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Year : 2005  |  Volume : 39  |  Issue : 4  |  Page : 237-239
Management of subtrochanteric fractures with a sliding hip screw-plate device


Tejasvini Hospital and SSIOT, Kadri, Mangalore, Karnataka, India

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   Abstract 

Background: Subtrocahnteric fractures pose a problem in management.
Methods: Twenty three subtrochanteric fractures were treated with sliding screw plate. Russell-Taylor Type II fractures were 78% and Type I were 22%.
Results: Union was achieved in 21 patients. Fractures with medial cortical comminution were most unstable and were at great risk of complication.
Conclusion: The sliding screw plate device is a reliable method of achieving union in subtrochanteric fractures in Russell Taylor type II fractures.

Keywords: Subtrochanteric fractures; Sliding screw plate.

How to cite this article:
Shetty M S, Kumar M A, Ireshanavar S S. Management of subtrochanteric fractures with a sliding hip screw-plate device. Indian J Orthop 2005;39:237-9

How to cite this URL:
Shetty M S, Kumar M A, Ireshanavar S S. Management of subtrochanteric fractures with a sliding hip screw-plate device. Indian J Orthop [serial online] 2005 [cited 2014 Nov 22];39:237-9. Available from: http://www.ijoonline.com/text.asp?2005/39/4/237/36577

   Introduction Top


Historically the problems encountered in the operative treatment of subtrochanteric fractures have been failure of fixation and non-union [1],[2] due to strong deforming muscle forces and frequent communition. Anatomic reduction is difficult to achieve and maintain, as the fracture occurs predominantly through cortical bone it is associated with prolonged healing time compared to other hip fractures.


   Materials and methods Top


Prospective and retrospective analysis of 26 cases done between January 2001 and June 2004, treated operatively with sliding hip screw. Of the 26 cases, 2 died within 6 months of discharge from the hospital and one case was lost for follow up and hence was excluded from this study. The remaining 23 cases were reviewed with regard to fracture type, time to union, blood loss and mobility.

Eighteen cases were Russell Taylor Type II and remaining 5 were Russell Taylor Type I. Sixteen patients were more than 50 years of age. Fourteen patients were males and 16 had right sided involvement. Operation was performed as soon as the medical condition permitted. All the patients were operated on a fracture table through lateral approach under image intensifier. Care was taken not to devascularise the comminuted fragments.

The purpose of the procedure was to achieve internal fixation with controlled sliding of the proximal fragment leading to union and hastening mobilization. If fractures deemed stable (bone to bone medial cortex contact), partial weight bearing was begun within 1 week. All the patients were capable of partial weight bearing within 2 months. The criteria for proceeding to full weight bearing were radiographic evidence of healing and absence of pain. The average time to full weight bearing was 2.5 months (6 weeks - - 11 months).

Radiographs were taken in the immediate post operative period, then at 6 weeks, 6 months and 1 year. Fracture union was defined as that period between injury and full weight bearing with a roentgenographically healed fracture characterised by cortical bridging of the fracture on 2 views. Delayed union was considered present if roentgenographs did not demonstrate fracture consolidation by 9 months. Malunion was defined as limb shortening or lengthening greater than 1 cm, 10 degree angulation in any plane or rotational malignment greater than 15 degree.


   Results Top


Union was achieved in 21 of 23 patients (91.3 %). The mean time to osseous union was 2.5 months (range 2 months-7 months). The average length of hospitalization was 15 days (8-26 days) in patients with injury only in the subtrochanteric area and 34 days (12-40) for subtrochanteric fractures with other associated injuries (poly trauma patients).

The average operating time was 95 min (60-180 min) and blood loss 675 ml (average). Primary bone grafting was done in 3 patients where medial buttress was not established.

There were 2 cases of nonunion, one of them had implant failure and subsequently united when treated with conventional nail and bone grafting. The failure was a result of non compliant patient and the screw hole of the plate being at the fracture site. [Figure - 2]. There were 3 cases of decubitus ulcer, 2 patients with delayed wound healing, UTI in 2 patients.


   Discussion Top


Subtrochanteric area is a highly stressed region in the the human skeletal system. Of the fractures of the proximal femur 07%-34% involve the subtrochanteric area. There is a bimodal distribution. Younger pts are associated with high energy trauma and are communited. Older pts are associated with low energy trauma and are in osteoporotic bone and are hence oblique or spiral pattern [3],[4],[5] .

Subtrochanteric area has been defined in various ways, but most commonly this term has been used to describe the area between the inferior border of the lesser trochanter and isthmus of the femoral shaft or the inferior border of the lesser trochanter to the junction of the proximal and middle third of the femur. The lower border of the Subtrochanteric area is not well defined, but generally the area 5 cm below the lesser trochanter is included [3],[4] . Classically the proximal fragment assumes a position of flexion, abduction and external rotation. The gluteus medius and minimus account for abducted position, iliopsoas for flexion, and short external rotators for the external rotation position of the limb.

Various modalities of treatment for subtrochanteric fractures like intramedullary nail devices, fixed angled plate device, sliding hip screw devices each with advantages and disadvantages. Advantage of intramedullary device is a load sharing device and theoretically allows for early weight bearing. Enders nail does not have rotational control. In fixed angled blade plates anatomic reduction and to secure intrafragmentary fixation with reconstitution of a medial cortical buttress is required and is technically difficult.

Sliding hip screw devices combines secure proximal fixation by the compression screw and good distal fixation by the plate allowing for controlled collapse of the fracture site while the appliance maintains the correct rotational alignment prevents excessive medial migration of the distal fragment. Sliding hip screws are technically easier, and do not splinter the fracture extension into the trochanteric area as they as common with the gamma nails.

In the past the reported range of union in patients treated with various types of internal fixation have been from 74 100% [2],[6],[7],[8],[9] . Sliding hip screw plate device is a reliable method of treatment for subtrochanteric fractures with extension into the piriformis fossa (Russell Taylors type II), where an intramedullary device is technically difficult to introduce and can split open the trochanter. Sliding hip screw plate device for Rusell Taylor Type II fractures is technically easier and less amount of radiation to the surgical team and patient. Blood loss is not considerable. Hence is recommended for Russell Taylor's type II fractures.

 
   References Top

1.Boyd HB, Griffen LL. Classification and treatment of trochanteric fractures. Arch Surg. 1949; 58: 853.  Back to cited text no. 1    
2. Fielding WJ, Cochran GB, Zickel RE. Biomechanical Characteristics and surgical management of subtrochanteric fractures. Orthop Clin N Am. 1974;15:629.  Back to cited text no. 2    
3. Sims SH. Subtrochanteric femur fractures. Orthop Clin N Am. 2002;33(1):113-26,  Back to cited text no. 3    
4.4, Tornetta P 3rd. Subtrochanteric femur fracture. J Orthop Trauma. 2002;16(4):280-3.  Back to cited text no. 4    
5. Watson HK, Campbell RD, Wade PA. Classification treatment and complications of the adult subtrochanteric fracture. J Trauma. 1964; 4: 457.  Back to cited text no. 5    
6. Asher MA, Tippett JW, Rockwood CA et al. Compression fixation of subtrochanteric fractures. Clin Orthop. 1976;117:202.  Back to cited text no. 6    
7. Fielding WJ, Magliato HJ. Subtrochanteric fractures. Surg Gynecol Obset. 1966; 122: 555.  Back to cited text no. 7    
8. Froimson AI. Treatment of comminuted subtrochanteric fractures of femur. Surg Gynecol Obset.1970; 131: 465.  Back to cited text no. 8    
9. Seinsheimer F. Subtrochanteric fractures of the femur. J Bone Joint Surg (Am). 1978; 60: 300.  Back to cited text no. 9    

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Correspondence Address:
M Shantharam Shetty
Tejasvini Hospital and SSIOT, Kadri, Mangalore, Karnataka
India
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    Abstract
    Introduction
    Materials and me...
    Results
    Discussion
    References
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