CHẤN THƯƠNG CHỈNH HÌNH

1. Proximal femoral fractures
femoral neck and
intertrochanteric
Dr. Le trinh

2. Proximal Femoral Fracture
Bimodal age distribution
 Elderly
 Majority
 Low energy
 Osteoporosis
 Female
 Major impact on costing of
Health care system
 Young
 High energy
 Male

3. Anatomy
Lateral circimflex artery
Medial circumflex artery

4. trochanteric
area-
extracapsular
31-A
neck fracture –
intracapsular,
extraarticular
31-B
head fracture-
intracapsular,
intraarticular
31-C
Proximal femoral fractures

5. Intra-Osseous vasculation

6. Garden Classification (1961)
I II
Applied to subcapital fractures
Type I & II
Undisplaced fractures if
internal fixed in good position
Union rate ~ 90%, AVN ~10%
I II
III IV
Type III & IV displaced & unstable
Difficult to predict complication
Non union rate >30%-40%
ANV as high as 40%
High degree of inter-observer
variation

7. Pauwels classification (1935)
 High degree of inter and intra-observer variation
 Preoperative angle has no correlation with the
subsequent incidence of complications
<30 30 - 70 >70
Stable
Unstable

8. AO Classification = 31
 B1- subcapital fracture
 B2 – transcervical fracture
 B3 – subcapital fracture displace
 classified according to displacement
 valgus impacted position most stable
B1
B2
B3

9. Classification?
what does determine outcome?
 displacement - undisplaced vs. displaced
 stability - stable vs. unstable
valgus impacted are stable

10. Prognosis
Depends on displacement
Avascular necrosis
Non-union
Osteoarthritis
Deformity (shortening, varus)

11. Indication for fixation
 Stable and undisplaced fracture: cannulated
screws – implant of choice
minimal exposure
parallel to allow compression
Internal fixation will result
in only 10% failure rate

12. Displaced fractures
Internal fixation—complications
 30% fixation failure / loss of reduction
 40%Avascular necrosis
 Non-union

13. Displaced & unstable fractures
 Elderly patients (the majority)
 High rate of failure for internal fixation
 Joint arthroplasty gives most reliable
results
 Early weight bearing
 Early return to ADL training
 Young patients
 Internal fixation should be attempted
 Arthroplasty could be a secondary
procedure

14. Treatment algorithm
Young
Reduction and fixation
Elderly
Displace & unstable
Arthritis

15. Summary
 Prognosis is dependent on degree of
displacement and stability
 Internal fixation is indicated for all
undisplaced (stable) fractures, and for all
fractures in young patients
 Arthroplasty is indicated for displaced fractures
in the elderly

16. Proximal femoral fractures
trochanteric

17. Proximal Femoral Fracture
Bimodal age distribution
 Elderly
 Majority
 Low energy
 Osteoporosis
 Female
 Major impact on costing of
Health care system
 Young
 High energy
 Male

18. Anatomy
 Trochanteric area about the insertion site of
the abductor musclulature
 Region with generous blood supply
 Nonunion and AVN <1%

19. Different between femoral neck and
trochanteric fracture
 Intracapsular fractures
 Treatment
mechanically based
 Result biologically
determined
 Extracapsular fractures
 Treatment mechanically
based
 Result mechanically
determined

20. Anatomy
159 degree
Pauwels 1935
Rydell 1966
The forces acting on the
hip in single –limb stance
amount to ~ three times
the body weight applied
at an angle of 159 degree

21. Anteversion

22. What does the patient want?
 Treatment that enables them to return to
normal as soon as possible
 Stand & walk

23. Treatment options
- Nonoperative:
- ± 14 weeks bed rest
- Virtually impossible
- Secondary displacement
obligatory
- Operative

24. Principle of operative treatment
 Reestablish the continuity of
bone between the head and
neck fragment and the shaft
and to place the fixation
device ―central‖ in the
femoral head

25. Fracture—implant assembly
 Bone quality
 Fragment geometry
 Reduction
 Choice of implant
 Implant placement

26. Bone—quality
- Patient determined
- Considerable variations

27. Fracture—geometry
 Stable fracture
 Posteromedial buttress remains intact or
minimally comminuted
 Unstable fracture
 Large segment of the posteromedial wall is
fractured free and comminuted

28. Classification
Kyle et al classification

29. Müller AO Classification is suitable
for group 31 - A1, A2, and A3

30. Implant
Sliding device
Non sliding
device

31.  Fracture geometry
 Patient factor
 Surgeon’s choice

32. Fixation is not enough
Stable and strong impant - early functional
recovery

33. Compressive
Sliding device
Extramdullary Intramedullary

34.  D > d
d D

36.  The Value of the Tip-Apex Distance in Predicting
Failure of Fixation of Peritrochanteric Fractures
of the Hip
 Baumgaertner, Michael R; Curtin, Stephen L; Lindskog, Dieter M; Keggi, John M
 The Journal of Bone & Joint Surgery Am 1995; 77: 1058 - 1064

37. TAD
 To describe the position of the screw
 Sum of distance of tip of screw to apex of
femoral head on AP and Lat views after
correction made for magnification
Cut out No cut out
Age Mean 85
(67 – 95)
Mean 76
(19 – 100)
Cut out No cut out
TAD Mean 38mm
(28 – 48mm)
Mean 24mm
(9 – 63)

38. Nail position
1
2
3
1
2
3
Highest rates of cut out in
posterior-inferior & anterior-
superior zone
Significantly higher than in the
centre zone
Ant
Pos

39. A=81.3 mm2
A=26.7 mm2
Bone removal (DHS) Bone compaction
Sliding device - screws or blade

40. - biological reduction
- Very stable reconstruction
- weak implant
- open procedure
Non weight bearing
Partial weight bearing
Non sliding implant

41. -Biological reduction
- stable reconstruction
- strong implant
- semi-closed procedure
Direct full weight
bearing
Intramedullary / sliding implant

42. Conclusion
31-A1 (―stable‖) fractures might be
treated with any sliding device
31-A2 (―unstable―) fractures can be
treated either with an intramedullary
device which permits immediate full
weight bearing or a sliding hip
screw
If Extramedullary device implant-
protective weight bearing exercise

43. Thank You