GRAND ROUND

Dr. Yasir JameelClinical Fellow Orthopadic Trauma

• 80 year old male sustaind fall at home and presented with hip pain to A&E

• History

• Age, sex, occupation• Presenting complain• History of PC• Past medical history• Past surgical history • Drugs, Allergies• Social history

Investigations

X-rays

X-rays

X-rays

Subtrochenteric femur fracture

• Subtrochanteric area typically defined as area from lesser trochanter to 5cm distal.

• fractures with an associated intertrochanteric component may be called intertrochanteric fracture with subtrochanteric extension or peritrochanteric fracture

Epidemiology

• Younger patients with a high-energy mechanism RTA

• may occur in elderly patients from a low-energy mechanism

• Pathologic or atypical femur fracture • Bisphosphonate use, particularly alendronate,

can be risk factor • Preveious neck fixation with screws placed

with entry below lesser trochenter

Anatomy

Pathoanatomy• Deforming forces on the proximal fragment • Abduction gluteus medius and gluteus minimus • Flexion iliopsoas • External rotation short external rotators • deforming forces on distal fragment • Adduction hip adductors • Shortening quads and hamstrings

Pathoanatomy

Biomechanics

• Posteriomedial femur undergoes compressive forces

• Lateral femur undergoes tensile forces

Russell-Taylor Classification

• Based on integrity of the piriformis fossa.• Designed to guide treatment of intramedullary nails

using a piriformis fossa starting point.

Type I - intact piriformis fossaA - lesser trochanter attached to proximal fragmentB - lesser trochanter detached from proximal fragment

Type II - fracture extends into piriformis fossaA - stable posterior-medial buttressB - comminution of lesser trochanter

Russell-Taylor Classification

RT Type 2 B

Treatment

• Nonoperative – observation with pain management • indications

– non-ambulatory patients with medical co-morbidities not fit for surgery

– limited role due to strong muscular forces displacing fracture and inability to mobilize patients without surgical intervention

Treatment

• Operative – intramedullary nailing (usually cephalomedullary)

• indications – historically Russel-Taylor type I fractures– newer design of intramedullary nails has expanded indications– most subtrochanteric fractures treated with IM nail

– fixed angle plate • indications

– surgeon preference– associated femoral neck fracture– narrow medullary canal– pre-existing femoral shaft deformity

Complications

• Varus/ procurvatum malunion

Complications

• Nonunion

Incidence of 0-8% , continued inability to bear weight at 4-6 months and continued pain. Varus malreduction is an important predictor of nonunion accompanied by implant failure.

Complications

• Malunion: Coxa varus: Caused by uncorrected abduction

deformity, nail entry point that is too lateral, and migration of hardware proximally in the femoral head and neck

Shortening: Due to uncorrected shortening intraoperatively and premature dynamization.

Rotational deformity: Do to uncorrected external rotation of proximal fragment. This can be assessed intraoperatively with visualization of the lesser trochanter

Complications

• Fixation failure: Most common in osteoporotic bone. Screw cutout in the femoral head; backing out of locking screws.

• Failure of implant: Excessive motion at fracture site leads to implant fatigue

• Do you have any question??????????????????

THANK YOU