Subtrochanteric Fractures Flashcards
denosumab or bisphosphonate use, particularly alendronate, can be risk factor
subtrochanteric fracture
deforming forces on the proximal fragment
abduction-gluteus medius and gluteus minimus
flexion-iliopsoas
external rotators-
rule out ____ femur fracture
pathologic or atypical
risk factors for atypical or pathologic femur fractures
bisphosphonates or denosumab
deforming forces on distal fragment
adduction and shortening
_____ leads to net compressive forces on medial cortex and tensile forces on lateral cortex
weight bearing
weight bearing leads to net compressive forces on medial cortex and _____ on lateral cortex
tensile forces
Look on ____ xray to identify piriformis fossa extension
lateral
Look on lateral xray to identify _____ extension
piriformis fossa
major criteria suggesting atypical fracture
Associated with no trauma or minimal trauma, as in a fall from a standing height or less
Fracture originates at the lateral cortex and is substantially transverse in its orientation, although it may become oblique as it crosses the medial femur
Noncomminuted
Complete fractures extend through both cortices and may be associated with a medial spike; incomplete fractures involve only the lateral cortex
Localized periosteal or endosteal thickening of the lateral cortex is present at the fracture site
Associated with no trauma or minimal trauma, as in a fall from a standing height or less
Fracture originates at the lateral cortex and is substantially transverse in its orientation, although it may become oblique as it crosses the medial femur
Noncomminuted
Complete fractures extend through both cortices and may be associated with a medial spike; incomplete fractures involve only the lateral cortex
Localized periosteal or endosteal thickening of the lateral cortex is present at the fracture site
major criteria suggesting atypical fracture
minor criteria for atypical fracture
Generalized increase in cortical thickness of the femoral diaphyses
Prodromal symptoms such as dull or aching pain in the groin or thigh
Bilateral incomplete or complete femoral diaphysis fractures
Delayed fracture healing
Specifically excluded are fractures of the femoral neck, intertrochanteric fractures with spiral subtrochanteric extension, pathological fractures associated with primary or metastatic bone tumors, and periprosthetic fractures
Generalized increase in cortical thickness of the femoral diaphyses
Prodromal symptoms such as dull or aching pain in the groin or thigh
Bilateral incomplete or complete femoral diaphysis fractures
Delayed fracture healing
Specifically excluded are fractures of the femoral neck, intertrochanteric fractures with spiral subtrochanteric extension, pathological fractures associated with primary or metastatic bone tumors, and periprosthetic fractures
minor criteria for atypical fracture
presentation:
long history of bisphosphonate or denosumab
history of thigh pain before trauma occurred
physical exam:
pain with motion
typically associated with obvious deformity (shortening and varus alignment)
flexion of proximal fragment may threaten overlying skin
recommended radiographic views
AP and lateral of the hip
AP pelvis
full length femur films including the knee
may assist with defining fragments in comminuted patterns but is not required
traction view
XR findings
proximal fragment flexed and abducted
distal fragment adducted and ER
____ fragment flexed and abducted
proximal
____ fragment adducted and ER
distal
bisphosphonate fracture features
lateral cortical thickening
increased diaphyseal cortical thickness
transverse vs. short oblique fracture orientation
medial spike (if complete fracture)
lack of comminution
lateral cortical thickening
increased diaphyseal cortical thickness
transverse vs. short oblique fracture orientation
medial spike (if complete fracture)
lack of comminution
bisphosphonate fracture
indications for non op
non-ambulatory patients with medical co-morbidities that would not allow them to tolerate surgery
limited role due to strong muscular forces displacing fracture and inability to mobilize patients without surgical intervention
indications for IM nail
historically Russel-Taylor type I fractures
newer design of intramedullary nails has expanded indications
most subtrochanteric fractures treated with IM nail
patients on bisphosphonate therapy with pain and radiographic evidence of stress fracture
historically Russel-Taylor type I fractures
newer design of intramedullary nails has expanded indications
most subtrochanteric fractures treated with IM nail
patients on bisphosphonate therapy with pain and radiographic evidence of stress fracture
indications for IM nail
indications for fixed angle plate
surgeon preference
associated femoral neck fracture
narrow medullary canal
pre-existing femoral shaft deformity
surgeon preference
associated femoral neck fracture
narrow medullary canal
pre-existing femoral shaft deformity
fixed angle plate indications
advantages of lateral positioning for IM nail
allows for easier reduction of the distal fragment to the flexed proximal fragment
allows for easier access to entry portal, especially for piriformis nail
allows for easier reduction of the distal fragment to the flexed proximal fragment
allows for easier access to entry portal, especially for piriformis nail
lateral positioning for IM nail advantages
advantages of supine positioning in IM nail
protective to the injured spine
address other injuries in polytrauma patients
easier to assess rotation
protective to the injured spine
address other injuries in polytrauma patients
easier to assess rotation
supine positioning for IM nail advantages
piriformis nail may mitigate risk of ____ from proximal valgus bend of trochanteric entry nail
iatrogenic malreduction
preserves vascularity
load-sharing implant
stronger construct in unstable fracture patterns
pros of intramedullary nailing
pros of intramedullary nailing
preserves vascularity
load-sharing implant
stronger construct in unstable fracture patterns
cons of IM nail
reduction technically difficult
mismatch of the radius of curvature
nails with a larger radius of curvature (straighter) can lead to ____ of the distal femur
perforation of the anterior cortex
IM nail complications
varus malreduction
fixed angle plate approach
lateral approach to the femur
may split or elevate vastus lateralis off later intermuscular septum
dangers include perforating branches of profunda femoris
lateral approach to the femur
dangers of lateral approach to the femur
perforating branches of profunda femoris
____ is contraindicated due to high rate of malunion and failure
sliding hip screw
blade plate may function as a ____
tension band construct
cons of fixed angle plate
compromise vascularity of fragments
inferior strength in unstable fracture patterns
complications:
Varus/ procurvatum malunion
nonunion
bisphosphonate fractures
the most frequent intraoperative complication with antegrade nailing of a subtrochanteric femur fracture is _____
varus and procurvatum (or flexion) malreduction
rates of nonunion lowest when using reamed, _____
statically locked IMN
nonunion can be treated with ____
allows correction of varus malalignment
plating
bisphosphonates must be discontinued
high rate of progression to fracture of ____
contralateral femur
nail fixation of bisphosphonate fractures increases risk of
iatrogenic fracture and nonunion
plate fixation of bisphosphonate fractures increases risk of
plate hardware failure
