文稿2014學(xué)習(xí)劉軍輝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 n most common in extracapsular hip fracture. n3 4 in fracture,

2、35.7 in hip fracture. nThe elder people nMortality:15-30% nFM Mechanisms nThe 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 res

3、ponses of 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 nThe Yonger population High-energy mechanism associated injuries Spine Fibala Pelvis npathologic

4、 fracture Clinical characteristics nThe elder population The poor quality of bone mass Systemic disorders Diabetes Cerebral-vascular disease n No-operation Pneumonia Bedsore DVT Urinary infection Risk Factors nAge: 65 years nCo-morbid factors: osteoporosis, endocrine disorders (hyperthyroidism, hypo

5、gondaism), GIT disorders interfering with calcium/ Vit D absorption, neurological disorders (Parkinsons) nGender: F Risk Factors nNutrition: lack of calcium and Vit D in diet, eating disorders (anorexia), high caffeine intake nSmoking nAlcohol nMedication: steroids, anticonvulsants, diuretics nEnvir

6、onmental factors: loose rugs, dim lighting, cluttered floors Anatomy and Biomechanical Calcar femorale Internal scaffolding system of trabecular bone n The Singh grading system Muscular Anatomy nThe iliopsoas nThe major abductors nThe adductors nThe external rotators nThe hip extensors Muscular Anat

7、omy nThe iliopsoas n acts primarily to fl ex and externally rotate the hip joint shorten the limb Muscular Anatomy nThe major abductors （the gluteus medius, the gluteus minimus, and the tensor fasciae latae） nshorten the limb nvarus deformity. Muscular Anatomy nThe adductors (the adductor longus, th

8、e adductor brevis, the posterior portion of adductor magnus,and the gracilis) nvarus nexternal rotation Muscular Anatomy nThe external rotators （the piriformis, the superior gemellus, the inferior， gemellus, the obturator internus, the obturator externus, and the quadratus femoris) nexternal rotatio

9、n Muscular Anatomy nThe hip extensors (hamstrings and gluteus maximus) nshorten the extremity Presentation and Diagnosis nF nPain, swelling, petechia nAxial pain nunable to weight bear on that leg nshortened leg with external rotation nDR（AP，cross-table lateral of Hip） nCT nTechnetium 99m bone scann

10、ing nMRI Classification nBoyd -Griffin Classification nAO Classification nEvans nEvans-Jensen Treatment nPurpose early mobilization functional recovery reducing complication Treatment nConservative: The nonambulatory demented patient with little evidence of pain, The septic patient The patient with

11、signifi cant skin breakdown over proposed surgical sites. In the 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 chan

12、ce to walk again Conservative nearly mobilization with no attempt to preserve normal anatomy (disregarding the fracture)（ no hope of walking again ） nStabilization of the fracture with traction （ 15% of body weight ，8-12W，） weight bearing is allowed until full union occurs n Operative Treatment nPri

13、nciple Stable reduction Rigid internal fixation Early mobilization Operative Treatment nOperation bone quality fracture pattern fracture reduction Anatomical reduction Closed Reduction Open Reduction implant design implant placement TIMING OF SURGERY nKenzora noted increased mortality at 1 year in p

14、atients surgically stabilized within 24 hours of admission. n12-24 hours medical evaluation and optimizing of the patient s condition nsurgery should proceed within 48 hours n No difference in pain level or complications between patients treated with or without skin traction. nScrew-side plate devic

15、e: Stable (31A1 and many 31A2 fractures) The richards srew-plat system DHS DCS nIntramedullary device: Unstable (A3 and probably some A2 fractures) Gamma nail PFN PFNa Intertan nScrew-side plate device 0.51cm 135? 150 ? Center or Posteroinferior DHS DHS+TSP n DCS Liss Invasive Stabilization System n

16、 PF-LCP n nEnder nail nGamma nail nPFN nPFNAR Intertan n AO-surgry 31A1 No-operation(indication) operation(indication) CRIF(indication) ORIF(indication) Nailing(indication) DHS(indication) DHS(indication) AO-surgry 31A2 No-operation(indication) operation(indication)CRIF(indication) Nailing(indicatio

17、n) DHS(indication) Sliding hip screw with TSP(indication) AO-surgry No-operation(indication) operation(indication) CRIF(indication) ORIF(indication) Nailing(indication) Dynamic condylar screw(indication) Tip 1: Use the Tip-to-Apex Distance nOlder theories about screw placement favored a low and occa

18、sionally a posterior position of the lag screw,thereby leaving more bone superior and anterior to the screw. nThe 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 nBaumgaertner et al 1995, T

19、he tip-to-apex distance(TAD) Tip 1: Use the Tip-to-Apex Distance nTAD 25 mm has been shown to be generally predictive of a successful result; nMost traumatologists aim for a TAD 20 mm. Tip 2: No Lateral Wall, No Hip Screw nFractures that involve the lateral wall of the proximal part of the femur are

20、, by defi nition, either reverse obliquity fractures or transtrochanteric fractures. nNailing Tip 3: Know the Unstable Intertrochanteric Fracture Patterns, and Nail Them A reverse obliquity fractureA transtrochanteric fracture. Tip 3: Know the Unstable Intertrochanteric Fracture Patterns, and Nail T

21、hem A four-part fracture with a large posteromedial fragment A fracture with subtrochanteric extension Tip 4: Beware of the Anterior Bow of the Femoral Shaft n radius of curvature of 2 m n resistance is encountered during insertion of a long intramedullary nail，obtain a lateral radiograph of the dis

22、tal part of the femur Tip 5: When Using a Trochanteric Entry Nail, Start Slightly Medial to the Exact Tip of the GreaterTrochanter Tip 6: Do Not Ream an Unreduced Fracture nThe intertrochanteric fracture should be reduced to an aligned position before reaming and passing of the intramedullary nail n

23、The way that these fractures look during reaming will not change after the nail has been inserted. Tip 7: Be Cautious About the NailInsertion Trajectory, and Do Not Usea Hammer to Seat the Nail nA hammer is not recommended since its use can lead to iatrogenic femoral fracture. nthe intramedullary na

24、il should be passed by hand nthe intramedullary canal to a diameter that is 1 mm larger than the diameter of the selected intramedullary nail Tip 8: Avoid Varus Angulation of the Proximal FragmentUse the Relationship Between the Tip ofthe Trochanter and the Center of the Femoral Head nthe tip of the greater trochanter and the center of the femoral head. These two points should be coplanar. nIf the center of the femoral head is distal to the tip of the greater trochanter,