Intertrochanteric Hip Fracture - Intramedullary Hip Screw Technique
- synonyms:
- CPT = 27245(open treatment of IT, pertrochanteric or subtrochanteric femoral fracture with IM implant)
Anatomy
Indications
- Unstable intertrochanteric hip fractures
- Subtrochanteric hip fractures
- Reverse obliquity intertrochanteric hip fractures
- Impending / pathologic proximal femur fracture
Contraindications
- Femoral neck fracture
- Hip anklyosis
- Femoral shaft deformity
Alternatives
Pre-op Planning / Special Considerations
- Pre-operative medical clearance for all elderly patients.
- Pre-operative planning based on A/P pelvis and A/P and cross-table lateral xrays. Determine neck angle (usually 135 degrees). Ensure appropriate sized implants are available and no deformites are present in the femur.
- Use long stem device for any fracture with subtrochanteric extension.
Technique
- Pre-operative antibiotics, +/- regional block
- General endotracheal anesthesia
- Supine position on fracture table. All bony prominences well padded. Perineal post must be well-padded.
- Cushion heel and forefoot and place in traction boot.
- Postion with affected leg adducted and the torso shifted away from the fracture sight to maximize exposure to greater trochanter.
- Unaffected leg placed in leg holder with knee flexed and hip flexed and internally rotated
- Reduce fracture under fluorscopic guidance, usually axial traction and internal rotation. Confirm anterior cortex of femur, anterior femoral neck, posterior femoral neck and entire femoral head can be seen fluoroscopically.
- Prep and drape in standard sterile fashion at least to the knee. Shower curtain drape.
- Mark tip of greater trochanter and angle of femoral neck in the A/P plane. Mark femoral shaft in lateral plane.
- 2cm lateral longitudinal incision 2-4cm above tip of greater trochanter.
- Place finger down to greater trochanter.
- Place 3.2mm guide pin must medial to the tip of the greater trochanter on the A/P view and centered on the lateral view.
- Ream distally over the guide wire as indicated by manufacture technique. Provide medially directed pressure to ensure lateral cortex is not removed.
- Ream distally as needed for selected nail.
- Nail and attached to insertion guide and placed into the intrameduallary canal over the guide wire. The guide wire is then removed. The nail should be seated with simple hand pressure. Hammering risks fracture propagation.
- Attached guide for the sliding hip screw/guide pin. Ensure the screw will be placed in the center / center postion by estimating using the guide pin of manuctures rediolucent guides. If the pin does not appear parallel to the neck ensure that the fracture is not malreduced (usually varus). Ensure nail is seated properly for a center-center position.
- 3.2mm guide pin is placed ensuring tip-apex distance of within 5-10mm of the femoral head articular surface.
- Consider inserting anti-rotation pin for screw insertion.
- Ream femoral neck/head over the guide wire per manufacture technique guide.
- Place hip screw, +/- compression screw. Ensure traction is released prior to placing compression screw.
- Place distal locking screw via a stab incision using guide.
- Irrigate.
- Close tensor fascia proximal to the trochanter.
- Close in layers.
Complications
- Screw cut-out: associated with tip-apex distance >25mm, increasing age of the patient, an unstable fracture, a poor reduction, & use of a high-angle (150deg) side-plate
- Loss of fixation
- Nonunion
- Malunion (malrotation)
- Osteonecrosis of the femoral head
- Femoral shaft fracture (IMHS)
- Painful hardware
Follow-up care
- Consider DVT prophylaxis.
- Weight-bearing as tolerated.
- Typically require short-term rehabilitation.
- Osteoporosis evaluation is generally indicated.
Outcomes
Review References
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