continued till the plate was removed on May 2014.

23/8/2013

Sub-trochFracture ExposedBone ends clearedRe-platingBone grafting

25/9/2013

15/1/2014

Discharge PersistingScrew gettingLooseFracture healingMobilized Full wt. bearing

5/3/2014

18/6/2014

FractureConsolidatedPlate removedScrew tractscuretted

23/6/2014

Finally

• Shortening of 2”

• Limited knee movements

• Walks without support with shoe raise

• No infection

• No pain

• No future planning for any hip replacement as there is no medullary canal in proximal femur.

DISCLAIMER

Information contained and transmitted by this presentation is based on personal experience and collection of cases at Choithram Hospital & Research centre, Indore, India. It is intended for use only by the students of orthopaedic surgery. Views and opinion expressed in this presentation are personal. Depending upon the x-rays and clinical presentations viewers can make their own opinion. For any confusion please contact the sole author for clarification. Every body is allowed to copy or download and use the material best suited to him. I am not responsible for any controversies arise out of this presentation. For any correction or suggestion please contact naneria@yahoo.com