Abstract reduction of proximal femur fragments due to the

Abstract

Subtrochanteric femur fracture fixation
remains one of the most challenging procedures to orthopedic surgeons. Apart of
the choices of implant used, patient positioning for intramedullary nailing of
subtrochanteric femoral fracture plays a crucial role in fracture reduction and
should be considered during preoperative planning. It is partly contributed to
the deforming muscle forces acting one the proximal fragment of femur. As
compared to supine position, intramedullary fixation in lateral decubitus with
traction of affected leg is believed achieve to easier reduction of proximal
femur fragments due to the deforming muscle forces, easier attainment of
intramedullary fixation entry point due to les interference of the thorax and
chest wall especially in obese patient.  We
report the case of a 28-year-old male patient who underwent intramedullary
fixation of right subtrochanteric fracture in lateral decubitus with traction
of the affected leg.

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Keywords: Subtrochanteric femur fracture,
lateral decubitus, traction

 

Introduction

Subtrochanteric fracture accounts for 25% of
proximal femur fracture and their distribution is bimodal which involves young
made adults and old females predominantly3.  Subtrochanteric fracture is unstable as result
of the high compressive and tensile forces of muscle that separate the fracture
segments. Therefore surgery is the optimal option for the patients with no
absolute contraindication. 
Intramedullary fixation has been gaining popularity for the past decades
due to its unique advantage- short force arm which can better distribute the
stress compared to extramedullary fixation5.
Intramedullary fixation in supine traction position has been well described.
However the literature describing intramedullary fixation in lateral decubitus
position with traction is scarce1. This is partly
contributed to its drawback as the positioning set up is more time
consuming.  Otherwise performing
intramedullary fixation in lateral decubitus position with traction table
provides an alternative to orthopedic surgeons for easier access to entry point
and fracture reduction. We reported a 28-year-old man who underwent
intramedullary fixation for subtrochanteric fracture in lateral decubitus
position in traction table. 

 

Case
Report

A 28-year-old man had injured his right lower
limb after a motor vehicle accident. Post trauma, he complained of pain over right
proximal thigh and was unable to lift up his right leg. Physical examination
revealed a deformity over right thigh with intact neurovascular function.
Standard pelvis and right femur radiographs show a fracture over right
subtrochanteric femur (Figure 1). Otherwise lesser trochanter and piriformis
fossa were intact.

 

The patient underwent intramedullary fixation
under general anesthesia using cephalomedullary nail. He was positioned in
lateral position on traction table, with the operative leg over the top of the
perineal post (Figure 2). Boot was attached to the table with traction applied;
hip was slightly adducted and moderately flexed. The leg was then internally
rotated 10-15 degrees.  Contra-lateral
knee was flexed with boot attached. Padding was placed over fibular neck
prominence over non operative leg. Closed reduction was achieved under C-arm
fluoroscopy guidance. C-arm was brought in perpendicular to the long axis of
the femur. When moving proximally and distally, the entire C-arm was moved, to
stay perpendicular to the long axis. To visualize the proximal femur and the
head, C-arm was rotated 15° over the top and tilted 45° cephalad. After
prepping and draping, 3-5cm of skin incision was made with greater trochanter
as the center. Entry point was identified following by guide wire insertion. The
force line of the limbs and fracture position were properly maintained followed
by intramedullary reaming and intramedullary nail insertion. Afterwards the
proximal and distal locking screws were inserted and fracture position was
confirmed under C-arm fluoroscopy.

 

Postoperatively patient was given intravenous
prophylactic antibiotics for 3 doses. He was initiated on the exercise of
muscle strength of lower limbs and functional exercises of hip joint
immediately after operation. He was discharged uneventfully post operative day
2. Weight bearing over operative leg was prohibited 8-12 weeks.

 

 

Discussion

Intramedullary fixation of subtrochanteric
fracture remains one of the most challenging procedures to orthopedic surgeons.
It is partly due to the several deforming forces subjected to the proximal
femur fragments: flexion (provoked by the iliopsoas), abduction (by the gluteus
medius), and external rotation (by the external rotators). The adductors,
inserted in the distal region of the femur, are responsible for the varus deformity4. Delayed union or
non union has been reported as a common complication of subtrochanteric
fracture as a result of limited contact surface area, decreased vascularity,
and high mechanical stresses which might impair the bone healing2.
 Therefore proper reduction prior to
fixation is detrimental to correct the rotation and flexion of proximal femur
fragments and hence to achieve satisfactory bone consolidation.

 

Several surgical techniques especially patient’s
position during intramedullary fixation have been described in literatures to
ease the reduction of subtrochanteric fracture. Patient may be placed in either
supine or lateral position with or without traction table. Previous literature
described placing patient in lateral decubitus position on traction table;
operative hip was flexed, adducted and knee was flexed with traction applied to
take account of any flexion of the proximal fracture fragment. Instead of
applying traction over flexed knee, we applied traction over the operative leg
with knee extended.   

 

Positioning patient in lateral decubitus with
traction of the operative leg offers several advantages to orthopedic surgeons.
Firstly it improves access to the entry point especially in obese patient as
the trunk is shifted away from surgical site which minimizes the interference
of entry point by the torso. Second there is a good control of proximal
fragment with less interference from the flank, chest wall or ribs. Thirdly, placing
patient in lateral decubitus with traction of affected leg could neutralize the
proximal femur fragment which tends to angulate in varus in supine position. However
fixation of subtrochanteric fracture in lateral position is without its
disadvantages. The techniques might compromise the pulmonary function. Secondly
venous congestion could be caused from the perineal post compressing the medial
thigh and femoral vessels. Apart from that sciatic nerve over the operated leg
might be at risk due to prolonged traction and hip flexion.  Finally many believe positioning in lateral
decubitus is more time consuming. However we believe that once familiarity is
gained the set-up time might not be different from the supine position.

 

Conclusion

The key point to reduce the complication of
subtrochanteric fracture fixation is the quality of the reduction. Deforming
muscle forces make treatment of subtrochanteric fractures challenging.
Therefore patient positioning is crucial to achieve satisfactory
reduction.  Intramedullary fixation in
lateral decubitus with traction of the affected leg offers an alternative to
orthopedic surgeons for easier attainment of reduction and intramedullary nail
entry point.