Femur, proximal: extraarticular fracture, intertrochanteric—31-A3 and complex spiral diaphyseal fracture—32-C1



10.1055/b-0034-87633

Femur, proximal: extraarticular fracture, intertrochanteric—31-A3 and complex spiral diaphyseal fracture—32-C1

Suthorn Bavonratanavech

Case description


A 40-year-old man was victim of a motorcycle accident and sustained a Gustilo-Anderson type II open fracture of the proximal left femur and a closed midshaft fracture of the ipsilateral tibia. Initial treatment consisted of debridement of the open fracture and closed reduction of the left tibial fracture, with immobilization in a short leg slab. The patient was transferred 7 days later for definitive fracture fixation. He had no other injury. X-rays of the left femur showed an intertrochanteric fracture with extension into the femoral shaft and an additional segmental fragment. There was no evidence of fever or local infection.



Indication for MIPO


Reconstruction by intramedullary nailing of the proximal femoral fracture may be possible but is technically problematic due to the short proximal fragment, which may result in varus deformity and an unstable fixation. A special long proximal femoral nail is another option and provides better fixation. However, it was not available as a standard implant at that time.


Bridge plating—with a condylar plate or a DCS—is better for stabilization of intertrochanteric fractures with extension into the shaft using the MIPO technique. This gives a stable fixation with minimal soft-tissue dissection.

a–b Gustilo-Anderson type II open fracture of the proximal left femur. c–d Closed midshaft fracture of the ipsilateral tibia and fibula.


Preoperative planning


A condylar blade plate with MIPO technique will be used to fix this fracture. The plate will function as a bridging plate to bypass the fracture site as well as being used as an indirect reduction tool because of its anatomical design. The proximal fragment is deformed from muscle pull in flexion, abduction, and external rotation. Once the proximal fixation is correctly angled and aligned, the side plate will lie along the shaft of the femur. The correct point of insertion and the length of the blade must be determined with the length of the side plate long enough to fix the distal fragment ( Fig 16.2-2 ).

a–g Preoperative planning determines the proper size of the implant. In this case, a condylar plate (16-hole, 70 mm blade) is selected. a The Schanz screw is inserted to counteract the muscle force and to bring the proximal femur into full AP hip alignment when viewed with image intensification. A guide wire is then inserted at 95° to the shaft axis and in the center of the femoral neck in AP and lateral view. The length of the blade is determined by measuring the guide wire from the lateral cortex to the head of the femur. b–c After the chisel tunnel is prepared the condylar blade is introduced through the prepared seating chisel tunnel. The blade is turned laterally until the side plate is fully embedded under the muscle and then the tip of the blade is rotated to insert into the seating chisel tunnel. d The plate is fixed to the proximal femur with two fully threaded cancellous bone screws through the plate. e–f After manual traction a Hohmann retractor is used to manipulate the displaced fragment to obtain the estimated femur length. The plate is aligned to the bone and cautery is used to mark the site where the second-last plate hole will be fixed. A Hohmann retractor is used to align the distal femur in the horizontal plane and the marked site is drilled in the center of and perpendicular to the bone. A cortex screw is inserted through the plate hole and into the predrilled bone hole. Tightening the screw will approximate the bone to the plate and provide correct rotation because the screw is set perpendicular to the bone. g When the alignment has been checked and is correct the intermediate fragment is fixed with a screw to bring it close to the plate. Additional cortex screws are fixed as the definitive fixation for the distal fragment. Note: these screws are inserted at different angles to increase pullout force.

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Jul 2, 2020 | Posted by in ORTHOPEDIC | Comments Off on Femur, proximal: extraarticular fracture, intertrochanteric—31-A3 and complex spiral diaphyseal fracture—32-C1

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