- Radiographic Findings:
- if possible intertrochanteric fractures should be closed reduced on the fracture table, prior to sterile draping;
- this allows adjustment of patient position (should it be necessary) and ensures that all equipement
is working properly (on occassion the fracture table will malfunction);
- radiographs are taken with special attention to cortical contact both medially (AP) and posteriorly (lateral);
- in some cases,
unstable intertochanteric fractures need to be reduced thru the incision;
-
stable frx:
- usually stable fractures achieve an adequate closed reduction;
- internal rotators of hip remain attached to distal frag, whereas usually some of
short
external rotators are still attached to proximal head & neck fragment;
- this alignment is important, for inorder to align distal frag, leg must usually be
held in some degree of external rotation;
- Method of Reduction:
- objective is to ahcieve
stable reduction, whether in an anatomic or nonanatomic in configuration;
- following GEA and positioning on frx table, traction is exerted on the slightly abducted extremity;
- more abduction is required for fractures that have a varus deformity;
-
stable reduction of intertroch frx requires providing medial & posterior cortical contact between major
proximal & distal frag in order to resist varus and posterior displacing forces;
- if good cortical contact is achieved as seen on the
AP view, and good posterior cortical
contact is seen on lateral view, frx can be fixed in anatomic position;
-
reduction is usually achieved w/ direct traction,
abduction, & ext. rotation;
- traction is most important element in reducing interoch frx, since it restores neck shaft angle;
- external rotation:
- comminuted frxs, esp when
lesser trochanter frag is large displaced
fragment, require more external rotation to close posterior defect;
- in comminuted fractures, it is especially important to avoid internal rotation since the patient will be left
with the fracture fixed in internal rotation which is a major functional disability;
-
posterior displacement:
- residual posterior displacement at frx site that requires femur to be lifted
anteriorly to secure anatomic reduction at the time of surgery;
- if posterior sag of frx occurs, frx should be reduced w/ upward pressure applied to buttock or femur;
- Open Reduction: Techniques:
- Tronzo Frx:
- frx w/ intact
lesser trochanter and large spike on proximal frag;
- inability to restore alignment of the distal fragment may result from
psoas muscle obstruction;
- in these frxs,
iliopsoas tendon remains attached to lesser trochanter, and long spike
on head & neck frag often gets caught between psoas and lesser troch;
- occurs when
lesser trochanter remains intact w/ large spike on proximal fragment;
- iliopsoas tendon remains attached to lesser troch, & long spike on
head often gets caught between iliopsoas &
lesser trochanter;
- even w/ strong traction, this frx tends to remain in varus;
- surgical release of psoas tendon off lesser troch allows reduction
- release of the iliopsoas tendon off
lesser trochanter
- for stability: these frxs require open reduction & notching of distal shaft so that neck frag will be
impacted into notch in shaft to prevent medial migration of the shaft;
-
4 part fracture:
- most important consideration is to insert the guide wire (and sliding screw) up into the center of the
femoral neck and head;
- often there will be posterior displacement of the distal fragment, which requires a strong assistant
to lift the fragment upwards with a bone hook;
- pressure must be reapplied during each passage of instruments across frx to prevent jamming of instruments on guide-pin;
- alternatively, the surgeon may disregard the distal shaft fragment when inserting the sliding screw;
- if the proximal shaft fragment gets in the way of central gudie pin placement, then
the triple reamer can be used to core a hole at the super edge of the lateral shaft fragment
inorder to provide better access for the guide wire to enter into the center of the
femoral neck and head;
- reversed obliquity:
- for stability, these frx require open reduction & notching of distal shaft so that neck
fragment will be impacted into notch in shaft to prevent medial migration of shaft;
- alternatively, these fractures can be adress using the lateral position without a fracture table;
- in this case the fracture is flex and rotated until anatomic reduction is achieved;
- the fracture is then held with lag screws, and subsequently the guide pin is inserted under flouro;
- Non Anatomic Methods:
- resorting to non anatomic means of achieving stability, for instance by osteotomy or medial
displacement of proximal shaft;
-
Wayne County Reduction:
-
Dimon and Hughston's technique
-
Sarmento's osteotomy
- compared to a medial displacement osteotomy, an anatomic reduction is more able to load the medial cortex in patients
w/ an unstable intertrochanteric fracture;
- references:
Biomechanical evaluation of anatomic reduction verus medial displacement osteotomy in unstable intertrochanteric fractures.
Chang, WS et al. CORR Vol 225. 1987. p 141-146.
