Subtrochanteric Fractures

Question 1

denosumab or bisphosphonate use, particularly alendronate, can be risk factor

Answer 1

subtrochanteric fracture

Question 2

deforming forces on the proximal fragment

Answer 2

abduction-gluteus medius and gluteus minimus
flexion-iliopsoas
external rotators-

Question 2

rule out ____ femur fracture

Answer 2

pathologic or atypical

Question 3

risk factors for atypical or pathologic femur fractures

Answer 3

bisphosphonates or denosumab

Question 4

deforming forces on distal fragment

Answer 4

adduction and shortening

Question 5

_____ leads to net compressive forces on medial cortex and tensile forces on lateral cortex

Answer 5

weight bearing

Question 6

weight bearing leads to net compressive forces on medial cortex and _____ on lateral cortex

Answer 6

tensile forces

Question 7

Look on ____ xray to identify piriformis fossa extension

Answer 7

lateral

Question 8

Look on lateral xray to identify _____ extension

Answer 8

piriformis fossa

Question 9

major criteria suggesting atypical fracture

Answer 9

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

Question 10

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

Answer 10

major criteria suggesting atypical fracture

Question 11

minor criteria for atypical fracture

Answer 11

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

Question 12

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

Answer 12

minor criteria for atypical fracture

Question 13

presentation:

Answer 13

long history of bisphosphonate or denosumab
history of thigh pain before trauma occurred

Question 14

physical exam:

Answer 14

pain with motion
typically associated with obvious deformity (shortening and varus alignment)
flexion of proximal fragment may threaten overlying skin

Question 15

recommended radiographic views

Answer 15

AP and lateral of the hip
AP pelvis
full length femur films including the knee

Question 16

may assist with defining fragments in comminuted patterns but is not required

Answer 16

traction view

Question 17

XR findings

Answer 17

proximal fragment flexed and abducted
distal fragment adducted and ER

Question 18

____ fragment flexed and abducted

Answer 18

proximal

Question 19

____ fragment adducted and ER

Answer 19

distal

Question 20

bisphosphonate fracture features

Answer 20

lateral cortical thickening
increased diaphyseal cortical thickness
transverse vs. short oblique fracture orientation
medial spike (if complete fracture)
lack of comminution

Question 21

lateral cortical thickening
increased diaphyseal cortical thickness
transverse vs. short oblique fracture orientation
medial spike (if complete fracture)
lack of comminution

Answer 21

bisphosphonate fracture

Question 22

indications for non op

Answer 22

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

Question 23

indications for IM nail

Answer 23

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

Question 24

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

Answer 24

indications for IM nail

Question 25

indications for fixed angle plate

Answer 25

surgeon preference associated femoral neck fracture narrow medullary canal pre-existing femoral shaft deformity

Question 26

surgeon preference associated femoral neck fracture narrow medullary canal pre-existing femoral shaft deformity

Answer 26

fixed angle plate indications

Question 27

advantages of lateral positioning for IM nail

Answer 27

allows for easier reduction of the distal fragment to the flexed proximal fragment allows for easier access to entry portal, especially for piriformis nail

Question 28

allows for easier reduction of the distal fragment to the flexed proximal fragment allows for easier access to entry portal, especially for piriformis nail

Answer 28

lateral positioning for IM nail advantages

Question 29

advantages of supine positioning in IM nail

Answer 29

protective to the injured spine address other injuries in polytrauma patients easier to assess rotation

Question 30

protective to the injured spine address other injuries in polytrauma patients easier to assess rotation

Answer 30

supine positioning for IM nail advantages

Question 31

piriformis nail may mitigate risk of ____ from proximal valgus bend of trochanteric entry nail

Answer 31

iatrogenic malreduction

Question 32

preserves vascularity load-sharing implant stronger construct in unstable fracture patterns

Answer 32

pros of intramedullary nailing

Question 33

pros of intramedullary nailing

Answer 33

preserves vascularity load-sharing implant stronger construct in unstable fracture patterns

Question 34

cons of IM nail

Answer 34

reduction technically difficult mismatch of the radius of curvature

Question 35

nails with a larger radius of curvature (straighter) can lead to ____ of the distal femur

Answer 35

perforation of the anterior cortex

Question 36

IM nail complications

Answer 36

varus malreduction

Question 37

fixed angle plate approach

Answer 37

lateral approach to the femur

Question 38

may split or elevate vastus lateralis off later intermuscular septum dangers include perforating branches of profunda femoris

Answer 38

lateral approach to the femur

Question 39

dangers of lateral approach to the femur

Answer 39

perforating branches of profunda femoris

Question 40

____ is contraindicated due to high rate of malunion and failure

Answer 40

sliding hip screw

Question 41

blade plate may function as a ____

Answer 41

tension band construct

Question 42

cons of fixed angle plate

Answer 42

compromise vascularity of fragments inferior strength in unstable fracture patterns

Question 43

complications:

Answer 43

Varus/ procurvatum malunion nonunion bisphosphonate fractures

Question 44

the most frequent intraoperative complication with antegrade nailing of a subtrochanteric femur fracture is _____

Answer 44

varus and procurvatum (or flexion) malreduction

Question 45

rates of nonunion lowest when using reamed, _____

Answer 45

statically locked IMN

Question 46

nonunion can be treated with ____ allows correction of varus malalignment

Answer 46

plating

Question 47

bisphosphonates must be discontinued high rate of progression to fracture of ____

Answer 47

contralateral femur

Question 48

nail fixation of bisphosphonate fractures increases risk of

Answer 48

iatrogenic fracture and nonunion

Question 49

plate fixation of bisphosphonate fractures increases risk of

Answer 49

plate hardware failure