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Orthobullets Trauma > Intertrochanteric Fractures > Flashcards

Intertrochanteric Fractures Flashcards

1
Q

risk factors

A

proximal humerus fractures increase risk of hip fracture for 1 year
osteoporosis
advancing age
increased number of comorbidities
increased dependency with ADLs

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2
Q

associated conditions

A

osteoporosis
recurrent falls
dementia
parkinsons
unsteady gait
visual impairment
medications

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3
Q

what is the normal neck shaft angle

A

130 +/- 7 degrees

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4
Q

what is normal anteversion

A

10 +/- 7 degrees

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5
Q

intertrochanteric area exists between ____

A

greater and lesser trochanters

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6
Q

vertical wall of dense bone that extends from posteromedial aspect of femoral shaft to posterior portion of femoral neck

A

calcar femorale

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7
Q

what is the calcar femorale?

A

vertical wall of dense bone that extends from posteromedial aspect of femoral shaft to posterior portion of femoral neck

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8
Q

level of involvement helps determine stable versus unstable fracture patterns

A

calcar

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9
Q

what is the radius of curvature of the femur?

A

average 114-120 cm

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10
Q

factors that decrease radius of curvature

A

elderly
asian
short stature

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11
Q

what are the deforming forces on the proximal segment?

A

flexion, abduction, ER

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12
Q

deforming flexion forces

A

iliopsoas
sartorius
rectus femoris
pectineus

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13
Q

deforming abduction forces

A

gluteus maximus
gluteus medius
gluteus minimus
tensor fascia lata

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14
Q

deforming external rotation forces

A

piriformis
superior gemellus
obturator internus
inferior gemellus
quadratus femoris

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15
Q

deforming forces on distal segment

A

adduction and shortening
adductor longus
adductor brevis
adductor magnus
gracilis

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16
Q

rich collateral circulation reduces risk of _____

A

nonunion

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17
Q

trochanteric anastomosis:

A

ascending branch of medial circumflex femoral artery (MFCA)
ascending branch of lateral circumflex femoral artery (LFCA)
deep branch of superior gluteal artery
inferior gluteal artery

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18
Q

area of lowest BMD in femoral neck bordered by 3 main compressive/tensile trabeculae

A

ward’s triangle

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19
Q

what is ward’s triangle

A

area of lowest BMD in femoral neck bordered by 3 main compressive/tensile trabeculae

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20
Q

extends from medial femoral head along calcar and excellent support to proximal femur

A

primary compressive trabeculae

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21
Q

what is the primary compressive trabeculae

A

extends from medial femoral head along calcar and excellent support to proximal femur

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22
Q

vertically oriented with a triangular configuration

A

primary compressive trabeculae

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23
Q

forms an arc through the superior cortex of the femoral head and neck

A

principle tensile trabeculae

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24
Q

what is the principle tensile trabedculae

A

forms an arc through the superior cortex of the femoral head and neck

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25
Q

extends from greater trochanter to inferior aspect of femoral head below fovea

A

principle tensile trabeculae

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26
Q

fan-like configuration crossing from greater trochanter to lesser and also comprises calcar

A

secondary compressive trabeculae

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27
Q

what is the secondary compressive trabeculae?

A

fan-like configuration crossing from greater trochanter to lesser and also comprises calcar

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28
Q

what is the definition of a stable IT fracture?

A

intact posteromedial cortex

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29
Q

clinical significance of stable IT fractures

A

will resist medial compressive loads once reduced

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30
Q

definition of an unstable IT fracture

A

fracture will collapse into varus or shaft will displace medially

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31
Q

fracture will collapse into varus or shaft will displace medially

A

unstable IT fracture

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32
Q

factors that make an IT fracture unstable:

A

reverse obliquity
subtrochanteric extension
large or comminuted posteromedial cortex

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33
Q

fracture line extending from medial cortex out through lateral cortex

A

reverse obliquity

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34
Q

what is reverse obliquity

A

fracture line extending from medial cortex out through lateral cortex

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35
Q

measured from 3 cm distal from innominate tubercle at 135 degrees to the fracture site

A

lateral wall thickness

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36
Q

lateral wall thickness measured from:

A

measured from 3 cm distal from innominate tubercle at 135 degrees to the fracture site

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37
Q

lateral wall thickness <_____ mm suggest risk of postoperative lateral wall fracture

A

20.5

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38
Q

<20.5 mm suggest risk of postoperative lateral wall fracture
which should be treated with

A

cephalomedullary nail

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39
Q

key role in stabilizing proximal femur by providing lateral buttress

A

lateral wall thickness

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40
Q

predictor of postoperative functional status

A

pre-injury functional status

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41
Q

physical exam inspection will reveal

A

shortened, externally rotated lower extremity

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42
Q

physical exam palpation will reveal

A

tenderness over greater trochanter

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43
Q

physical exam:

A

pain with log roll and axial load
unable to perform active straight leg raise
TTP over greater trochanter

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44
Q

radiographic views to obtain

A

AP pelvis
AP hip
cross table lateral
full length femur

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45
Q

improve accuracy of fracture classification with direct impact on surgical planning

A

traction internal rotation view

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46
Q

compare this view to contralateral hip and assess neck shaft angle

A

AP pelvis

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47
Q

defines fracture pattern

A

AP hip

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48
Q

helps assess for posterior cortex comminution

A

cross table lateral

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49
Q

how does an AP hip view help you

A

defines fracture pattern

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50
Q

how does a cross table lateral help you

A

helps assess for posterior cortex comminution

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51
Q

full length femur films show what

A

assess subtrochanteric extension
possibility of pathological fracture
estimate length of intramedullary nail
assess femoral bowing
assess canal diameter

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52
Q

assess subtrochanteric extension
possibility of pathological fracture
estimate length of intramedullary nail
assess femoral bowing
assess canal diameter

A

full length femur films

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53
Q

second line imaging to evaluate for occult fracture
no access or contraindication to MRI

A

CT

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54
Q

CT indications

A

second line imaging to evaluate for occult fracture
no access or contraindication to MRI

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55
Q

MRI indications

A

occult hip fracture
isolated greater trochanteric fracture to evaluate for intertrochanteric extension

56
Q

occult hip fracture
isolated greater trochanteric fracture to evaluate for intertrochanteric extension

A

MRI

57
Q

bone marrow edema STIR or fat-suppressed T2
line of decreased intensity on T1 coronal view corresponding with signal on T2 and STIR

A

MRI findigns

58
Q

MRI findings

A

bone marrow edema STIR or fat-suppressed T2
line of decreased intensity on T1 coronal view corresponding with signal on T2 and STIR

59
Q

nonambulatory patients
high risk for perioperative mortality
skin breakdown at surgical site
incomplete fractures

A

non op

60
Q

non op indications

A

nonambulatory patients
high risk for perioperative mortality
skin breakdown at surgical site
incomplete fractures

61
Q

non op modalities

A

non-weight bearing with early mobilization from bed to chair

62
Q

non op outcomes

A

high mortality rate
84.4% at 1-year
higher rates of pneumonia, UTI, decubitus ulcers, and DVT
low risk of displacement with occult fracture

63
Q

mortality rate if non op

A

84.4% at 1 year

64
Q

operative techniques

A

cephalomedullary nail
ORIF
arthroplasty

65
Q

cephalomedullary nail indications

A

stable fracture patterns
unstable fracture patterns
reverse obliquity fractures
subtrochanteric extension
lack of integrity of femoral wall

66
Q

stable fracture patterns
unstable fracture patterns
reverse obliquity fractures
subtrochanteric extension
lack of integrity of femoral wall

A

cephalomedullary nail indications

67
Q

ORIF indications

A

stable fracture pattern

68
Q

sliding hip compression (SHS) screw (most common)
proximal femur locking plate
95 degree blade plate (rarely used)

A

ORIF techniques

69
Q

ORIF techniques

A

sliding hip compression (SHS) screw (most common)
proximal femur locking plate
95 degree blade plate (rarely used)

70
Q

salvage for failed internal fixation
severely comminuted fractures
preexisting severe degenerative hip arthritis
severely osteoporotic bone that is unlikely to hold internal fixation

A

arthroplasty indications

71
Q

arthroplasty indications

A

salvage for failed internal fixation
severely comminuted fractures
preexisting severe degenerative hip arthritis
severely osteoporotic bone that is unlikely to hold internal fixation

72
Q

biologically friendly with potentially closed technique
less estimated blood loss (EBL)
can be used in unstable fracture patterns
decreased bending strain on implant

A

cephalomedullary nail

73
Q

cephalomedullary nail pros

A

biologically friendly with potentially closed technique
less estimated blood loss (EBL)
can be used in unstable fracture patterns
decreased bending strain on implant

74
Q

periprosthetic fracture
higher implant cost than sliding hip screw
violation of hip abductors for insertion

A

cephalomedullary nail

75
Q

cephalomedullary nail cons

A

periprosthetic fracture
higher implant cost than sliding hip screw
violation of hip abductors for insertion

76
Q

advantages of a short nail

A

ease of use
decreased OR time
decreased EBL
lower implant cost

77
Q

disadvantages of long nail

A

increased OR time
increased EBL
increased radiation exposure
possible mismatch of implant bow and femur

78
Q

advantages of long nail

A

theoretical benefit of protecting entire femur

79
Q

short nail can tolerate up to ____ cm of subtrochanteric extension

A

3-4

80
Q

proven track record
femoral head rotation during insertion

A

lag screw

81
Q

theoretical benefit of compacting cancellous bone around blade during insertion
avoids removal of bone with reamer
biomechanical studies showing higher cutout resistance

A

helical blade

82
Q

helical blade benefits

A

theoretical benefit of compacting cancellous bone around blade during insertion
avoids removal of bone with reamer
biomechanical studies showing higher cutout resistance

83
Q

lag screw or helical blade cutout
anterior perforation of femur
perimplant fracture

A

cephalomedullary nail

84
Q

complications of cephalomedullary nail

A

lag screw or helical blade cutout
anterior perforation of femur
perimplant fracture

85
Q

lag screw with tip-apex distance should be less than ____ mm

A

25

86
Q

lag screw with tip-apex distance <____ mm is associated with reduced failure rates

A

25

87
Q

4 hole plates show no benefit clinically or biomechanically over ___ hole plates

A

2

88
Q

sliding hip screw pros

A

allows dynamic interfragmentary compression
lower implant cost
no violation of hip abductors

89
Q

allows dynamic interfragmentary compression
lower implant cost
no violation of hip abductors

A

sliding hip screw

90
Q

sliding hip screw cons

A

open technique
increased blood loss
not advisable in unstable fracture patterns
excessive fracture collapse
limb shortening
medialization of shaft
anterior spike malreduction in left-sided, unstable fractures due to screw torque

91
Q

open technique
increased blood loss
not advisable in unstable fracture patterns
excessive fracture collapse
limb shortening
medialization of shaft
anterior spike malreduction in left-sided, unstable fractures due to screw torque

A

sliding hip screws

92
Q

proximal femoral locking plate indication

A

infrequently used
consider in young patient with unstable fracture

93
Q

allow for intraoperative fracture compression
avoid excessive postoperative fracture compression
maintain limb length
avoid shaft medicalization

A

proximal femoral locking plate

94
Q

proximal femoral locking plate pros

A

allow for intraoperative fracture compression
avoid excessive postoperative fracture compression
maintain limb length
avoid shaft medicalization

95
Q

cons of proximal femoral locking plate

A

limited evidence
highly dependent on surgeon experience
must obtain anatomic reduction

96
Q

arthroplasty technique

A

long stem with calcar-replacing prosthesis often needed
must attempt fixation of greater trochanter to shaft

97
Q

arthroplasty pros

A

possible early return to unrestricted weight bearing
not reliant on internal fixation in osteoporotic bone

98
Q

arthroplasty cons

A

increased blood loss and OR time
increased cost
may require prosthesis that some surgeons are less familiar with

99
Q

complications:

A

Implant failure and cutout
nonunion and malunion
peri-implant fracture
Anterior perforation of the distal femur
Postoperative anemia and transfusions

100
Q

implant failure risk factors

A

older age
osteoporosis
fracture type
quality of reduction
tip-apex distance (TAD)

101
Q

older age
osteoporosis
fracture type
quality of reduction
tip-apex distance (TAD)

A

risk factors for implant failure

102
Q

tip apex distance

A

sum of distances from tip of lag screw to apex of femoral head on AP and latera

103
Q

sum of distances from tip of lag screw to apex of femoral head on AP and latera

A

tip apex distance

104
Q

goal tip apex distance

A

<25 mm

105
Q

TAD >45 mm associated with _____% failure rate

A

60

106
Q

treatment of implant failure and cutout in a young patient

A

corrective osteotomy and/or revision open reduction and internal fixation

107
Q

treatment of implant failure and cutout in an elderly patient

A

total hip arthroplasty

108
Q

nonunion incidence

A

<2%

109
Q

____ can occur with excessively lateral starting point (>3mm)

A

varus malreduction

110
Q

varus malreduction can occur with excessively ____ starting point (>3mm)

A

lateral

111
Q

hip pain with persistent radiolucent defect at fracture site 4-7 months after surgery

A

nonunion/malunion

112
Q

diagnosis of nonunion/malunion

A

hip pain with persistent radiolucent defect at fracture site 4-7 months after surgery
rule out infection

113
Q

nonunion/malunion treatment options

A

valgus intertrochanteric osteotomy + bone grafting
arthroplasty

114
Q

____ CMN typically fracture just distal to tip of nail

A

short

115
Q

short CMN typically fracture where

A

just distal to tip of nail

116
Q

____ CMN typically fracture more around the rod

A

long

117
Q

long CMN typically fracture where

A

around the rod

118
Q

distal interlocking screw protective against ____

A

fracture

119
Q

treatment of short CMN peri implant fracture

A

distally inserted lateral femoral plate with cables
revise to long CMN

120
Q

treatment of long CMN peri implant fracture

A

closed reduction and insertion of distal locking screw
distal femoral plating (fracture distal to tip)

121
Q

risk factors for anterior perforation of the distal femur

A

mismatch of the radius of curvature of the femur (shorter) and implant (longer)
posterior starting point on the greater trochanter

122
Q

mismatch of the radius of curvature of the femur (shorter) and implant (longer)
posterior starting point on the greater trochanter

A

anterior perforation of the distal femur risk factors

123
Q

post op transfusion rate

A

> 30%

124
Q

what medication is recommended to use to decrease EBL and post op transfusions

A

TXA

125
Q

Mortality risk in the first year following fracture

A

15-30%

126
Q

mortality at 1 year with non op

A

84.4%

127
Q

male gender (25-30% mortality) vs female (20% mortality)
higher in intertrochanteric fracture (vs femoral neck fracture)
operative delay of >2 days
age >85 years
2 or more pre-existing medical conditions
ASA classification (ASA III and IV increases mortality)

A

increase mortality

128
Q

factors that increase mortality

A

male gender (25-30% mortality) vs female (20% mortality)
higher in intertrochanteric fracture (vs femoral neck fracture)
operative delay of >2 days
age >85 years
2 or more pre-existing medical conditions
ASA classification (ASA III and IV increases mortality)

129
Q

factors that decrease mortality

A

Surgery within 48 hours decreases 1 year mortality
early medical optimization and co-management with medical hospitalists or geriatricians

130
Q

surgery within ____ decreases 1 year mortality

A

48 hours

131
Q

what is the one third general rule?

A

1/3 regain function
1/3 lose one level of independence
1/3 mortality rate

132
Q

_____% maintain pre-injury ambulatory status

A

41

133
Q

_____% become more dependent on assistive devices

A

40

134
Q

_____% became household ambulators

A

12

135
Q

_____% became nonfunctional ambulators

A

8

Orthobullets Trauma (63 decks)

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