Hip fixation

*

*

*Extracapsular fractures (pertrochanteric

fractures)

*Intracapsular fractures (neck of femur)

*

*

*Posteromedial comminution (calcar)

*Subtrochanteric extension / reverse oblique

*Involvement of lateral cortex

*

*Sliding hip screw (SHS)

*Cephalomedullary device

*Fixed angle device

*

*For stable fractures

*Provide compression at fracture site

*Failure rates up to 12.5% reported

*Limited ability to resist fracture collapse and

medialization

*High failure in reverse oblique

*8 fold increase in failure rate in unstable

fractures (Palm et al. 2007)

TAD

should be

<25mm

*

*Best for unstable fractures

*Provides shorter lever arm – reduced bending forces

compared to SHS

*Acts as buttress to proximal femur

*Prevents medialization of shaft

*Biological advantage – less soft tissue disruption

*Femur fracture known complication of short nails

*No advantage over SHS in stable fractures

(a) Reverse obliquity fracture

(b) Cephalomedullary device acts as buttress to resist lateral displacement

of prox femur

Shorter lever arm in CMD – reduce bending forces

*

*DCS or blade plate – both at 95 degrees

*Infrequently used now

*No fracture impaction

* Increase femur head penetration if fracture collapse

*Blade plates

*Resist prox femur lateral translation

*Can be used in reverse oblique fractures – better than

SHS (Haidukewych et al. 2001)

*Has use in revision op – engage bone lower in femoral

head

*

*

*In undisplaced fracture – all can fix

*<60 years old – reduce and fix

*>80 years old – arthroplasty

*Type of arthroplasty best – no definitive study yet

*60 – 80 years old – opinions vary

*Good bone stock – can still reduce and fix

*But latest studies show more complications in

this age group if fix

*Therefore: own preference

Displaced

fractures

*

*Proper reduction is most important

*Gentle traction with internal rotate

* If failed closed, do open reduction – Watson Jones

approach preferable

* If highly comminuted – valgus deformity is more

stable

* If varus angulation of 20 degrees a/w 55% risk of

failure (Arnold et al 1984)

*

*Majority by cannulated screw or SHS with

derotational screw – provided can get

compression with loading (pauwels 1 + 2)

*In pauwels 3 – high shear forces – best with

fixed angled device

Pauwel osteotomy for vertical NOF fracture

*

*

*Remove haemarthrosis

*By aspirate or capsulotomy

*Postulated to reduce intracapsular pressure

*Timing of surgery

*Conflicting evidence

*Osteocyte death occurs slowly (2-3 weeks)

*Fix after 7 days no effect on rate of non-union or

AVN (Barnes et al 1976)

*16% rate of AVN in >12 hours fixation delay (Jain

et al 1994)

*

*Extracapsular – fracture stability determines

decision

*Intracapsular – patient’s age, displacement and

bone quality determines decision

*