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Subtrochanteric fracture

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Subtrochanteric fracture

  1. 1. Subtrochanteric fracture Orthopaedic surgeon : Zagarzusem.E
  2. 2. Fielding classification Subtrochanteric fractures is based on the level of the subtrochanteric region through which the fracture extends. • type I: at the level of the lesser trochanter (most common) • type II: within the region 2.5 cm below the lesser trochanter • type III: within the region 2.5 cm to 5 cm below the lesser trochanter (least common)
  3. 3. Seinsheimer’s classification • Type I: Nondisplaced fracture or one with less than • 2 mm of displacement • Type II: Two-part fracture • Type IIa: Transverse fracture • Type IIb: Spiral configuration with the lesser trochanter • attached to proximal fragment • Type IIc: Spiral configuration with the lesser trochanter • attached to distal fragment • Type III: Three-part fracture • Type IIIa: Three-part spiral configuration with the lesser • trochanter a part of the third fragment • Type IIIb: Three-part spiral configuration with the third • part a butterfly fragment • Type IV: Comminuted fracture with four or more • Fragments • Type V: Subtrochanteric - intertrochanteric configuration
  4. 4. Temporary Thomas splint Indications • Medically unfit for surgery • Polytrauma, in extremis
  5. 5. External fixator (subtrochanteric)
  6. 6. Compression plating - DCS (subtrochanteric)
  7. 7. Compression plating - locking plate (subtrochanteric)
  8. 8. preparation • Abducted contralateral leg The patient is positioned supine with the contralateral leg flexed and abducted.
  9. 9. Supine position without traction • The patient is positioned supine on a radiolucent table. The pelvis may be elevated by a firm cushion.
  10. 10. Bilateral traction • The patient is positioned supine with both legs in traction on a traction table.
  11. 11. Lateral decubitus position • The patient is positioned in lateral decubitus with the contralateral leg resting on the fracture table.
  12. 12. Knee flexed 30° • The patient is positioned supine on a radiolucent table with the knee in 30° flexion.
  13. 13. Approach • Antegrade nailing approach with piriformis entry point
  14. 14. Lateral approach • he fascia lata is split longitudinally and the vastus lateralis muscle is elevated off of the intermuscular septum.
  15. 15. • Skin incision
  16. 16. Opening the fascia lata • The fascia lata is incised with a scalpel and split with scissors parallel to the skin incision, along its fibers. • The muscle fascia over the vastus lateralis is exposed.
  17. 17. Separation of vastus lateralis from fascia lata • In the next step, the vastus lateralis is separated by blunt dissection from the fascia lata.
  18. 18. • The vastus lateralis is now retracted anteromedially. • The muscle fascia investing the vastus lateralis is incised about 1 cm anterior to the intermuscular septum.
  19. 19. Mobilization of vastus lateralis from intermuscular septum • The muscle is detached from the lateral intermuscular septum and the linea aspera with a periosteal elevator.
  20. 20. Minimally invasive ostheosynthesis approach • They vary according to the fracture location: • proximal (segment 1) • mid-shaft (segment 2) • distal femur (segment 3) sections.
  21. 21. MIO approach to the subtrochanteric region Skin incision • The lateral proximal incision starts at the greater trochanter and continues distally as far as needed.
  22. 22. Opening the fascia lata
  23. 23. Treatment • Stable fractures: Close reduction with DHS(Dynamic hip screw)
  24. 24. • Unstable fractures: Close reduction Gamma-nail(Small lever arm)
  25. 25. • Subtrochanteric fracture of femur without trauma in a patient with a new onset fracture. The figure shows a subtrochanteric fracture in a 66- yr-old woman with a history of 8 yr risedronate treatment.
  26. 26. Subtrochanteric fractures are from the base of the lesser trochanter to 5 cm distal
  27. 27. Low Subtroch Fx’s Most low subtrochanteric fractures with an intact piriformis fossa can be treated with a 1st gen IM Nail
  28. 28. When piriformis fossa is not involved and the lesser trochanter is fractured, a 2nd generation nail may be used
  29. 29. Nail or… Plate
  30. 30. Complications • Varus/ procurvatum malunion • Nonunion • Malunion: - Coxa varus - Shortening - Rotational deformity - Fixation failure - Failure of implant
  31. 31. D.S:Закр.подвертельный перелом правой бедренной кости со- смещ D.S: Closed subtrochanteric fracture of right femur
  32. 32. Do you have any question?
  33. 33. Thank you so much