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The first 25 slides, exactly as they appear. The full deck has 128 content slides.
Orthopaedics
Intertrochanteric Fractures of the Femur
Built from Tang — Orthopaedic Trauma Vol 2: Lower Extremity
What’s inside
9 sections · 128 slides
Overview
- What this topic covers
Foundations
The fracture, the anatomy, and how it displaces
- What is an intertrochanteric fracture?
- How common, and in whom (Koval et al. 1996)
- Why this is really a disease of frail elderly people
- The proximal femur is built like a crane arm
- Trabecular 'crane arm' of the proximal femur
- The calcar femorale: the hidden keystone
- Cross-section through the calcar femorale
- Why the broken pieces drift apart: muscle pull
- Muscle forces that displace the fracture
- How the fracture happens
Classification and assessment
Naming the pattern, then judging stability
- Evans classification: is it stable after reduction?
- Evans classification in detail
- Evans classification pattern types
- AO-OTA classification: comminution AND the lateral wall
- AO-OTA classification: stable vs unstable subtypes
- AO-OTA subtypes at a glance
- Clinical assessment at the bedside
- Imaging: from plain film to CT to MRI
- Plain-film appearance of an intertrochanteric fracture
- CT and 3D reconstruction of the fracture (axial)
- CT and 3D reconstruction of the fracture (coronal / 3D)
- How to spot an UNSTABLE fracture on imaging
- Special and 'potentially unstable' patterns to respect
- Special fracture types to respect
- Special fracture types (further panels)
Treatment
Deciding whether, when and how to operate
- When surgery is NOT the answer (conservative care)
- Principles and timing of surgical treatment
- The two mainstay operations - trade-offs
- Matching the implant to the Evans type
- Choosing the fixation method
Sliding hip screw (DHS) technique
Step by step on the traction table
- Setup, reduction and the coxa vara/valga check
- Fluoroscopic check for coxa vara and coxa valga
- Reduction quality - a little valgus is your friend
- Why slight valgus reduces torque and shortening
- Surgical approach to the lateral femur
- Lateral approach: skin, fascia and vastus lateralis
- Assisting reduction with a pointed reduction clamp
- Guide wire, angle and entry point
- DHS guide-wire entry and neck-axis alignment
- Reaming depth and seating the plate
- Measuring depth and aligning the T-handle to the plate
- Seating the plate and intraoperative compression
- When to compress, and how to protect against rotation
- Trochanter-protecting plate and spiral blade
- The biomechanical weak spot of the DHS
- Shear at a reversed fracture can break the fixator
Intramedullary nailing
The centric, minimally invasive workhorse
- Positioning for intramedullary nailing
- Correct body position and pelvic tilt for nailing
- Planning the incision from surface landmarks
- Surface landmarks defining the nail entry incision
- Reduce first - always before reaming
- C-arm confirmation of reduction before proceeding
- The A1.3 problem: taming a rotated proximal fragment
- Limited-incision reduction of an A1.3 fracture
- Finding and protecting the entry point
- Entry point 5 mm lateral to the greater-trochanter apex
- Controlling cortical and medullary reaming direction
- Inserting the main nail and setting its depth
- Setting main-nail depth and restoring neck-shaft angle
- Confirming nail position and depth (further panels)
- Placing the cephalomedullary (head-neck) screw
- Cephalomedullary guide-wire placement, AP and lateral
- Locking the blade and intraoperative compression
- Blade locking and intraoperative compression sequence
- Distal locking - static or dynamic
- Distal locking: static versus dynamic
- Postoperative radiograph after intramedullary nailing
- Pitfall 1: a wrong entry point ruins the reduction
- How entry-point deviation causes reduction failure
- Pitfall 2: choosing the wrong implant
- Spiral blade compacts bone; threads need drilling
- Pitfall 3: avoid separating the fracture ends
- Pitfall 4: do not over-dissect the soft tissue
- Soft-tissue damage from open nailing leading to failure
- Pitfall 5: distal locking and tip fracture
- Distal locking: two screws versus one
- Design principle 1: controlling rotation
- Anti-rotation designs for the femoral head and neck
- Design principle 2: sliding compression
- Sliding-compression designs and 'Z' screw retreat
- Design principle 3: the limit of locking plates
- Locking-plate failure in an unstable fracture
- Locking-plate failure case (further imaging)
Arthroplasty
Replacing the head when fixation cannot win
- When to replace rather than fix
- Reconstructing the proximal femur - the key step
- Wire-cerclage fixation of the trochanters
- Wire-cerclage technique (further steps)
- Setting the prosthesis correctly
- Estimating prosthesis depth in a 90-year-old case
- Arthroplasty: cautions and the 301 Hospital view
Complications and biomechanics
Why fixation fails, and how to prevent it
- Tip-apex distance (TAD): predicting failure
- Measuring the tip-apex distance (TAD)
- TAD: acceptable versus excessive (further panels)
- TAD calculation and implant-angle effect
- Reduction quality drives TAD in intramedullary nailing
- Poor reduction producing an excessive TAD
- Poor-reduction / high-TAD case (further imaging)
- Telescoping and the idea of secondary stabilisation
- Telescoping collapse in an A2.1 three-part fracture
- DHS secondary stabilisation needs the lateral wall
- DHS stabilisation and the lateral wall
- DHS lateral-wall case (further panels)
- Stable fracture healing by direct medial contact
- Why the intramedullary nail forgives instability
- Secondary stabilisation after intramedullary nailing
- Medial support: the mechanical heart of the matter
- DHS vs nail: eccentric versus centric loading
- DHS cantilever failure without medial support
- The lateral wall: the last line of defence
- Lateral-wall involvement: varus and shortening
Summary
The take-home messages
- Three ideas to carry away
- Practical rules that prevent failure
- Why is a sliding hip screw contraindicated in a reversed intertrochanteric fracture?
- References (1/4)
- References (2/4)
- References (3/4)
- References (4/4)
- Orthopaedic Trauma Surgery - Volume 2: Lower Extremity