Intertrochanteric Fractures Flashcards
(135 cards)
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
2
Q
associated conditions
A
osteoporosis
recurrent falls
dementia
parkinsons
unsteady gait
visual impairment
medications
3
Q
what is the normal neck shaft angle
A
130 +/- 7 degrees
4
Q
what is normal anteversion
A
10 +/- 7 degrees
5
Q
intertrochanteric area exists between ____
A
greater and lesser trochanters
6
Q
vertical wall of dense bone that extends from posteromedial aspect of femoral shaft to posterior portion of femoral neck
A
calcar femorale
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
8
Q
level of involvement helps determine stable versus unstable fracture patterns
A
calcar
9
Q
what is the radius of curvature of the femur?
A
average 114-120 cm
10
Q
factors that decrease radius of curvature
A
elderly
asian
short stature
11
Q
what are the deforming forces on the proximal segment?
A
flexion, abduction, ER
12
Q
deforming flexion forces
A
iliopsoas
sartorius
rectus femoris
pectineus
13
Q
deforming abduction forces
A
gluteus maximus
gluteus medius
gluteus minimus
tensor fascia lata
14
Q
deforming external rotation forces
A
piriformis
superior gemellus
obturator internus
inferior gemellus
quadratus femoris
15
Q
deforming forces on distal segment
A
adduction and shortening
adductor longus
adductor brevis
adductor magnus
gracilis
16
Q
rich collateral circulation reduces risk of _____
A
nonunion
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
18
Q
area of lowest BMD in femoral neck bordered by 3 main compressive/tensile trabeculae
A
ward’s triangle
19
Q
what is ward’s triangle
A
area of lowest BMD in femoral neck bordered by 3 main compressive/tensile trabeculae
20
Q
extends from medial femoral head along calcar and excellent support to proximal femur
A
primary compressive trabeculae
21
Q
what is the primary compressive trabeculae
A
extends from medial femoral head along calcar and excellent support to proximal femur
22
Q
vertically oriented with a triangular configuration
A
primary compressive trabeculae
23
Q
forms an arc through the superior cortex of the femoral head and neck
A
principle tensile trabeculae
24
Q
what is the principle tensile trabedculae
A
forms an arc through the superior cortex of the femoral head and neck
25
extends from greater trochanter to inferior aspect of femoral head below fovea
principle tensile trabeculae
26
fan-like configuration crossing from greater trochanter to lesser and also comprises calcar
secondary compressive trabeculae
27
what is the secondary compressive trabeculae?
fan-like configuration crossing from greater trochanter to lesser and also comprises calcar
28
what is the definition of a stable IT fracture?
intact posteromedial cortex
29
clinical significance of stable IT fractures
will resist medial compressive loads once reduced
30
definition of an unstable IT fracture
fracture will collapse into varus or shaft will displace medially
31
fracture will collapse into varus or shaft will displace medially
unstable IT fracture
32
factors that make an IT fracture unstable:
reverse obliquity
subtrochanteric extension
large or comminuted posteromedial cortex
33
fracture line extending from medial cortex out through lateral cortex
reverse obliquity
34
what is reverse obliquity
fracture line extending from medial cortex out through lateral cortex
35
measured from 3 cm distal from innominate tubercle at 135 degrees to the fracture site
lateral wall thickness
36
lateral wall thickness measured from:
measured from 3 cm distal from innominate tubercle at 135 degrees to the fracture site
37
lateral wall thickness <_____ mm suggest risk of postoperative lateral wall fracture
20.5
38
<20.5 mm suggest risk of postoperative lateral wall fracture
which should be treated with
cephalomedullary nail
39
key role in stabilizing proximal femur by providing lateral buttress
lateral wall thickness
40
predictor of postoperative functional status
pre-injury functional status
41
physical exam inspection will reveal
shortened, externally rotated lower extremity
42
physical exam palpation will reveal
tenderness over greater trochanter
43
physical exam:
pain with log roll and axial load
unable to perform active straight leg raise
TTP over greater trochanter
44
radiographic views to obtain
AP pelvis
AP hip
cross table lateral
full length femur
45
improve accuracy of fracture classification with direct impact on surgical planning
traction internal rotation view
46
compare this view to contralateral hip and assess neck shaft angle
AP pelvis
47
defines fracture pattern
AP hip
48
helps assess for posterior cortex comminution
cross table lateral
49
how does an AP hip view help you
defines fracture pattern
50
how does a cross table lateral help you
helps assess for posterior cortex comminution
51
full length femur films show what
assess subtrochanteric extension
possibility of pathological fracture
estimate length of intramedullary nail
assess femoral bowing
assess canal diameter
52
assess subtrochanteric extension
possibility of pathological fracture
estimate length of intramedullary nail
assess femoral bowing
assess canal diameter
full length femur films
53
second line imaging to evaluate for occult fracture
no access or contraindication to MRI
CT
54
CT indications
second line imaging to evaluate for occult fracture
no access or contraindication to MRI
55
MRI indications
occult hip fracture
isolated greater trochanteric fracture to evaluate for intertrochanteric extension
56
occult hip fracture
isolated greater trochanteric fracture to evaluate for intertrochanteric extension
MRI
57
bone marrow edema STIR or fat-suppressed T2
line of decreased intensity on T1 coronal view corresponding with signal on T2 and STIR
MRI findigns
58
MRI findings
bone marrow edema STIR or fat-suppressed T2
line of decreased intensity on T1 coronal view corresponding with signal on T2 and STIR
59
nonambulatory patients
high risk for perioperative mortality
skin breakdown at surgical site
incomplete fractures
non op
60
non op indications
nonambulatory patients
high risk for perioperative mortality
skin breakdown at surgical site
incomplete fractures
61
non op modalities
non-weight bearing with early mobilization from bed to chair
62
non op outcomes
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
mortality rate if non op
84.4% at 1 year
64
operative techniques
cephalomedullary nail
ORIF
arthroplasty
65
cephalomedullary nail indications
stable fracture patterns
unstable fracture patterns
reverse obliquity fractures
subtrochanteric extension
lack of integrity of femoral wall
66
stable fracture patterns
unstable fracture patterns
reverse obliquity fractures
subtrochanteric extension
lack of integrity of femoral wall
cephalomedullary nail indications
67
ORIF indications
stable fracture pattern
68
sliding hip compression (SHS) screw (most common)
proximal femur locking plate
95 degree blade plate (rarely used)
ORIF techniques
69
ORIF techniques
sliding hip compression (SHS) screw (most common)
proximal femur locking plate
95 degree blade plate (rarely used)
70
salvage for failed internal fixation
severely comminuted fractures
preexisting severe degenerative hip arthritis
severely osteoporotic bone that is unlikely to hold internal fixation
arthroplasty indications
71
arthroplasty indications
salvage for failed internal fixation
severely comminuted fractures
preexisting severe degenerative hip arthritis
severely osteoporotic bone that is unlikely to hold internal fixation
72
biologically friendly with potentially closed technique
less estimated blood loss (EBL)
can be used in unstable fracture patterns
decreased bending strain on implant
cephalomedullary nail
73
cephalomedullary nail pros
biologically friendly with potentially closed technique
less estimated blood loss (EBL)
can be used in unstable fracture patterns
decreased bending strain on implant
74
periprosthetic fracture
higher implant cost than sliding hip screw
violation of hip abductors for insertion
cephalomedullary nail
75
cephalomedullary nail cons
periprosthetic fracture
higher implant cost than sliding hip screw
violation of hip abductors for insertion
76
advantages of a short nail
ease of use
decreased OR time
decreased EBL
lower implant cost
77
disadvantages of long nail
increased OR time
increased EBL
increased radiation exposure
possible mismatch of implant bow and femur
78
advantages of long nail
theoretical benefit of protecting entire femur
79
short nail can tolerate up to ____ cm of subtrochanteric extension
3-4
80
proven track record
femoral head rotation during insertion
lag screw
81
theoretical benefit of compacting cancellous bone around blade during insertion
avoids removal of bone with reamer
biomechanical studies showing higher cutout resistance
helical blade
82
helical blade benefits
theoretical benefit of compacting cancellous bone around blade during insertion
avoids removal of bone with reamer
biomechanical studies showing higher cutout resistance
83
lag screw or helical blade cutout
anterior perforation of femur
perimplant fracture
cephalomedullary nail
84
complications of cephalomedullary nail
lag screw or helical blade cutout
anterior perforation of femur
perimplant fracture
85
lag screw with tip-apex distance should be less than ____ mm
25
86
lag screw with tip-apex distance <____ mm is associated with reduced failure rates
25
87
4 hole plates show no benefit clinically or biomechanically over ___ hole plates
2
88
sliding hip screw pros
allows dynamic interfragmentary compression
lower implant cost
no violation of hip abductors
89
allows dynamic interfragmentary compression
lower implant cost
no violation of hip abductors
sliding hip screw
90
sliding hip screw cons
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
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
sliding hip screws
92
proximal femoral locking plate indication
infrequently used
consider in young patient with unstable fracture
93
allow for intraoperative fracture compression
avoid excessive postoperative fracture compression
maintain limb length
avoid shaft medicalization
proximal femoral locking plate
94
proximal femoral locking plate pros
allow for intraoperative fracture compression
avoid excessive postoperative fracture compression
maintain limb length
avoid shaft medicalization
95
cons of proximal femoral locking plate
limited evidence
highly dependent on surgeon experience
must obtain anatomic reduction
96
arthroplasty technique
long stem with calcar-replacing prosthesis often needed
must attempt fixation of greater trochanter to shaft
97
arthroplasty pros
possible early return to unrestricted weight bearing
not reliant on internal fixation in osteoporotic bone
98
arthroplasty cons
increased blood loss and OR time
increased cost
may require prosthesis that some surgeons are less familiar with
99
complications:
Implant failure and cutout
nonunion and malunion
peri-implant fracture
Anterior perforation of the distal femur
Postoperative anemia and transfusions
100
implant failure risk factors
older age
osteoporosis
fracture type
quality of reduction
tip-apex distance (TAD)
101
older age
osteoporosis
fracture type
quality of reduction
tip-apex distance (TAD)
risk factors for implant failure
102
tip apex distance
sum of distances from tip of lag screw to apex of femoral head on AP and latera
103
sum of distances from tip of lag screw to apex of femoral head on AP and latera
tip apex distance
104
goal tip apex distance
<25 mm
105
TAD >45 mm associated with _____% failure rate
60
106
treatment of implant failure and cutout in a young patient
corrective osteotomy and/or revision open reduction and internal fixation
107
treatment of implant failure and cutout in an elderly patient
total hip arthroplasty
108
nonunion incidence
<2%
109
____ can occur with excessively lateral starting point (>3mm)
varus malreduction
110
varus malreduction can occur with excessively ____ starting point (>3mm)
lateral
111
hip pain with persistent radiolucent defect at fracture site 4-7 months after surgery
nonunion/malunion
112
diagnosis of nonunion/malunion
hip pain with persistent radiolucent defect at fracture site 4-7 months after surgery
rule out infection
113
nonunion/malunion treatment options
valgus intertrochanteric osteotomy + bone grafting
arthroplasty
114
____ CMN typically fracture just distal to tip of nail
short
115
short CMN typically fracture where
just distal to tip of nail
116
____ CMN typically fracture more around the rod
long
117
long CMN typically fracture where
around the rod
118
distal interlocking screw protective against ____
fracture
119
treatment of short CMN peri implant fracture
distally inserted lateral femoral plate with cables
revise to long CMN
120
treatment of long CMN peri implant fracture
closed reduction and insertion of distal locking screw
distal femoral plating (fracture distal to tip)
121
risk factors for anterior perforation of the distal femur
mismatch of the radius of curvature of the femur (shorter) and implant (longer)
posterior starting point on the greater trochanter
122
mismatch of the radius of curvature of the femur (shorter) and implant (longer)
posterior starting point on the greater trochanter
anterior perforation of the distal femur risk factors
123
post op transfusion rate
>30%
124
what medication is recommended to use to decrease EBL and post op transfusions
TXA
125
Mortality risk in the first year following fracture
15-30%
126
mortality at 1 year with non op
84.4%
127
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)
increase mortality
128
factors that increase mortality
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
factors that decrease mortality
Surgery within 48 hours decreases 1 year mortality
early medical optimization and co-management with medical hospitalists or geriatricians
130
surgery within ____ decreases 1 year mortality
48 hours
131
what is the one third general rule?
1/3 regain function
1/3 lose one level of independence
1/3 mortality rate
132
_____% maintain pre-injury ambulatory status
41
133
_____% become more dependent on assistive devices
40
134
_____% became household ambulators
12
135
_____% became nonfunctional ambulators
8
