What’s the Claim?
We almost never cover selective review articles, as they’re normally fraught with all sorts of bias, but we’re letting down our guard this week because this one’s so practical. A nice review in JOT gives the why and the how on tricky intertrochanteric fractures, with a particular focus on preventing “the slide” (subsidence of the head and neck fragment) that can occur when unstable ones are treated with an intramedullary nail.
How’s It Stack Up?
The authors’ suggestion that high-energy, unstable intertrochanteric fractures are different and tougher is well documented. What makes this article worth a look — it’s freely available in full-text form and well worth your time to go deep if you see these tougher hip fractures — are the technical pearls it offers for the common specific causes of instability in these fractures. We’ll focus on one of those here, but you may wish to look at the others by pulling up the full article when your time allows.
What’s Our Take?
CORRelations’ advisor in Fractures & Trauma, Jaimo Ahn, MD, likes the suggestion this article makes and offers this:
The comminuted IT (pertroch or peritroch), especially with an unstable lateral wall piece, can make life hard for you and the patient. In those fractures, consider opening, reducing, and stabilizing with a small accessory plate.
Here are the key points from the article for lateral wall reconstruction in this setting:
- Use a lateral approach (which is extensile into a Watson Jones approach, if/as needed to see the intertroch or basicervical fracture)
- Place small or mini fragment locking plates (with unicortical screws, if needed) to stay clear of the intramedullary canal and the nail's cephalomedullary screws
- Consider larger plates and screws, though they are not as easily contoured, when the femur is large enough to allow you to shoot the screws around the nail
- Look to place the plate anteriorly, because there usually is more space there, given the cephalomedullary screw’s trajectory (that starts posterolateral up the anteverted femoral neck)
- Maintain careful technique; minimize soft tissue stripping
The article’s authors also believe that integrated dual-screw nails may be helpful (a belief shared by others), and that locking the set screw after compressing the fracture when using such an implant is helpful at preventing shortening, without cost in terms of nonunion.
Chan DS, Moghadamian ES. Preventing the Slide in High-Energy Intertrochanteric Fractures With Intramedullary Nails. J Orthop Trauma. 2023;37(10S):S5-S10.