Orthopaedic grand round

1. GRAND ROUND
Dr. Yasir Jameel
Clinical Fellow Orthopadic Trauma

2. • 80 year old male sustaind fall at home and
presented with hip pain to A&E

3. • History

4. • Age, sex, occupation
• Presenting complain
• History of PC
• Past medical history
• Past surgical history
• Drugs, Allergies
• Social history

5. Investigations

6. X-rays

7. X-rays

8. X-rays

9. Subtrochenteric femur fracture
• Subtrochanteric area typically defined as area
from lesser trochanter to 5cm distal.
• fractures with an associated intertrochanteric
component may be called intertrochanteric
fracture with subtrochanteric extension or
peritrochanteric fracture

10. Epidemiology
• Younger patients with a high-energy
mechanism RTA
• may occur in elderly patients from a low-
energy mechanism
• Pathologic or atypical femur fracture
• Bisphosphonate use, particularly alendronate,
can be risk factor
• Preveious neck fixation with screws placed
with entry below lesser trochenter

11. Anatomy

12. Pathoanatomy
• Deforming forces on the proximal fragment
• Abduction
gluteus medius and gluteus minimus
• Flexion
iliopsoas
• External rotation
short external rotators
• deforming forces on distal fragment
• Adduction
hip adductors
• Shortening
quads and hamstrings

13. Pathoanatomy

14. Biomechanics
• Posteriomedial femur undergoes compressive
forces
• Lateral femur undergoes tensile forces

15. Russell-Taylor Classification
• Based on integrity of the piriformis fossa.
• Designed to guide treatment of intramedullary nails
using a piriformis fossa starting point.
Type I - intact piriformis fossa
A - lesser trochanter attached to proximal fragment
B - lesser trochanter detached from proximal fragment
Type II - fracture extends into piriformis fossa
A - stable posterior-medial buttress
B - comminution of lesser trochanter

16. Russell-Taylor Classification

17. RT Type 2 B

18. Treatment
• Nonoperative
– observation with pain management
• indications
– non-ambulatory patients with medical co-morbidities not fit
for surgery
– limited role due to strong muscular forces displacing fracture
and inability to mobilize patients without surgical intervention

19. Treatment
• Operative
– intramedullary nailing (usually cephalomedullary)
• indications
– historically Russel-Taylor type I fractures
– newer design of intramedullary nails has expanded indications
– most subtrochanteric fractures treated with IM nail
– fixed angle plate
• indications
– surgeon preference
– associated femoral neck fracture
– narrow medullary canal
– pre-existing femoral shaft deformity

20. Complications
• Varus/ procurvatum malunion

21. Complications
• Nonunion
Incidence of 0-8% , continued inability to bear
weight at 4-6 months and continued pain.
Varus malreduction is an important predictor
of nonunion accompanied by implant failure.

22. Complications
• Malunion:
Coxa varus: Caused by uncorrected abduction
deformity, nail entry point that is too lateral, and
migration of hardware proximally in the femoral
head and neck
Shortening: Due to uncorrected shortening
intraoperatively and premature dynamization.
Rotational deformity: Do to uncorrected external
rotation of proximal fragment. This can be
assessed intraoperatively with visualization of the
lesser trochanter

23. Complications
• Fixation failure: Most common in osteoporotic
bone. Screw cutout in the femoral head;
backing out of locking screws.
• Failure of implant: Excessive motion at
fracture site leads to implant fatigue

24. • Do you have any question??????????????????

25. THANK YOU