2. LESSER
TUBEROSITY
AP pelvis and AP hip of an elderly patient
with a three-part intertrochanteric hip fracture.
3. LATERAL RADIOGRAPH
ISCHIUM
LESSER
TROCHANTER
FEMUR
The set up on the fracture table does not require the uninjured leg to be
placed in hyperflexion and abduction. The legs may be scissored to
allow for good lateral radiographs of the affected side without putting the
opposite hip at risk.
4. This image demonstrates the position of the fracture
table with the patient’s affected arm over the chest
and well padded.
5. SCDs ON
DURING
PROCEDURE
This image demonstrates the scissoring of the legs with the
affected side slightly flexed and the unaffected side slightly
extended. Notice that sequential compression devices remain
on the legs during the procedure.
6. A view from below demonstrates the position of the arm.
7. The C-arm is brought in from an angle approximately 30 degrees
distal to the patient. The AP radiograph is taken with the C-arm
slightly over rotated to give a more perfect AP view with respect
to the anatomy of the proximal femur and the lateral view.
8. The incision should begin proximally at the
trochanteric
ridge and need extend approximately 10 centimeters
down the thigh.
9. ITB
The incision brought down to the level of the
iliotibial band and fascia lata.
10. ITB
The iliotibial band is incised with a knife. A Metzenbaum
scissors is used to dissect under the band, which is divided
in line with the incision.
11. The iliotibial band is incised with a knife. A Metzenbaum
scissors is used to dissect under the band, which is divided
in line with the incision.
12. With retraction of the iliotibial band, the vastus
lateralis fascia is visualized.
VASTUS
LATERALIS
ITB
13. A sharp rake is introduced anteriorly and is used to retract the
vastus lateralis anteriorly. An incision is then made in the
fascia just anterior to the most posterior aspect of the femur.
14. A sharp rake is introduced anteriorly and is used to retract the
vastus lateralis anteriorly. An incision is then made in the
fascia just anterior to the most posterior aspect of the femur.
15. A periosteal elevator can be used to elevate the lateralis
off the femur with care taken to avoid perforating branches.
16. A Bennett retractor can be placed over the anterior
surface of the femur, exposing the lateral edge of
the femur.
17. AP x-ray demonstrating abduction of the proximal fragment
and displacement of the posteromedial fragment.
18. A bone hook can be used, as can a clamp or other
technique, to reduce the abduction in the proximal
fragment.
19. Once a reduction is obtained and confirmed on the AP
and lateral radiographs, the angle guide is placed against
the
lateral surface of the femur in order to place the guidewire
for the lag screw.
20. The natural anteversion of the hip requires commensurate
external rotation of the jig in order to drive the wire into the
center of the head.
21. X-rays demonstrating the position of the guidewire
through the jig in the AP and lateral planes.
22. After the appropriate measurement for the lag screw is
made, the femur is prepared by reaming. In this case, a long
barrel
was chosen and the appropriate reamer is selected.
23. If the bone is of good quality, a tap may be used.
25. When using a small incision, the side plate must be slid from proximal
to distal along the femoral shaft, then drawn back up proximally such
that it is within the wound.
26. In order to seat the side plate, its distal end must be held
gently off bone, such that the side plate is parallel with the
femur in order to engage the lag screw.
27. Once the plate is terminally seated and tapped in place,
it is affixed to the cortex using standard screw fixation.
29. In this particular situation, the posteromedial fragment was
rather large, thus it was elected to fix it with a lag screw.
This must be done from a position anterior to the side plate.
30. This is the case because the side plate must be slightly
posterior to the midline in order to direct the lag screw
into the center of the head, given the normal anteversion
of the neck.
31. The posteromedial fragment cannot be lagged through the
plate because the angle of the screw through the plate
would be too great. Thus, the screw is placed from anterior
to the plate as seen in this figure.
32. Lateral view of the posteromedial fragment
reduction with a clamp.
33. The image shows the drill that is placed into
the lesser trochanter.
34. Final AP radiograph demonstrating excellent fixation and
compression across the intertrochanteric fracture as well
as lag screw fixation of the lesser trochanter.
35.
36. VASTUS LATERALIS
ITB
The closure is then performed with a running
stitch of the vastus lateralis.
37. ITB
The iliotibial band is repaired using interupted sutures;
the skin will then be closed in layers.
