Technical Pearl: Watch Out for Anterior Malreduction When Fixing Intertrochanteric Hip Fractures — What Now?

The CORRelations post "Technical Pearl: Watch Out for Anterior Malreduction When Fixing Intertrochanteric Hip Fractures" raises several important points, including:

• Pay attention to tip-apex distance
• Ensure the anterior neck lines up with the distal fragment
• Avoid varus malreduction

In my experience practicing in three very different venues, learning through the Orthopaedic Trauma Association, and examining ABOS candidates for years, the vast majority of U.S. surgeons use a fracture table for these procedures. And all of the above recommendations are great when the fracture reduces like it's supposed to.

But, what do you do when the fracture just won’t reduce on the fracture table?

I have found that certain intertrochanteric femoral fractures are best treated in the lateral position on a radiolucent table. Many times, the quicker I bail out to this technique, the better the outcome. And not incidentally, coming off the fracture table early – if it’s not working – results in far less stress being placed on the staff. Gentle traction by an unskilled assistant is generally all that is needed to effect a perfect reduction. In situations where a recalcitrant fracture defies closed reduction, the patient then is in the ideal position for an open or limited open reduction, which can efficiently move the case along.

And there are some fracture patterns where I just leave the fracture table in the hallway from the start, including:

• Substantially displaced intertrochanteric fractures
• Displaced intertrochanteric fractures that start off in severe valgus
• Intertrochanteric fractures with subtrochanteric extension
• Intertrochanteric fractures with marked displacement in the sagittal plane

Getting the reduction right is key, yes, but don’t kill yourself on the fracture table to do it. Come off the fracture table and into the lateral position as soon as you get the sense that the fracture is defying your best efforts at reduction. Don’t make these harder than they need to be.