Femur, proximal: extraarticular fracture, intertrochanteric—31-A3 and wedge diaphyseal fracture—32-B1

10.1055/b-0034-87636

Femur, proximal: extraarticular fracture, intertrochanteric—31-A3 and wedge diaphyseal fracture—32-B1

Suthorn Bavonratanavech

Case description

A 65-year-old female motorcycle passenger fell from a motorcycle and sustained a multifragmented persubtrochanteric femoral fracture with severe pain and deformity of the left thigh. She had no other associated injury. X-rays of the left femur showed an intertrochanteric fracture with extension into the femoral shaft and a major medial wedge segment. There was an additional nondisplaced fracture line along the intertrochanteric area. The patient was first immobilized with skeletal traction while waiting for preoperative assessment.

Indication for MIPO

There are several implant options available to fix this type of fracture configuration. Internal fixation with cephalointramedullary nailing is biomechanically advantageous compared to extramedullary implants. However, closed reduction is technically problematic for nail introduction due to the large medial wedge fragment, unless limited open reduction is performed to reduce the fracture prior to nail insertion.

Bridge plating is also an option. A plate can be used as a reduction tool to reduce the fracture prior to definitive fixation. The condylar blade plate or a dynamic condylar screw is another alternative for stabilization of intertrochanteric fractures with extension into the shaft using the MIPO technique. This gives a stable fixation with minimal soft-tissue dissection. In this case the patient had compromised bone quality so the proximal femur 13-hole LCP was chosen and applied using the MIPO technique.

a–c AP x-ray of the pelvis excludes other injuries of the right hip and pelvis. AP and lateral x-rays of the left proximal femur show a spiral wedge fracture at the level of the lesser trochanter extending down to the shaft, and a displaced major medial wedge fragment with disruption of the medullary canal. There is a nondisplaced hairline fracture running from the greater to the lesser trochanter.

Preoperative planning

a The first step, after exposure of the proximal femur, is to fix the nondisplaced intertrochanteric fracture with a cortical lag screw placed away from where the plate will be positioned. b The selected proximal femur LCP is attached with the threaded drill guide and introduced through the proximal incision to align with the greater trochanter extended down to the vastus ridge. Three guide wires are inserted at 95°, 120°, and 135° to check the position both in AP and lateral views. In the small proximal femur it may not be possible to use the long screw to pass along the calcar femoris into the femoral head. Once the positions are corrected, three cannulated LHSs are inserted. c–e With manual traction to locate the second-last hole of the plate that lies on the bone, drilling directly in the midlateral cortex and perpendicular to the bone, a cortex screw is inserted. After tightening, the bone will be reduced and held with the plate. After the length has been checked and is correct an additional cortex screw placed closer to the fracture will improve the quality and stability of the reduction. f The alignment is checked for length, axis, and rotation. The wedge fragment is reduced by using a bone hook or Schanz screw to pull it towards the side plate. g–h Cortex screws are fixed through the plate hole into the wedge fragment. Additional LHSs are then added to provide optimal stability for the construct.

Operating room setup

Anesthesia

Either general or regional anesthesia may be selected, the choice depends on the general condition and fitness of the patient. In this case general anesthesia was used.

Patient and image intensifier positioning

The patient is positioned supine on the radiolucent operating table, a rolled towel under the injured knee, with thigh and hip in flexion. The buttock on the injured side is elevated using a rolled towel. The image intensifier is positioned on the opposite side of the operating limb ( Fig 16.5-3 ). Before draping it is recommended to position the C-arm and check the image in both AP and lateral views. Preoperative assessment of the uninjured hip in external and internal rotation should be recorded as a reference for comparison with the injured side after preliminary fixation.