Femur, proximal: extraarticular fracture, pertrochanteric, multifragmentary—31-A2



10.1055/b-0034-87635

Femur, proximal: extraarticular fracture, pertrochanteric, multifragmentary—31-A2

Theerachai Apivatthakakul, Suthorn Bavonratanavech

Case description


A 24-year-old man was involved in a motorcycle accident and sustained closed multifragmentary fractures of the right proximal femur at the level of the lesser trochanter with extension down to the proximal shaft. No other injury was sustained.



Indication for MIPO


As the fracture is multifragmentary, indirect reduction with fixation that provides relative stability is recommended. Open and direct reduction should be avoided because of the higher risk of complications, such as delayed union and infection, due to the disturbance in blood supply during operative intervention.

a–b X-rays show an intertrochanteric fracture with comminution extending down to subtrochanteric area.


Preoperative planning


In the preoperative planning, various treatment options are considered. The proximal femoral nail (PFN) and the dynamic hip screw (DHS) are deemed unsuitable as the lateral cortex is fractured at the entry point for the hip screw. As the point of insertion for the 95°-angled implants is intact, either the condylar plate or the dynamic condylar screw (DCS) may be used. The DCS is selected as it is the stronger implant and technically easier to apply. Once the hip screw is inserted in the correct position the side plate will align along the femoral shaft and manual indirect reduction is possible. A DCS with 70 mm screws and 16-hole side plate will be used ( Fig 16.4-2 ).

a In the case of a short proximal femur there are deforming forces from muscles that distort the normal anatomy and the landmark for guide-wire insertion into the femoral head and neck. b The recommended technique is insertion of a Schanz screw into the proximal femur which counteracts muscle pull into the AP hip. Placement of the Schanz screw should not interfere with guide-wire insertion. The guide wire is inserted at 95° in AP and about 5° anteversion. The C-arm is used to check the position of the guide wire and replacement may be necessary for its correct positioning before reaming for the DCS. c Screw length is determined with a direct measuring device after the guide wire is inserted in the correct position in AP and lateral, with reduction of 1 cm from the articular surface of the femoral head. After reaming with the triple reamer a DCS is inserted using a screw 5 mm longer than measured. This allows for 5 mm at the end of the screw to stay outside the lateral cortex of the femur to facilitate side-plate insertion. d A submuscular, epiperiostal tunnel is prepared. The side plate is slipped along the femoral shaft with the barrel pointing laterally and turned in after it is fully introduced. The Schanz screw is used to manipulate the proximal fragment and to facilitate insertion of the side plate. e–g An additional cortex screw is inserted proximally to secure the fixation. After manual traction (f) another cortex screw is inserted as an indirect reduction tool and to hold the distal fragment in temporary fixation (g). h The alignment of axis and length is checked with image intensification before definitive fixation. Rotation is checked by comparing the degree of internal and external rotation of the injured hip with preoperative range of motion of the uninjured hip. Three screws span the plate and fix the femur distally.

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Jul 2, 2020 | Posted by in ORTHOPEDIC | Comments Off on Femur, proximal: extraarticular fracture, pertrochanteric, multifragmentary—31-A2

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