LESSER TUBEROSITY

AP pelvis and AP hip of an elderly patient with a three-part intertrochanteric hip fracture.

LATERAL RADIOGRAPH

ISCHIUM

FEMUR

LESSER TROCHANTER

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.

This image demonstrates the position of the fracture table with the patients affected arm over the chest and well padded.

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.

A view from below demonstrates the position of the arm.

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.

The incision should begin proximally at the trochanteric ridge and need extend approximately 10 centimeters down the thigh.

ITB

The incision brought down to the level of the iliotibial band and fascia lata.

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.

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.

ITB

VASTUS LATERALIS

With retraction of the iliotibial band, the vastus lateralis fascia is visualized.

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.

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.

A periosteal elevator can be used to elevate the lateralis off the femur with care taken to avoid perforating branches.

A Bennett retractor can be placed over the anterior surface of the femur, exposing the lateral edge of the femur.

AP x-ray demonstrating abduction of the proximal fragment and displacement of the posteromedial fragment.

A bone hook can be used, as can a clamp or other technique, to reduce the abduction in the proximal fragment.

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.

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.

X-rays demonstrating the position of the guidewire through the jig in the AP and lateral planes.

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.

If the bone is of good quality, a tap may be used.

AP radiograph of the lag screw being terminally seated.

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.

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.

Once the plate is terminally seated and tapped in place, it is affixed to the cortex using standard screw fixation.

AP radiograph of the lag screw and side plate in position.

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.

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.

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.

Lateral view of the posteromedial fragment reduction with a clamp.

The image shows the drill that is placed into the lesser trochanter.

Final AP radiograph demonstrating excellent fixation and compression across the intertrochanteric fracture as well as lag screw fixation of the lesser trochanter.

ITB

The closure is then performed with a running stitch of the vastus lateralis.

ITB

The iliotibial band is repaired using interupted sutures; the skin will then be closed in layers.