Dynamic hip screw (DHS) fixation

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• bleeding and blood transfusion
• wound infection
• screw cut-out through the femoral head and loss of fixation
• excessive collapse with limb shortening and limp
• non-union (uncommon) and need for revision or hip replacement
• fracture of the lateral wall during surgery, needing an extra plate or a nail
• deep vein thrombosis and pulmonary embolism
• medical complications and death in the elderly (chest infection, heart events)
• pressure injury to the well leg (peroneal nerve) from positioning on the fracture table

Pre-operative details for this operation

1. SideRightLeftmarked
2. Date and time of injury, mechanismlow-energy fall / high-energy injury; cause of fall if medical
3. Fracture classificationAO/OTA 31A131A231A3 (DHS not advised)subgroup; reverse oblique or transverse pattern needs a nail or fixed-angle plate
4. X-rays reviewedAP pelvis, cross-table lateral hip, full femur AP and lateral. Traction view if taken. CT if lateral wall doubtful
5. Lateral wallIntactThin (under 21 mm)Fractured
6. Neck-shaft angle of the normal sidedecides the plate angle (e.g. 135 degrees)
7. Associated injuries and skinwrist / shoulder fractures, head injury, pressure areas over hip, sacrum, heels
8. Medical optimisationHb, electrolytes, ECG, anticoagulants / antiplatelets and when stopped, physician clearance
9. Implant availableplate angles, plate lengths, lag screw lengths, trochanteric stabilising plate and a nail as back-up

Anaesthesia and position

1. AnaesthesiaSpinalSpinal + epiduralGeneral
2. PositionFracture table, well leg in well-leg holderFracture table, scissor positionperineal post padded, heel in boot, peroneal nerve of well leg padded
3. C-arm positionFrom the opposite sideBetween the legsAP and lateral views of the hip confirmed before draping
4. Reduction manoeuvretraction, abduction, internal rotation (degrees), support under thigh for posterior sag; closed / percutaneous aids / open
5. Reduction check on C-armneck-shaft angle normal or slight valgus, less than 20 degrees angulation on lateral, less than 4 mm translation

Operative findings

1. Fracture pattern seen on C-arm / at surgerynumber of parts, lesser trochanter fragment, posteromedial comminution
2. Lateral wall at the endIntactFractured during reaming (action taken)
3. Bone qualityGoodOsteoporotic
4. Quality of reductionAnatomicAcceptable (describe)Varus / posterior sag remaining

Procedure (steps)

1. Skin preparation and drapingantiseptic, isolation drape
2. Incisionlateral, from vastus ridge distally, length in cm
3. ExposureFascia lata split. Vastus lateralis split or elevated off the septum. Perforators coagulated / ligated. Vastus origin released from the ridge
4. Guide pin entry pointfor 135 degrees about 2 cm below the vastus ridge, level of lesser trochanter; move 1 cm per 5 degrees for other angles
5. Anteversion pin and angled guidefree pin along anterior neck; angled guide flush to lateral cortex
6. Guide pin positioncentre-centre in the head on AP and lateral, to within 5 mm of subchondral bone; derotation pin if used
7. Measured guide pin lengthin mm, read from the measuring gauge
8. ReamingTriple reamer set 5 mm less than measured length. Guide pin checked on C-arm not advancing into pelvis. Tap used or not
9. Lag screw insertedlength in mm, over guide pin, with centring sleeve; insertion wrench handle aligned with femoral shaft
10. Side plate seated and fixedplate slid over lag screw, tamped onto lateral cortex, guide pin removed; number of cortical screws, bicortical, lengths
11. Traction released and compressionCompression screw inserted and leftCompression screw used then removedManual compression only
12. Tip-apex distanceAP + lateral in mm (aim under 25 mm)
13. Final C-arm images savedAP and lateral hip showing whole implant; number of images / screening time if recorded
14. Additional fixationNoneTrochanteric stabilising plateConverted to nail (reason)

Closure, drains and dressing

1. Wash and debridementdevitalised tissue removed, irrigation
2. DrainNoneSuction drain (size)
3. Layered closurevastus fascia, fascia lata, subcutaneous tissue and skin separately: suture material for each
4. Dressing
5. Distal circulation and well-leg / perineum check after removal from fracture tablepulses, heel and perineal skin

Specimens and implants

1. Platebarrel angle (degrees), number of holes, make, catalogue number, lot / batch number (sticker pasted)
2. Lag screwlength in mm, make, lot / batch number (sticker pasted)
3. Compression screwLeft inNot used / removed
4. Cortical screwsnumber and length of each, lot / batch number
5. Trochanteric stabilising plate (if used)size, make, lot / batch number

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Vitals, urine output, pain scorefrequency
2. Limb checkdistal pulses, sensation, swelling
3. Check X-rayAP and lateral hip in recovery, including the whole implant
4. Mobilisation and weight bearingsit up and out of bed from POD 1 when medically safe; weight bearing as tolerated unless stated otherwise
5. Thromboprophylaxismechanical and drug, dose, start time
6. Pressure caretwo-hourly turning, heel and sacral care, air mattress if available
7. InvestigationsHb and electrolytes on POD 1
8. Drain and dressingdrain removal time if placed; first dressing day
9. Follow-upwound check at 2 weeks; X-rays at 2, 6 and 12 weeks for collapse, implant position and union

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery