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Closed Reduction of Intertrochanteric Fractures


- Radiographic Findings:
    - if possible intertrochanteric fractures should be closed reduced on the fracture table, prior to sterile draping;
    - allows adjustment of patient position (should it be necessary) and ensures that all equipement is working properly (on occassion frx table will malfunction);
    - radiographs are taken with special attention to cortical contact both medially (AP) and posteriorly (lateral);
    - in some cases, unstable intertochanteric fractures need to be reduced thru the incision;
    - stable frx:
          - usually stable fractures achieve an adequate closed reduction;
          - internal rotators of hip remain attached to distal frag, whereas usually some of short external rotators are still attached to proximal head & neck fragment;
                 - this alignment is important, for inorder to align distal frag, leg must usually be held in some degree of external rotation;

- Method of Reduction:
    - objective is to ahcieve stable reduction, whether in an anatomic or nonanatomic in configuration;
    - following GEA and positioning on frx table, traction is exerted on the slightly abducted extremity;
           - more abduction is required for fractures that have a varus deformity;
    - stable reduction requires providing medial & posterior cortical contact between major proximal & distal frag in order to resist varus and posterior displacing forces;
    - if good cortical contact is achieved as seen on the AP view, and good posterior cortical contact is seen on lateral view, frx can be fixed in anatomic position;
    - reduction is usually achieved w/ direct traction,  abduction, & ext. rotation;
           - traction is most important element in reducing interoch frx, since it restores neck shaft angle;
           - external rotation:
                  - comminuted frxs, esp when lesser trochanter frag is large displaced fragment, require more external rotation to close posterior defect;
                  - in comminuted fractures, it is especially important to avoid internal rotation since the patient will be left with the fracture fixed in internal rotation which is a major functional disability;
    - posterior displacement:
           - residual posterior displacement at frx site that requires femur to be lifted anteriorly to secure anatomic reduction at the time of surgery;
           - if posterior sag of frx occurs, frx should be reduced w/ upward pressure applied to buttock or femur;

- Open Reduction: Techniques:
    - Tronzo Frx:
         - frx w/ intact lesser trochanter and large spike on proximal frag;
         - inability to restore alignment of the distal fragment may result from psoas muscle obstruction;
         - in these frxs, iliopsoas tendon remains attached to lesser trochanter, and long spike on head & neck frag often gets caught between psoas and lesser troch;
         - occurs when lesser trochanter remains intact w/ large spike on proximal fragment;
         - iliopsoas tendon remains attached to lesser troch, & long spike on head often gets caught between iliopsoas & lesser trochanter;
         - even w/ strong traction, this frx tends to remain in varus;
         - surgical release of psoas tendon off lesser troch allows reduction
         - release of the iliopsoas tendon off lesser trochanter
         - these frxs require open reduction & notching of distal shaft so that neck frag will be impacted into notch in shaft to prevent medial migration of the shaft;
    - 4 part fracture:
         - most important consideration is to insert the guide wire (and sliding screw) up into the center of the femoral neck and head;
                - often there will be posterior displacement of the distal fragment, which requires a strong assistant to lift the fragment upwards with a bone hook;
                        - pressure must be reapplied during each passage of instruments across frx to prevent jamming of instruments on guide-pin;
                - alternatively, the surgeon may disregard the distal shaft fragment when inserting the sliding screw;
                        - if the proximal shaft fragment gets in the way of central gudie pin placement, then the triple reamer can be used to core a hole at the super edge of lateral shaft fragment inorder to provide better access for the guide wire to enter into the center of the femoral neck and head;
    - reversed obliquity:
         - for stability, these frx require open reduction & notching of distal shaft so that neck fragment will be impacted into notch in shaft to prevent medial migration of shaft;
         - alternatively, these fractures can be adress using the lateral position without a fracture table;
                - in this case the fracture is flex and rotated until anatomic reduction is achieved;
                - the fracture is then held with lag screws, and subsequently the guide pin is inserted under flouro;

- Non Anatomic Methods:
    - resorting to non anatomic means of achieving stability, for instance by osteotomy or medial displacement of proximal shaft;
           - Wayne County Reduction
           - Dimon and Hughston's technique
           - Sarmento's osteotomy
    - compared to a medial displacement osteotomy, an anatomic reduction is more able to load the medial cortex in patients w/ an unstable intertrochanteric fracture;
           - reference:
                  Biomechanical evaluation of anatomic reduction verus medial displacement osteotomy in unstable intertrochanteric fractures.


A Vascular Complication of Trochanteric- Entry Femoral Nailing on a Fracture Table