*
*
*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
*
Recommended
