2014学习刘军辉- Femoral Fractures

1、Femoral Intertrochanteric Fractures,Liu Junhui,Department of Orthopaedics, SRRSH Hospital, Zhejiang University,Reference,From the extracapsular femoral neck to the area just distal to the lesser trochanter.,Definitaon,General Situation,most common in extracapsular hip fracture. 3 4 in fracture, 35.7

2、 in hip fracture. The elder people Mortality:15-30% FM,Mechanisms,The elder population Low-energy falls falls Postural and gait disturbances Decreased visual Hearing acuity Osteoporosis （1）The orientation of the faller should lead to an impact at or near the trochanter. （2）the protective responses o

3、f the patient （3）local soft tissues around the hip are unable to dissipate energy adequately （4） the bone strength is less than that necessary to withstand the residual energy imparted,Mechanisms,The Yonger population High-energy mechanism associated injuries Spine Fibala Pelvis pathologic fracture,

4、Clinical characteristics,The elder population The poor quality of bone mass Systemic disorders Diabetes Cerebral-vascular disease No-operation Pneumonia Bedsore DVT Urinary infection,Risk Factors,Age: 65 years Co-morbid factors: osteoporosis, endocrine disorders (hyperthyroidism, hypogondaism), GIT

5、disorders interfering with calcium/ Vit D absorption, neurological disorders (Parkinsons) Gender: F,Risk Factors,Nutrition: lack of calcium and Vit D in diet, eating disorders (anorexia), high caffeine intake Smoking Alcohol Medication: steroids, anticonvulsants, diuretics Environmental factors: loo

6、se rugs, dim lighting, cluttered floors,Anatomy and Biomechanical,Calcar femorale,Internalscaffolding system of trabecular bone,The Singh grading system,Muscular Anatomy,The iliopsoas The major abductors The adductors The external rotators The hip extensors,Muscular Anatomy,The iliopsoas acts primar

7、ily to ex and externally rotate the hip joint shorten the limb,Muscular Anatomy,The major abductors （the gluteus medius, the gluteus minimus, and the tensor fasciae latae） shorten the limb varus deformity.,Muscular Anatomy,The adductors (the adductor longus, the adductor brevis, the posterior portio

8、n of adductor magnus,and the gracilis) varus external rotation,Muscular Anatomy,The external rotators （the piriformis, the superior gemellus, the inferior， gemellus, the obturator internus, the obturator externus, and the quadratus femoris) external rotation,Muscular Anatomy,The hip extensors (hamst

9、rings and gluteus maximus) shorten the extremity,Presentation and Diagnosis,F Pain, swelling, petechia Axial pain unable to weight bear on that leg shortened leg with external rotation DR（AP，cross-table lateral of Hip） CT Technetium 99m bone scanning MRI,Classification,Boyd -Griffin,Classification,A

10、O,Classification,Evans,Evans-Jensen,Treatment,Purpose early mobilization functional recovery reducing complication,Treatment,Conservative: The nonambulatory demented patient with little evidence of pain, The septic patient The patient with signicant skin breakdown over proposed surgical sites. In th

11、e end stages of terminal illness Patients with unstable medical problems that are not correctable patients with old, less symptomatic fractures early mobilization ( Lose walking function ） Lyon and Nevins：nonambulatory or had little chance to walk again,Conservative,early mobilization with no attemp

12、t to preserve normal anatomy (disregarding the fracture)（ no hope of walking again ） Stabilization of the fracture with traction （ 15% of body weight ，8-12W，） weight bearing is allowed until full union occurs,Operative Treatment,Principle Stable reduction Rigid internal fixation Early mobilization,O

13、perative Treatment,Operation bone quality fracture pattern fracture reduction Anatomical reduction Closed Reduction Open Reduction implant design implant placement,TIMING OF SURGERY,Kenzora noted increased mortality at 1 year in patients surgically stabilized within 24 hours of admission. 12-24 hour

14、s medical evaluation and optimizing of the patient s condition surgery should proceed within 48 hours No difference in pain level or complications between patients treated with or without skin traction.,Screw-side plate device: Stable (31A1 and many 31A2 fractures) The richards srew-plat system DHS

15、DCS Intramedullary device: Unstable (A3 and probably some A2 fractures) Gamma nail PFN PFNa Intertan,Screw-side plate device 0.51cm 135? 150 ? Center or Posteroinferior,DHS,DHS+TSP,DCS,Liss Invasive Stabilization System,PF-LCP,Ender nail,Gamma nail,PFN,PFNAR,Intertan,AO-surgry,31A1,No-operation(indi

16、cation),operation(indication),CRIF(indication),ORIF(indication),Nailing(indication),DHS(indication),DHS(indication),AO-surgry,31A2,No-operation(indication),operation(indication),CRIF(indication),Nailing(indication),DHS(indication),Sliding hip screw with TSP(indication),AO-surgry,No-operation(indicat

17、ion),operation(indication),CRIF(indication),ORIF(indication),Nailing(indication),Dynamic condylar screw(indication),Tip 1: Use the Tip-to-Apex Distance,Older theories about screw placement favored a low and occasionally a posterior position of the lag screw,thereby leaving more bone superior and ant

18、erior to the screw. The ideal position for a lag screw in both planes is deep and central in the femoral head within 10 mm of the subchondral bone,Tip 1: Use the Tip-to-Apex Distance,Baumgaertner et al 1995, The tip-to-apex distance(TAD),Tip 1: Use the Tip-to-Apex Distance,TAD 25 mm has been shown t

19、o be generally predictive of a successful result; Most traumatologists aim for a TAD 20 mm.,Tip 2: No Lateral Wall, No Hip Screw,Fractures that involve the lateral wall of the proximal part of the femur are, by denition, either reverse obliquity fractures or transtrochanteric fractures. Nailing,Tip

20、3: Know the Unstable Intertrochanteric FracturePatterns, and Nail Them,A reverse obliquity fracture,A transtrochanteric fracture.,Tip 3: Know the Unstable Intertrochanteric FracturePatterns, and Nail Them,A four-part fracture with a large posteromedial fragment,A fracture with subtrochanteric extens

21、ion,Tip 4: Beware of the Anterior Bowof the Femoral Shaft,radius of curvature of 2 m resistance is encountered during insertion of a long intramedullary nail，obtain a lateral radiograph of the distal part of the femur,Tip 5: When Using a Trochanteric Entry Nail, Start Slightly Medial to the Exact Ti

22、p of the GreaterTrochanter,Tip 6: Do Not Ream an Unreduced Fracture,The intertrochanteric fracture should be reduced to an aligned position before reaming and passing of the intramedullary nail The way that these fractures look during reaming will not change after the nail has been inserted.,Tip 7:

23、Be Cautious About the NailInsertion Trajectory, and Do Not Usea Hammer to Seat the Nail,A hammer is not recommended since its use can lead to iatrogenic femoral fracture. the intramedullary nail should be passed by hand the intramedullary canal to a diameter that is 1 mm larger than the diameter of

24、the selected intramedullary nail,Tip 8: Avoid Varus Angulation of the Proximal FragmentUse theRelationship Between the Tip ofthe Trochanter and the Center of the Femoral Head,the tip of the greater trochanter and the center of the femoral head. These two points should be coplanar. If the center of the femoral head is distal to the tip of the greater trochanter, th