Peggers’ Super Summary Subtrochanteric Fractures of the Femur

Indications:

  • Low of extended subtrochanteric fractures
  • Unstable intertrochanteric fractures with reverse pattern
  • Fractures with Peritrochanteric or diaphyseal extension
  • Failed plate fixation
  • Pathological lesion or fractures

Anatomy:

  • Superior gluteal nerve is 5cm proximal to GT
  • Abductor muscles cause varus of distal portion
  • Iliopsoas causes flexion of proximal portion of femur

Associated injuries

  • Pelvis
  • Knee

Preoperative Planning:

  • Often flexed and in varus
  • Review imaging to see fracture extension
  • Extension into neck
  • Trochanteric region
  • Piriformis fossa (posterior and medial to GT)
  • Femoral properties
  • Femoral length
  • Canal diameter
  • Neck shaft diameter

Equipment

  • Prosthesis
  • Intramedullay
  • Proximal Femoral nail (short or long)
  • Gamma nail
  • Recon Nail
  • Extramedullary
  • Blade plate
  • Traction table
  • II
  • Haygroves and reduction tools if fracture site needs to be reduced via open technique
  • Schanz pins are useful for percutaneous reduction of distal fragment

Operative Room Planning

INTRODUCTION

  • Confirm Consent / Mark / WHO form / Abx at induction

POSITION

LATERAL

  • Allows hip flexion to reduce fracture
  • Start point easier
  • Protects superior gluteal nerve

SUPINE

  • Less assistance
  • Easier II use
  • 150 adduction to facilitate guide wire and nail entrance

DRAPING

  • Will depend on final postioning
  • Antiseptic solution from iliac crest to below knee
  • Lateral drape like a hemiarthroplasty BUT leave knee exposed for distal locking screw
  • Supine drape like a DHS with distal femur exposed to allow locking screw insertion distally

Surgical Approach

  • Reduce fracture on table before to allow simpler fixation
  • Make an incision from proximal to distal on the patient 5-8cm above GT
  • Incise the gluteus maximus fascia and split the fibres in line with the fibres
  • Insert curved awl or 2.8mm guide wire to locate entry point of GT (medial side and central on lateral II)
  • Use II to ensure correct insertion of wire pass the fracture site check AP/Lat before reaming at the level of the knee
  • NB on lateral knee radiography check the guide wire is central to avoid reaming the anterior cortex and creating a stress riser
  • ANY MALREDUCTION and starting reaming will only result in eccentric reaming and worsening of deformity
  • Use the cannulated drill bit to ream as far as possible until reaching the protection sleeve
  • Ream to 1.0 size bigger than the prosthesis – reaming is stopped until diaphyseal chatter isfelt over the isthmus
  • Nail length is measured using a ruler
  • Insert an appropriate length nail paying attention to rotation of the handle may cause malalignment of the nail
  • Nail is inserted until the neck and head pins appear in alignment
  • The head screws should be central or slightly inferiorly and posteriorly
  • NB check nail length before locking nail proximately – if the cephalic screw is inferior in the neck and superior in the head the femur may be in varus
  • Lastly the guide wire is backed out and distal locking screws are inserted via the ‘perfect circle’ technique
  • Check radiographs are used both proximately and distally
  • If removal may be required an end cap is placed in the proximal end of the nail

Closure

  • Irrigate ++
  • Haemostasis
  • No1 vicryl for fascia
  • 2/0 vicryl for fat and subcutaneous
  • 3/0 nylon or vicryl rapide for the skin
  • Dressings

Operative Note

Unstable # NOF right Recon nailing + static locking

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GA,Supine position

# table

sterile preparation

lead butter manoeuvre

satrisfactory reduction

Standard recoh nailing procedure

medullary canal sequentially reamed over a guide wire upto size 14

13x 360 nail introduced

static locking

satisfactory images

closed in layers

Cleaned and dressed

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antibiotics x 3 doses

analgesics

Rpt bloods 48 hrs= change dressings

Mobilise within comfort

Sutures out 2 weeks

# clinic 6 weeks

  • LeadbetterTechnique:
  • flex the hip to 900
  • with slight adduction, and apply traction in line with the femur
  • next, while maintaining traction, apply internal rotation to 450 (idea is that when the hip is flexed to 900 all muscles about the hip are maximally relaxed)

Complications:

Early

  • Infection
  • Periprosthetic fracture
  • Damage to superior gluteal nerve

Late

  • Proximal screw cut out or failure
  • Non or Malunion
  • Nail breakage

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