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Femur Fractures: Subtrochanteric To Supracondylar
Femur Fractures: Subtrochanteric To Supracondylar
Instructional Course
Lecture Handout
Evaluation of fracture
Surgical Planning
Implant Choices
o Piriformis fossa
o Greater trochanter
o Lesser trochanter
o Supine
o Lateral
o Fracture Table
o Piriformis Nail
o Trochanteric Nail
Problems
Wrong
Right
For IM nailing:
Reduction during reaming and the correct starting point are the keys to
optimal results
Operative tricks
Use instruments, clamps to reduce flexion and abduction
deformities prior to reaming
Start piriformis foss nail in line with shaft, guide pin NOT
pointing towards the lesser trochanter
The trochanteric insertion site should be just MEDIAL to the
tip of the trochanter
Skin incision for IM nailing is NOT at the tip of the trochanter
but rather 5-8 cms proximal and in line with the shaft
MUST have a way to assess LENGTH and ROTATION
References
1. Starr AJ, Hay MT, Reinert CM, Borer DS, Christensen KC.
Cephalomedullary nails in the treatment of high-energy proximal femur
fractures in young patients: a prospective, randomized comparison of
trochanteric versus piriformis fossa entry portal. J Orthop Trauma. 2006
Apr;20(4):240-6.
2. Perez EA, Jahangir AA, Mashru RP, Russell TA. Is there a gluteus
medius tendon injury during reaming through a modified medial trochanteric
portal? A cadaver study J Orthop Trauma. 2007 Oct;21(9):617-20.
3. Ostrum RF, Marcantonio A, Marburger R. A critical analysis of the
eccentric starting point for trochanteric intramedullary femoral nailing.
J Orthop Trauma. 2005 Nov-Dec;19(10):681-6.
4. French BG, Tornetta P 3rd. Use of an interlocked cephalomedullary nail
for subtrochanteric fracture stabilization. Clin Orthop Relat Res. 1998
Mar;(348):95-100.
5. McConnell T, Tornetta P 3rd, Benson E, Manuel J.
Gluteus medius tendon injury during reaming for gamma nail insertion. Clin
Orthop Relat Res. 2003 Feb;(407):199-202.
6. Streubel PN, Wong AH, Ricci WM, Gardner MJ.
Is there a standard trochanteric entry site for nailing of subtrochanteric femur
fractures. J Orthop Trauma. 2011 Apr;25(4):202-7.
Initial
Evaluation
Marker
of
energy
transfer
ATLS
Good
2ndary/tertiary
survey
Image
joint
above
and
joint
below
Knee
exam
Femoral
neck
Blood
Loss
1-3
units
per
femur
Never
blame
hypotension/
large
hct
drop
on
the
femur
shaft
fracture
without
working
up
the
other
potential
sites
of
blood
loss
External/
Chest/
Abdomen/
Pelvis
Ipsilateral
Femoral
Neck/
Shaft
Fractures
2.5-5%
of
femoral
shaft
fractures
Vertically
oriented
fractures
Often
minimally
displaced
Preop
x-rays,
preop
CT,
C
arm,
post
op
x-rays
Injury
AP
Pelvis
Challenge
Optimal
view
of
neck
is
15
degrees
of
IR
On
the
trauma
AP
pelvis
the
proximal
femur
is
usually
in
ER
CT
Scans
Lower
cuts
on
the
abdominal-pelvic
CT
include
the
femoral
neck
Methods
of
Fixation
Many,
many,
many
described
in
the
literature
Depends
on
whether
the
femoral
neck
fracture
is
detected
prior
to
or
after
fixation
of
the
femoral
shaft
fracture
Current
recs:
use
2
separate
devices
for
reduction
and
stabilization
of
each
fracture
individually
FN:
Nonunion/
AVN
Predictors
of
success:
Less
displacment
No
postero-medial
comminution
Anatomic
reduction
Stable
fixation
Fixation
Options
1)
Shaft:
retrograde
nail
/
Neck
sliding
hip
screw
and/
or
cannulated
screws
2)
Femoral
shaft
plate/
Neck:
sliding
hip
screw
and/
or
cannulated
screws
3)
Shaft:
IMN/Neck:
screws
placed
anterior
to
the
nail
Useful:
when
neck
fx
is
found
after
IMN
4)
Shaft
and
neck:
Cephalomedullary
nails
Stabilizes
both
fractures
Difficult
to
reduce/hold
2
deductions
at
one
and
stabilize
two
fractures
at
the
same
time
Femoral
Shaft
Fracture
Management
Management
Options
Cast:
not
for
anyone
older
than
???4-6ish
Traction-
temporizing
only
External
fixation-
temporizing
only
IMN
Plating
using
MIPPO
techniques
Traction
Initial
treatment
Decreases
pain
Decreases
ongoing
soft
tissue
damage
Traction
pin
Evaluate
the
knee
prior
to
pin
placement
Knee
effusion??
External
Fixation
Use
for
definitive
fixation
is
associated
with
multiple
problems:
Knee
stiffness
Malunion,
nonunion
Pin
site
infection/
osteomyelitis
Piriformis
Fossa
Start
Co-linear
with
shaft/
Posterior
Advantage:
In
line
with
the
axis
of
the
femoral
canal
PF
Disadvantage:
Anterior
displacement
by
more
than
6
mm
causes
high
hoop
stresses
that
can
cause
bursting
of
the
femoral
cortex
Lateral
or
medial
displacement
does
not
have
as
great
an
effect
Lateral
Trochanteric
Entry
Obese
&
muscular
patients
:
Faster
Less
radiation
Troch
Nail
Insertion
for
Femoral
Shaft
Fractures
Nail
designed
for
troch
insertion:
Proximal
lateral
bend
Prospective
trial/
61
consecutive
patients
46
patients
with
f/u
of
12
months
(12-25)
45/46
healed
after
1
operation
No
angular
mal-unions
(>10
degrees)
GT
Start/
Femoral
Shaft
Fractures:
Troch
Nail
Starting
Point
5
different
nails
3
different
troch
starting
points:
Tip
of
the
GT
2-3
mm
medial
2-3
mm
lateral
Subtroch
reverse
oblique
osteotomy
21
cadaveric
bones
The
tip
was
the
best
starting
point:
Best
alignment
regardless
of
the
nail
used
Lateral
start
was
the
worst
Always
led
to
varus
and
gapping
of
the
lateral
cortex
Conclusions:
Start
at
the
tip
or
just
medial
to
it
Avoid
a
lateral
start
point
Dont
ream
out
the
lateral
cortex
Retrograde
Femoral
Nailing
Starting
point
Just
anterior
to
the
ACL
fracture
Worry
with
open
fractures
Damage
to
the
ACL
during
insertion
Indications
for
Retrograde
IMN
1)
Multiple
Injuries
No
need
for
a
fracture
table/
or
bumps
Can
prep
and
drape
all
four
extremities
at
the
same
time
Access
to
chest
and
abdomen
not
blocked
2)
Ipsilateral
Femoral
Neck/
Shaft
Fractures
Treat
each
fracture
with
a
separate
device
3)
Obese
Patients
Very,
very
difficult
to
get
an
antegrade
starting
hole
4)
Floating
Knee
Same
incision
fir
the
tibial
and
femoral
nails
5)
Pre-existing
Hardware
Antegrade
starting
site
is
blocked
THR,
prior
hip
fractures,
etc
6)
Peri-prosthetic
Fractures
TKA
The
prosthesis
has
to
have
a
box
in
it
Make
sure
you
know
if
its
there/
the
diameter
of
it/
an
if
it
is
in
line
with
the
canal
7)
Knee
Arthrotomy
Incision
is
already
there
Contraindicated
with
gross
contamination
because
the
wound
will
now
communicate
with
the
fracture
site
8)
Ipsilateral
acetabulum
fractures
that
require
ORIF
Keep
away
from
the
area
of
future
incisions
9)
Pregnancy
???
Decreases
fetal
radiation
exposure????
10)
Through
knee
amputations
Looking
at
the
starting
point
11)
Contamination
of
the
antegrade
starting
hole
locations
(burns,
open
wounds,
etc)
12)
Unstable
spine
injuries
Patient
is
supine
on
the
table
without
the
need
for
any
bumps
Reamed
vs
Unreamed
Nails
Reaming:
Advantages?
Larger
diameter
nail
WBAT
on
12mm
nails
Increased
contact
area
between
IMN
and
endosteal
bone
Temporary
endosteal
perfusion
injury
with
hyperemic
periosteal
response
Autogenous
bone-grafting
The
Lung
and
Reaming
Reaming
Femoral
Shaft
Fx
Thoracic
injury
determines
the
pulmonary
complications!!!
In
a
resuscitated
patient
Notthe
Use
Of
A
Reamed
IM
Nail
Charash
J
Trauma
1994
Van
Os
J
Trauma
1994
Ziran
J
Trauma
1997
Bone
Clin
Orthop
1998
Bosse
JBJS
79A
1997
Prospective
,
randomized,
multi-center
trial
322
fractures:
Divided
based
on
ISS
<
>
18
Then
randomized
to
either
reamed
(171
fxs)
or
unreamed
IMN
(151
fxs)
All
were
nailed
within
24
hours
of
injury
Unreamed
group:
2/46
ARDS
P=.42
(not
sig)
2
deaths
Reamed
group:
3/63
ARDS
2
deaths
Need
39,817
patients
in
each
group
to
detect
a
difference
between
reamed
and
unreamed
nails
Canadian
Orthopedic
Trauma
Society
JBJS
2003
1/2/16
Supracondylar fxs:
Nail vs Plate
Paul Tornetta III
Professor
Boston Medical Center
Disclosures!
Publications:
Rockwood and Green, Tornetta and Ricci TIFS, Tornetta and Einhorn;
Subspecialty series, Court-Brown, Tornetta; Trauma, AAOS; OKU
Trauma, ICL Trauma, Tornetta; Op Techn in Ortho Surg, OTA Slide
project;Journals:; JOT; Deputy editor, CORR, JAAOS, JBJS; Reviewer
Intellectual Property
What to Choose?
A vs B vs C
A: extraarticular
B: partial articular
B: partial articular
Intact
portion of joint to
stabilize to
C: extraarticular with
intraarticular extension
A vs B vs C
A: extraarticular
B: partial articular
Intact
portion of joint to
stabilize to
C: extraarticular with
intraarticular extension
A vs B vs C
A: extraarticular
Principles
Restore
Intact
portion of joint to
stabilize to
C: extraarticular with
intraarticular extension
Principles
Restore
Length
Length
Alignment
Alignment
Angular
Angular
Rotational
Rotational
1/2/16
A Fractures
A Fractures
A Fractures
Options
Options
Options
Nail
Nail
Nail
Enough
room for
locking screws
Plate
Enough
room for
locking screws
Plate
Fixed
angle
room for
locking screws
Plate
Fixed
B Fractures
Enough
angle
B Fracture
Fixed
angle
Percutaneous ORIF
Shear fractures
Stabilize
To
B Fracture
C Fractures
Combination of A and B
Principles:
Restore
joint . C A
Stabilize
shaft
Complexity
of joint determines
options for stabilization
Fixed angle
1/2/16
Supracondylar Fractures
Short IM nails (GSH type)
Compared to fixed angle:
Equal
to varus load
Indications
IM Nails
Advantages
Midline
Disadvantages
incision
Indirect reduction
Minimal stripping
Blood loss
Reaming
IM Nails
Intraarticular
Large
Locking
Stress
Metaphyseal
comminution irrelevant
starting point
intercondylar portal ?
holes
S/P Nailing
Final
Grade 3 Open C2 Fx
1/2/16
Nonunion.BG
Technique
Midline incision
Poke
hole vs arthrotomy
Technique
Radiolucent table
Bolster
Distractor ?
Portal
Direct up shaft on AP and lat
Over-ream 1.5 mm
Lock at lesser trochanter
Incision
Arthrotomy
Portal Location
Canal Location
Nail Curvature
ch
Tro
Blu
men
ov
Gro
lear
stat
1/2/16
Portal Location
Portal Location
Even 1 mm
Proud is Bad!!
AP View
AP View
Flexion Arc
Avg arc 17
34 - 51
AP View
Physiologic
Valgus
Starter Reamer
Distally Lock
Check Length
1/2/16
Proximal Locking
Example
cross
1 cm medial
Blocking Screws
Blocking Reduction!
Results
Finals
Lucas 1993
25
Fractures (9 open)
A (6), type C (19)
6 Acute bone grafts
Avg. ROM > 100
Type
6 Required manipulation
1
Short, 1 12 varus
Late intraarticular infection
Two iatrogenic fractures
1
1/2/16
Results
Iannacone 1994
41
Technique
Bone quality
Distal femoral notching
Arthrofibrosis
Contraindicated if closed
intercondylar box
Treatment
Plates
Midline incision
Slightly
Obtain reduction
Ream 1.5 mm over nail size
Statically lock
Postop early motion
Results
Union in > 90%
Indications
Complex
Below
Low
Intraarticular
THA
A type fractures
Bowed
Distal
femora
1/3 fractures
1/2/16
Deformity
Intraarticular Fragment
Articular Reduction
Articular Reduction
Planned Axis
95
AP VIEW
Affix to Screw
LATERAL VIEW
Reduction
Fluoro
1/2/16
Fluoro
Incisions
2 Weeks
2 Weeks
1/2/16
6 Weeks
4 Months
stresses
Poor
varus collapse
Problems
Locked plates:
Fixed
angle periarticular
segments
Indirect
reductions
Biologically
friendly
Osteoporotic
bone
Problems..
Locked plates:
Fixed
angle periarticular
segments
Indirect
reductions
Biologically
friendly
Osteoporotic
bone
Problems
Locked plates:
Fixed
angle periarticular
segments
Indirect
reductions
Biologically
friendly
Osteoporotic
bone
metadiaphyseal
dissociation
surgery
10
1/2/16
Locked Plating
Incision
Deep Incision
Outrigger
Metadiaphyseal Reduction
Intraarticular fractures
Joint fixation
Outside
plate
Metadiaphyseal
reduction
Extraarticular fractures
Around knee implants
Visualization
11
1/2/16
Instrumentation
Slide in Plate
Provisionally Fix
Simple
Keep angles correct
Appropriate guides
Limit pieces
Screw options
Place Fixation
Final Alignment
Healing is Good
Grade 3A fx at 10
weeks
Good principles
Indirect reduction
Worst Problems
Initial Treatment
Delayed Fixation
Grade 3 open
12
1/2/16
Delayed Grafting
Delayed Grafting
Lateral Postop
5 Months
Periprosthetic Fractures
Periprosthetic Fractures
Periprosthetic Fractures
Periprosthetic Fractures
Periprosthetic Fractures
13
1/2/16
Henderson, et al
Henderson, et al
12 Matched pairs
Not for reduction
Review 15 pubs, 3 abstracts
Plate vs nail
SOLVED
SOLVED
www.orthotraumaresearch.com
SOLVED
158 Patients
SMFA
Bother
EQ
Health
EQ
Index
Malalignment >5
22%
Nails
Nail
22.2
22.9
79.1
0.76
32%
Plates
Plate
26.8
28.5
72
0.70
p=
0.29
0.3
0.11
0.25
No difference
WB,
Alignment
SOLVED
114
6.2
2.8
2.4
Plate 111
3.7
2.81
2.7
0.63
0.57
0.71
0.33
p=
Alignment
Valgus > 5
Varus > 5
Nail
12%
10%
Plate
28%
4%
Nail
Valgus > 5
Varus > 5
Nail
12%
10%
Plate
28%
4%
P = 0.05
14
1/2/16
SMFA
SOLVED
So Far
143 Patients (target 160)
45
40
35
30
25
75
Nails
68
Plates
Adverse events
20
52
15
10
Total
25%
20
3 Months
6 Months
12 Months
Alignment
Device related
Alignment
Valgus > 5
Varus > 5
Nail
9 (12%)
Plate
14 (20%)
1 (2%)
Adverse Events
Complications
Valgus > 5
Varus > 5
Nail
9 (12%)
Plate
14 (20%)
1 (2%)
Case Example
Nail
Plate
2 Nail
8 Screws
3
8 Plates
(3 out)
2
Nonunion
Infection
Arthrofibrosis
Painful Implant
Loose
Postop
5 DVT, 1 Death
20% Both groups
Revision
5%
8%
Nails
Plates
Hardware removal
15%
10%
15
1/2/16
3 Weeks
Nail!!!
Multitrauma..Open
CT
Intraop
Plate
Final
Summary
Nails
Metaphyseal
Long
comminution
shaft extension
Elderly
patients
Minimal
intraarticular extension
16
1/2/16
Summary
Plates
Complex
joint injury
Lock distally
Flexible construct
Deformity
TKA
of shaft
with no box
17