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Re: R HIP / FEMUR FX + L FEMUR FX
Jeff Richmond 02 Февраль 2007, 00:29
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The most critical injury is the proximal fracture on the right.
Supine position on a radiolucent table.
Temporary (k-wire/guidewire) fixation in the neck if it can be anatomically reduced closed, open if necessary.
Retrograde nail right femur being careful that you don't knock off the neck fx.
DHS with de-rotation screw for neck (make sure you carefully tap the screw path so as not to spin off the reduction when the screw purchases, possible
even with a derotation screw) and use a plate that overlaps your nail (can put plate screws around nail, or through a locking hole). Alternatively, the synthes locking proximal femoral plate could be used.
Left side- same table/postion, antegrade nail
Jeff Richmond
North Shore University Hospital
Manhasset, NY
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Re: R HIP / FEMUR FX + L FEMUR FX
Chip Routt 02 Февраль 2007, 00:32
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Timing- now for the right, and now for the left if he remains well after the right is completed.
Sequence Right neck, right shaft, then left shaft.
2 positions 2 drapes/preps, rolled oblique for both.
Implants plenty of opinions exist for the right side...some would use neck screws anteriorly after reduction, then with a slender reamed locked nail
pushed in behind the neck screws for the shaft... some will advocate a recon nail for both...some will use a sliding screw for the neck then a retrograde shaft nail...some would use the sliding neck screw and a shaft plate also...lots of options.
I prefer excellent neck reduction either closed or open, screws high and low anteriorly for it, then a frail locked nail slipped in behind the neck screws for the shaft.
Some will also advocate hip capsulotomy as well to relieve capsular pressure related issues... it¹s done when you choose ORIF of the neck.
The left shaft fracture should accommodate an antegrade reamed locked nail after reduction, unless I¹ve missed some detail on the films as shown.
I¹d use 2 preps and drapes and assure that he¹s well after the right side before rolling on to the left.
Easy on the reaming-
Chip
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Re: R HIP / FEMUR FX + L FEMUR FX
Отправитель: Jjohn Schlechter 02 Февраль 2007, 14:55
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Dr. Routt,
Thank you for your reply. This maybe a stupid question. I am assuming that a "frail nail" is a
smaller diameter nail?
JS
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Re: R HIP / FEMUR FX + L FEMUR FX
David Zamorano 02 Февраль 2007, 00:34
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basicervical neck is normally treated with hip screw or cephalomedullary nail.
i would use fx table with 2 preps/drapes
after perfect reduction (either closed or open) i would attempt 1 implant to treat both (i.e. TFN or Intertan). can do anything though like Dr. Routt mentioned. intertan is nice because of the rotational stability it imparts in the neck
i would use an antegrade nail on the left
dpz
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Re: R HIP / FEMUR FX + L FEMUR FX
Alexaander Chelnokov 02 Февраль 2007, 00:36
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Dear John
> Timing and sequence of surgery ( which fx to fix first)
I would go to the simple side (left) first because if start with more difficult side and something goes wrong one can get stuck. And it is nice to know that when all problems still are sorted out you will have nothing more to do with the patient.
> Pt positioning
Supine - any other options?
> Implant(s)
Chip Routt listed all main options. The right proximal fracture looks closer to trochanteric. Most elegant solution would be to fix all with a single implant with minimal incisions. Long Gamma nail or any other reconstruction or proximal type nails are suitable. Technically less demanding wiuld be temporary neck pinning as is, retrograde nailing of the shaft, then final reduction and fixation of the trochanteric fracture as isolated, by DHS with 2 holes plate. Good luck.
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R HIP / FEMUR FX + L FEMUR FX
