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82 year old female with an intertrochanteric fracture

In this example, we are going to follow the course of events as an inter-trochanteric femur fracture is repaired on a Saturday morning.  This patient is an elderly female in her 80′s (remember that > 75% of hip fractures occur in women) and she was admitted to the hospital on a Friday night after falling at home when she tripped over a throw rug.  She was admitted to the hospital via the emergency department and was seen by her primary care physician who cleared her for surgery.  She had a few other medical problems, but none of them precluded surgery within the first 24 hours of admission.  The most common reason for a delay in surgery is the regular use of blood thinners such as Coumadin or Plavix or symptoms of chest pain or fainting that led up to the fall, and which need to be evaluated prior to surgery.  Overnight, the calf and foot of the fractured leg were wrapped in a foam boot and 5 pounds of traction was applied to the leg.  This traction is called “Buck’s Traction” and it helps to reduce painful muscular spasms that occur in the area of the hip.  Narcotic pain medications and muscle relaxants were given overnight in order to keep the patient comfortable.

female right intertrochanteric AP pelvis  intertrochanteric hip fracture anatomy

The following morning, the correct surgical site was marked by writing “yes” on the broken leg after the surgeon had the opportunity to confirm with the patient that this was the painful leg and also to check the X-rays from the Emergency Department, making sure that everyone was in agreement about which leg we were operating upon.  The procedures for verifying the correct surgical site vary from hospital to hospital, but most procedures today require that the surgeon “signs the site” where the incision will be made.  Just prior to the operation starting, a “time-out” was held during which the operative team reviewed the plan for surgery and the side of the fracture.  The patient was wheeled back to the operating room by the operating room staff and the anesthesiologist hooked her up to the required monitors and induced anesthesia.  Typically, patients with hip fractures are put to sleep in the same bed, and later moved to the operating table since moving them around causes a fair amount of pain.  However, if a spinal anesthetic is desired, then sometimes we will carefully lift the patient onto the operating table and position them on their side before placing the spinal.

anesthesia hip fracture interview  anesthesia hip fracture propofol

Once the patient was moved to the fracture table, the broken limb was placed in traction and a combination of longitudinal traction — pulling on the foot — and internal rotation of the foot lined up the fracture fragments.  in more complicated fracture patterns, it becomes necessary to use all sorts of strategies to get the fractures to line up before the intra-medullary nail can be inserted.  Once the portable X-ray unit confirmed that the fracture was lined up, a lateral “shower curtain” prep was used to isolate the operative site from the rest of the patient’s body.  The X-ray machine was then used to localize the correct position for the start of the incision and a 3 to 4 centimeter incision was made just proximal to the greater trochanter.  Through this incision a guide pin was started in the tip of the greater trochanter and advanced across the fracture site and into the intra-medullary canal of the femur.  Once the pin was placed in the correct position, a reamer was used to enlarge the hole.  The trochanteric femoral nail was then assembled by the scrub technician and it was slid over the guide wire and tapped once or twice with a mallet to seat it to the appropriate depth.  Intra-operative x-rays were used throughout these steps to make sure that everything is going well.  Via a separate small incision on the lateral side of the hip a guide pin was drilled through the femur and aimed at the center of the femoral head.  The trajectory of this guide pin was determined by the outrigger that connects to the intra-medullary nail.  Once the guide pin was in the center of the femoral head, an interconnecting helical blade was tapped into the center of the head.  A screw that was built into the nail at the top of the nail was engaged to stop the helical blade from rotating out of position and a single screw was placed through the distal end of the nail in order to further stabilize the fracture construct.

hip fracture reduction with C arm  hip fracture operation  trochanteric femoral nail  hip fracture surgeon  incision minimally invasive hip fracture surgery

Believe it not, this entire operation typically takes about 30 to 45 minutes and afterwards the trochanteric femoral nail has bridged the fracture site with enough stability that the patient can begin to bear full weight immediately.  In a typical case, the patient will be seen twice daily by physical therapy beginning the day after the operation and will typically stay in the hospital for 3 to 4 days after the operation before being discharged to a rehabilitation facility.

Here is a link to the intra-operative xrays taken during the course of fixation of an inter-trochanteric femoral fracture.

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