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1、,LESSERTUBEROSITY,AP pelvis and AP hip of an elderly patient with a three-part intertrochanteric hip fracture.,LATERAL RADIOGRAPH,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 radiogr
2、aphs of the affected side without putting the opposite hip at risk.,ISCHIUM,LESSERTROCHANTER,FEMUR,This image demonstrates the position of the fracturetable with the patients affected arm over the chestand well padded.,SCDs ONDURINGPROCEDURE,This image demonstrates the scissoring of the legs with th
3、eaffected side slightly flexed and the unaffected side slightlyextended.Notice that sequential compression devices remainon 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
4、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 incis
5、ion brought down to the level of theiliotibial band and fascia lata.,ITB,The iliotibial band is incised with a knife.A Metzenbaumscissors is used to dissect under the band,which is dividedin line with the incision.,The iliotibial band is incised with a knife.A Metzenbaumscissors is used to dissect u
6、nder the band,which is dividedin line with the incision.,With retraction of the iliotibial band,the vastus lateralis fascia is visualized.,VASTUSLATERALIS,ITB,A sharp rake is introduced anteriorly and is used to retract thevastus lateralis anteriorly.An incision is then made in thefascia just anteri
7、or to the most posterior aspect of the femur.,A sharp rake is introduced anteriorly and is used to retract thevastus lateralis anteriorly.An incision is then made in thefascia just anterior to the most posterior aspect of the femur.,A periosteal elevator can be used to elevate the lateralisoff the f
8、emur 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 fragmentand displacement of the posteromedial fragment.,A bone hook can be used,as can
9、 a clamp or othertechnique,to reduce the abduction in the proximalfragment.,Once a reduction is obtained and confirmed on the AP and lateral radiographs,the angle guide is placed against thelateral surface of the femur in order to place the guidewirefor the lag screw.,The natural anteversion of the
10、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
11、.In this case,a long barrelwas 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 b
12、ack up proximally such that it is within the wound.,In order to seat the side plate,its distal end must be heldgently 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 usi
13、ng standard screw fixation.,AP radiograph of the lag screw and side plate in position.,In this particular situation,the posteromedial fragment wasrather 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 sid
14、e plate must be slightlyposterior to the midline in order to direct the lag screwinto the center of the head,given the normal anteversionof the neck.,The posteromedial fragment cannot be lagged through theplate because the angle of the screw through the plate would be too great.Thus,the screw is pla
15、ced from anteriorto 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 intothe lesser trochanter.,Final AP radiograph demonstrating excellent fixation andcompression across the intertrochanteric fracture as wellas lag screw fixation of the lesser trochanter.,ITB,VASTUS LATERALIS,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.,
