import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: Exit sciatic notch 3-5cm proximal to greater trochanter tip, run between gluteus medius and minimus **Protection**: Keep entry point at or below tip of greater trochanter. Avoid proximal dissection beyond 3cm above GT. Split gluteal muscles in line with fibers only. **Location**: Exits pelvis through greater sciatic notch, ~5cm posterior to greater trochanter at level of hip joint **Protection**: Avoid excessive posterior dissection. No retractors placed posteriorly. Careful with fracture manipulation in external rotation. Monitor sciatic nerve function post-operatively. **Location**: Medial aspect of femoral neck, gives retinacular vessels supplying femoral head (posterior-superior branch most important) **Protection**: Minimize soft tissue stripping around fracture. Careful guidewire and cephalic screw placement - stay intraosseous. Avoid multiple screw attempts. **Location**: Crosses ASIS, runs lateral to sartorius, highly variable course anterior to hip **Protection**: Percutaneous technique with minimal anterior dissection. Small skin incision. Blunt dissection only when necessary. Incision centered over GT avoids LFCN. **Location**: Insert onto greater trochanter (medius - lateral facet, minimus - anterior facet) **Protection**: Split muscles in line with fibers. Avoid excessive lateral dissection. Entry point at tip or just medial prevents splitting GT and disrupting insertion. Repair any significant tears. **Patient Position**: Supine on fracture table with traction. Affected leg in boot with traction apparatus. Unaffected leg abducted in hemilithotomy position or leg holder, or extended and abducted on leg support. Perineal post well-padded with gel pad to prevent pudendal nerve injury. C-arm positioned between legs for optimal AP and lateral views without repositioning. **Surgical Approach**: Percutaneous greater trochanter entry with minimal incision **Incision**: 5cm longitudinal incision over greater trochanter tip, centered and extending proximally ## Indications ### Absolute Indications - Unstable intertrochanteric fractures (AO 31-A2.2, A2.3, A3) - Reverse obliquity fractures (medial cortex proximal) - Intertrochanteric fractures with subtrochanteric extension - Pathological intertrochanteric fractures - Ipsilateral femoral neck and shaft fractures ### Relative Indications - Stable intertrochanteric fractures (AO 31-A1, A2.1) in young patients - Failed Dynamic Hip Screw requiring conversion - Lateral wall thickness less than 20mm - Severely osteoporotic bone requiring better load sharing ### Contraindications **Absolute**: - Active infection at surgical site - Inadequate bone stock precluding screw fixation (consider arthroplasty) - Severe medical comorbidities precluding surgery **Relative**: - Previous ipsilateral femoral instrumentation - Severe deformity preventing nail passage - Very narrow femoral canal (less than 8mm) ## Pre-operative Planning ### Imaging Assessment - **AP pelvis**: Assess fracture pattern, measure lateral wall thickness, check for pelvic ring injury - **AP and lateral hip**: Classify fracture (AO classification), assess comminution, measure neck-shaft angle - **Contralateral hip**: Template nail size, assess normal anatomy for comparison - **Full-length femur**: Rule out shaft extension, plan nail length ### Critical Measurements - **Lateral wall thickness**: Measure perpendicular distance from lateral cortex to fracture line at level of lesser trochanter. Less than 20mm indicates unstable pattern requiring long nail - **Neck-shaft angle**: Normal 125-135°. Pre-operative varus indicates need for careful reduction - **Femoral canal diameter**: Measure at isthmus on contralateral side to select nail diameter - **Femoral length**: Compare to contralateral for length assessment ### Nail Selection - **Short nail**: 170-240mm for isolated intertrochanteric fractures with intact lateral wall - **Long nail**: 340-420mm for subtrochanteric extension, lateral wall comminution, reverse obliquity - **Diameter**: Typically 10-11mm based on isthmus diameter - **Screw vs Blade**: Helical blade for osteoporotic bone (better purchase), screw for better bone ## Operative Technique - Detailed Steps ### Step 1: Setup & Closed Reduction Setup & Closed Reduction: Position patient supine on fracture table. Apply gel padding to perineal post. Place affected limb in boot with traction apparatus. Unaffected leg in hemilithotomy or extended position. Prepare and drape in standard fashion. Apply gentle longitudinal traction (typically 10-20kg). Internally rotate leg 10-15° to correct typical external rotation deformity of distal fragment. Use fluoroscopy to assess reduction on AP and lateral views. **Acceptable Reduction**: - Anatomic or slight valgus alignment (5-10° valgus acceptable, varus NOT acceptable) - Restoration of medial cortical continuity (medial support critical) - No posterior sag on lateral view (apex posterior deformity increases malunion risk) - Rotation corrected (internally rotate 10-15° typically) **If closed reduction fails**: Consider percutaneous joystick with Schanz pin in greater trochanter for manipulation. Alternatively, small incision for pointed reduction clamp on medial cortex. Accept imperfect reduction if medial support achieved - anatomic reduction not always possible in comminuted fractures. **Technical Tip**: EXAM KEY: 'I position patient on fracture table with well-padded perineal post. I apply longitudinal traction and internally rotate the leg 10-15° to correct the typical external rotation deformity. On fluoroscopy, I accept anatomic or slight valgus alignment - varus is NOT acceptable as it increases cut-out risk. Restoration of medial cortical support is CRITICAL for stability. No posterior sag on lateral view. If closed reduction fails, I use percutaneous Schanz pin joystick in GT for manipulation.' - Over-distraction causing difficulty with nail passage and increased non-union risk - Persistent varus malreduction - MAJOR risk factor for cut-out - Posterior sag causing apex posterior deformity and malunion - Pudendal nerve compression from poorly padded perineal post (numbness, pain) - Femoral neck fracture from excessive or forceful manipulation - Sciatic nerve injury from external rotation force ### Step 2: Incision & Entry Point Incision & Entry Point: Palpate greater trochanter (GT) tip - most prominent lateral point. Make 5cm longitudinal skin incision centered over tip of GT, extending proximally along femur. Incise subcutaneous tissue with electrocautery. Incise fascia lata (iliotibial band) in line with skin incision. Split gluteus medius and minimus fibers bluntly in line with muscle fibers - avoid excessive splitting. **ENTRY POINT CRITICAL**: - **Trochanteric entry nail** (most modern nails): At tip of GT or just medial (2-3mm medial to tip) - **Piriformis entry nail**: Piriformis fossa, approximately 1cm medial to GT tip **Fluoroscopic Confirmation**: - **AP view**: Entry point at tip of GT or just medial. NOT lateral to GT (causes varus). NOT too medial (risks medial cortex perforation or valgus) - **Lateral view**: Entry point MUST be in line with center of femoral canal. Too anterior causes anterior cortex perforation. Too posterior causes posterior perforation or difficulty passing nail **Technical Tip**: EXAM KEY: 'I make 5cm longitudinal incision over the tip of the greater trochanter. Entry point is CRITICAL for preventing malalignment. For trochanteric entry nails, I aim for the tip of GT or 2-3mm medial on AP view. On LATERAL view, the entry point MUST be aligned with the center of the femoral canal - this is equally important. Too lateral an entry causes varus malalignment. Too medial risks medial cortex perforation. I confirm entry point on BOTH AP and lateral fluoroscopy before creating the portal.' - Entry too lateral = varus malalignment (common error) - Entry too medial = valgus or medial cortex perforation - Entry too anterior = anterior cortex perforation, nail prominence - Entry too posterior = posterior perforation, difficulty seating nail - Superior gluteal nerve injury if dissection extends more than 3cm proximal to GT - Iatrogenic femoral neck fracture from improper entry point or technique - Splitting of greater trochanter damaging abductor insertion ### Step 3: Entry Portal Creation Entry Portal Creation: Use T-handle awl or powered entry reamer to create entry portal. For trochanteric entry, open cancellous bone of GT tip. For piriformis entry, find piriformis fossa medial to GT. Hold awl/reamer perpendicular to lateral cortex, advance with controlled force through lateral cortex into medullary canal. Confirm on fluoroscopy - tool should advance toward center of femoral canal on lateral view. Feel for cortical breakthrough distally indicating entry into medullary canal. Do not force - use gentle rotational movements. **Technical Tip**: EXAM KEY: 'I use T-handle awl or powered entry reamer to create the entry portal. I hold the instrument perpendicular to the lateral cortex and advance with controlled force. On lateral fluoroscopy, I confirm the trajectory is toward the center of the femoral canal, not anterior or posterior. I feel for cortical breakthrough indicating entry into the medullary canal. Proper entry portal prevents malalignment and cortical perforation.' - Anterior or posterior cortex perforation if trajectory wrong - Creating false passage outside medullary canal - Splitting or fracturing the greater trochanter - Damage to abductor insertion on GT - Femoral neck fracture from excessive force - Propagation of fracture pattern ### Step 4: Guidewire Passage & Reduction Confirmation Guidewire Passage & Reduction Confirmation: Select ball-tipped guidewire (typically 3mm diameter). Insert guidewire through entry portal into medullary canal. Advance with gentle rotational movements to help cross fracture site into distal fragment. Guide wire trajectory using fluoroscopy - aim for CENTER of canal on both AP and lateral views. At fracture site, wire should be central - eccentric wire leads to eccentric nail placement. **Guidewire Position Check**: - **At entry**: Central in proximal fragment - **At fracture site**: Central position maintained - **Distally**: Central in medullary canal, parallel to cortices - **Final position**: Terminate 3-4cm above knee joint Confirm fracture reduction maintained after wire passage. If reduction lost during wire passage, remove wire, re-reduce, and pass wire again. Do not proceed with poor reduction. **Technical Tip**: EXAM KEY: 'I pass a ball-tipped guidewire across the fracture using gentle rotational movements. The wire MUST be central on both AP and lateral views - eccentric wire placement leads to eccentric nail position and malalignment. I check wire position at entry, at fracture site, and distally. I confirm the fracture reduction is maintained after wire passage. The wire terminates 3-4cm above the knee joint to allow nail length measurement.' - Guidewire takes false passage outside medullary canal - Eccentric wire placement causing eccentric nail and malalignment - Loss of fracture reduction during wire passage - Distal anterior cortex perforation (common if wire too anterior) - Wire advancement into knee joint causing pain and cartilage damage - Wire advancement too far preventing subsequent steps - Fracture distraction from wire passage ### Step 5: Nail Length Measurement & Selection Nail Length Measurement & Selection: With guidewire in final position, measure nail length from entry point to distal extent. Use measuring device or ruler on fluoroscopy with magnification correction. **Nail Length**: - **Short nail**: 170-240mm, terminating in metaphyseal region. Typical length 220-240mm - **Long nail**: 340-420mm, terminating 3-4cm above knee joint. Typical length 360-380mm **Short vs Long Decision**: - **SHORT nail**: Stable patterns (AO 31-A1, A2.1), intact lateral wall more than 20mm, no subtrochanteric extension - **LONG nail**: Unstable patterns, lateral wall comminution less than 20mm, subtrochanteric extension, reverse obliquity, pathological fractures **Nail Diameter**: Based on canal diameter at isthmus. Typical 10-11mm. Ream 1-1.5mm over nail diameter. Mark nail insertion depth on guidewire with depth gauge or marker. **Technical Tip**: EXAM KEY: 'I measure nail length to terminate appropriately - for short nail in metaphyseal region, for long nail 3-4cm above knee joint line. My decision for SHORT vs LONG nail is based on: lateral wall thickness (less than 20mm requires long nail), subtrochanteric extension (requires long nail), fracture pattern stability (reverse obliquity requires long). SHORT nail for stable intertrochanteric fractures with intact lateral wall. Nail diameter selected based on isthmus diameter, typically 10-11mm. I will ream 1-1.5mm over nail diameter.' - Nail too short = stress riser at nail tip, risk of distal femur fracture - Nail too long = impingement on knee joint, anterior knee pain - Wrong nail type for fracture pattern (short for unstable = high failure risk) - Nail diameter too large = intraoperative fracture during insertion - Nail diameter too small = inadequate stability, increased risk of implant failure ### Step 6: Reaming (if indicated) Reaming Decision: REAMED vs UNREAMED. Most intertrochanteric fractures are REAMED for better cortical contact and rotational stability. **REAMED technique**: - Sequential flexible reamers over guidewire - Start 1mm larger than canal diameter at isthmus - Increase in 0.5mm increments - Final reamer diameter 1-1.5mm larger than nail diameter - Ream to cortical chatter (feel vibration indicating cortical contact) - Copious irrigation during reaming to prevent heat necrosis - Monitor guidewire position continuously - prevent advancement **UNREAMED**: Reserved for severe chest injury (fat embolism concern), very comminuted fractures, or bleeding disorders **Technical Tip**: EXAM KEY: 'For intertrochanteric fractures, I typically REAM the femoral canal as this provides better cortical contact and rotational stability compared to unreamed technique. I use sequential flexible reamers over the guidewire in 0.5mm increments. I ream to 1-1.5mm over the final nail diameter. I ream to cortical chatter which I can feel as vibration through the reamer. Critical steps: copious irrigation to prevent heat necrosis, continuously monitor guidewire position to prevent advancement. I would only use UNREAMED technique in specific circumstances like severe pulmonary injury where fat embolism is a major concern.' - Fat embolism syndrome from reaming (more common with long nails, bilateral procedures) - Heat necrosis of bone without adequate irrigation - Guidewire advancement or loss of position during reaming - Cortical perforation with overly aggressive reaming - Fracture propagation distally from reaming forces - Intraoperative fracture if reaming too large ### Step 7: Nail Insertion Nail Insertion: Mount nail on insertion jig/handle according to manufacturer instructions. Ensure nail orientation is CORRECT - anteroposterior curvature should match femoral bow (apex anterior). Check nail is fully seated on jig. Insert nail over guidewire with gentle rotational movements (clockwise/counterclockwise) and controlled mallet blows to advance. Do not use excessive force. **Insertion Depth**: - Nail should be flush with GT tip or 5-10mm proud (above tip) - NEVER bury nail below GT tip - makes removal extremely difficult - Confirm depth on lateral fluoroscopy **Position Check**: - **AP view**: Nail centered in medullary canal, appropriate rotation - **Lateral view**: Nail centered, no anterior or posterior perforation, correct depth at entry - **At fracture site**: Nail crosses fracture centrally, reduction maintained - **Distally**: Nail centered in canal **Technical Tip**: EXAM KEY: 'I mount the nail on the insertion jig ensuring correct orientation - the anteroposterior curvature must match the femoral bow with apex anterior. I insert the nail over the guidewire using gentle rotational movements and controlled mallet blows. I advance to predetermined depth - the nail should be flush with or 5-10mm proud of the GT tip. I specifically do NOT bury the nail below the GT tip as this makes future removal extremely difficult if needed. I confirm position on AP and lateral fluoroscopy - the nail should be centered in the canal on both views with no cortical perforation.' - Nail inserted backwards (wrong orientation) causing malalignment - Nail buried too deep below GT = extremely difficult removal - Nail left too proud = prominent hardware, abductor irritation - Anterior cortex perforation if nail curvature doesn't match femoral bow - Posterior perforation if entry too posterior - Fracture distraction if nail too long proximally or impacting at fracture - Loss of reduction during nail insertion - Splitting of proximal fragment ### Step 8: Cephalic Screw/Blade Insertion - CRITICAL STEP Cephalic Screw/Blade Insertion: This is the MOST CRITICAL step for preventing cut-out. **Guidewire Placement**: - Using targeting jig attached to nail, insert guidewire for cephalic screw - Angle typically 130-135° from femoral shaft (CCD angle) - TARGET POSITION: Center-center or inferior-center in femoral head on BOTH AP and lateral - Think 3x3 grid: on AP (superior/center/inferior), on lateral (anterior/center/posterior) - CENTER-CENTER is optimal - INFERIOR-CENTER is acceptable - AVOID superior position - highest cut-out risk **Depth**: - Aim for DEEP placement: 5-10mm from subchondral bone on ALL views - Measure on both AP and lateral fluoroscopy - Too shallow = inadequate purchase, cut-out risk - Too deep or penetration = joint damage **Tip-Apex Distance (TAD) - CRITICAL**: - Measure distance from tip of screw to apex of femoral head on AP radiograph - Measure same distance on lateral radiograph - SUM these distances (after correcting for magnification) - TAD MUST BE LESS THAN 25mm - TAD greater than 25mm = exponentially increased cut-out risk **Screw Insertion**: - Ream over guidewire to measured depth - For helical blade: insert to predetermined depth, compress if system allows - For lag screw: insert to depth, typically 85-95mm length depending on head size - Confirm final position on AP and lateral - Recheck TAD calculation - Confirm no joint penetration **Technical Tip**: EXAM KEY: 'Cephalic screw position is THE MOST CRITICAL factor for preventing cut-out. I aim for CENTER-CENTER or INFERIOR-CENTER position in the femoral head on BOTH AP and lateral views. I specifically AVOID superior placement which has the highest cut-out risk. Deep placement is essential - I aim for 5-10mm from subchondral bone on all views. The TIP-APEX DISTANCE is the single most important measurement - I calculate this by summing the distance from screw tip to apex of head on AP and lateral radiographs. TAD MUST be less than 25mm. Studies show TAD less than 25mm has 6% cut-out rate, while TAD greater than 25mm increases cut-out exponentially. I use calibrated ruler or measurement tool to ensure accuracy.' - Superior-posterior placement = HIGHEST cut-out risk (avoid at all costs) - TAD greater than 25mm = exponentially increased cut-out rate - Joint penetration causing cartilage damage and early arthritis - Anterior perforation of femoral neck (check lateral view) - Posterior perforation of neck (check lateral view) - Screw too short = poor purchase, cut-out risk - Screw too long = joint penetration - Iatrogenic femoral neck fracture from screw insertion or multiple attempts - Z-effect or reverse Z-effect (screw backs out with loading) ### Step 9: Distal Locking Distal Locking: Purpose is to control rotation and length. Decision: static vs dynamic locking. **Short Nail**: - Typically ONE or TWO static distal locking screws through targeting jig - Insert through stab incisions - Confirm position with fluoroscopy - screws must pass through nail - Bicortical purchase essential **Long Nail**: - **STATIC locking** (2 screws - distal and middle holes): For subtrochanteric involvement, unstable patterns, need for rigid fixation - **DYNAMIC locking** (1 screw - distal hole only): For pure intertrochanteric fractures, allows axial compression at fracture site **Technique**: - Confirm screw trajectory through targeting jig or freehand with fluoroscopy - Drill through both cortices - Measure screw length with depth gauge - Insert screws to engage both cortices - Confirm on fluoroscopy: screws through nail, bicortical engagement **Technical Tip**: EXAM KEY: 'For distal locking, my decision is between static and dynamic. For SHORT nail, I use one or two static distal screws through the targeting jig. For LONG nail, I use STATIC locking with two screws (distal and middle holes) if there is subtrochanteric extension or unstable pattern requiring rigid fixation. I use DYNAMIC locking with one distal screw only for pure intertrochanteric fractures to allow axial compression at the fracture site which promotes healing. I confirm bicortical engagement and screws passing through nail on fluoroscopy.' - Screws miss nail holes (not engaging nail) = no rotational control - Unicortical purchase = inadequate stability and fixation - Screws too long = far cortex prominence, soft tissue irritation, possible vascular injury - Screws too short = loss of fixation - Wrong locking mode for fracture pattern (dynamic for unstable = loss of fixation) - Thermal necrosis if drilling without irrigation - Fracture at distal screw sites ### Step 10: Final Assessment & Closure Final Assessment & Closure: Remove guidewire. If helical blade system with compression capability, apply compression using set screw mechanism. **COMPREHENSIVE FINAL FLUOROSCOPY CHECK** (Critical for exam): 1. **Fracture reduction**: Anatomic or slight valgus, medial cortical support restored, no posterior sag 2. **Nail position**: Centered in canal on AP and lateral, appropriate depth (flush or 5-10mm proud) 3. **Cephalic screw**: Center-center or inferior-center position, TAD less than 25mm, 5-10mm from subchondral bone, no joint penetration 4. **Distal locking**: Screws through nail, bicortical engagement 5. **No cortical perforation**: Check entire nail length on both views 6. **Leg length**: Compare to contralateral - should be within 1cm 7. **Rotation**: Compare to contralateral - patella should face forward with leg neutral Release traction gradually and recheck fracture stability and alignment on fluoroscopy. Some settling is acceptable. Copious saline irrigation. Close fascia lata with absorbable sutures. Close subcutaneous layer with absorbable sutures. Skin closure with staples or sutures. Sterile dressing. Document final images for medical record - save AP and lateral showing all implants. **Technical Tip**: EXAM KEY: 'My final assessment is comprehensive and systematic. I check: (1) Fracture reduction maintained with valgus acceptable and medial support, (2) Nail position centered and appropriate depth, (3) Cephalic screw position with TAD less than 25mm - this is critical, (4) Distal locking screws through nail, (5) No cortical perforation anywhere, (6) Leg length and rotation compared to contralateral. I release traction gradually to allow controlled settling and recheck alignment. I document final images for the medical record including views showing TAD measurement which is important medicolegally.' - Unrecognized joint penetration by cephalic screw - Malrotation (compare to contralateral limb carefully) - Leg length discrepancy (typically shortening with comminuted fractures) - Loss of reduction on traction release indicating instability - Persistent varus alignment (unacceptable - increases cut-out) - Unrecognized cortical perforation - Inadequate documentation ### Additional Important Complications **Z-effect and Reverse Z-effect**: Migration of cephalic screw within nail, causing loss of fixation. Z-effect: screw backs out laterally. Reverse Z-effect: screw migrates medially. Prevention: adequate screw engagement, compression with helical blade systems. Management: revision if symptomatic. **DVT/PE**: High risk in elderly intertrochanteric fracture population. Incidence 40-60% without prophylaxis. Prevention: mechanical prophylaxis (TED stockings, pneumatic compression), chemical prophylaxis (LMWH, NOAC per local protocol), early mobilization. Management: anticoagulation, may require IVC filter if recurrent. **Mortality**: 30-day mortality 5-10%, 1-year mortality 20-30% in elderly population. Prevention: orthogeriatric co-management, early surgery (within 48 hours of admission), medical optimization. Management: multidisciplinary care. ## Immediate Post-operative (Day 0-1) **Recovery & Monitoring**: - Recovery in PACU with standard monitoring - Neurovascular examination of operative limb - document motor and sensory function - Check wound for hematoma or excessive drainage - Pain management: multimodal analgesia (paracetamol, NSAIDs if not contraindicated, opioids PRN) - Minimize opioids in elderly to reduce delirium risk **Thromboprophylaxis**: - Mechanical: TED stockings, pneumatic compression devices - Chemical: LMWH (enoxaparin 40mg SC daily) or NOAC per local protocol - Continue for minimum 35 days or until fully mobile - Balance bleeding risk vs thrombosis risk **Early Mobilization**: - Mobilize on DAY 1 if medically stable - Physiotherapy assessment - Weight bearing as tolerated (WBAT) IMMEDIATELY for stable fixation - Protected weight bearing (PWB) only if severe osteoporosis or concern for bone quality ## Week 1-6 **Weight Bearing**: - WBAT for most patients with stable fixation - Progress from frame/walker to crutches as able - Aim for independent mobility by 6 weeks **Physiotherapy**: - Gait training with assistive device - Hip ROM exercises (avoid excessive external rotation early) - Quadriceps strengthening - Functional mobility training **Follow-up**: - Wound check at 2 weeks (remove staples/sutures) - X-rays at 6 weeks: AP and lateral hip, assess reduction, implant position, early healing ## Week 6-12 **Assessment**: - X-rays at 6 weeks and 12 weeks - Check for cut-out (progressive superior migration of cephalic screw) - Assess fracture healing: callus formation, trabeculation across fracture - Monitor for loss of reduction or implant failure **Progression**: - Increase weight bearing as tolerated - Wean from assistive devices - Return to pre-injury mobility level as goal ## Month 3-6 **X-rays at 6 months**: - Confirm fracture union - Check implant position - any change from immediate post-op - TAD measurement - any increase indicates cut-out risk **Criteria for Union**: - Bridging callus on 3 of 4 cortices - Trabeculation across fracture site - No pain with weight bearing - No movement at fracture site clinically ## Long-term **Implant Removal**: NOT routine. Only remove if: - Symptomatic prominent hardware causing pain - Anterior thigh pain from nail - Complete fracture healing (minimum 12 months) - Patient request with documented healed fracture **Monitoring**: - Hip pain should prompt X-rays to rule out cut-out or arthritis - Monitor for late complications: AVN (rare with intertrochanteric), arthritis ## Orthogeriatric Co-management **Critical for elderly patients**: - Multidisciplinary team: orthopedics, geriatrics, physio, OT, nursing - Medical optimization: manage comorbidities (cardiac, diabetes, renal) - Falls assessment and prevention - Bone health: calcium, vitamin D, consider bisphosphonates or denosumab - Nutritional support - Cognitive assessment - Discharge planning and rehabilitation **Evidence**: Orthogeriatric co-management reduces mortality, complications, and length of stay. ## Key Evidence ## Exam Pearls - High Yield ### Technical Pearls **Entry Point Precision**: - Entry point determines alignment more than any other step - Too lateral = varus (common error) - Lateral view equally important as AP - must be in line with canal **TAD Calculation**: - Practice calculating TAD from sample X-rays - Know that TAD less than 25mm is evidence-based, not arbitrary - Be able to explain to examiner how you would measure this **Screw Position Strategy**: - "Center-center or inferior-center, never superior" - Know the 3x3 grid system for describing position - Superior placement has highest cut-out risk due to thin subchondral bone and high stress **Short vs Long Decision Tree**: - Lateral wall less than 20mm = long nail - Subtrochanteric extension = long nail - Reverse obliquity = long nail - Stable pattern with intact lateral wall = short nail acceptable ### Viva Preparation **Opening Statement for Viva**: "Cephalomedullary nailing is the treatment of choice for unstable intertrochanteric fractures, reverse obliquity patterns, and fractures with subtrochanteric extension. The critical technical factors are achieving adequate reduction with medial cortical support, precise entry point to prevent malalignment, and optimal cephalic screw position with TAD less than 25mm to minimize cut-out risk." **Common Viva Questions**: 1. "What is tip-apex distance?" - Have clear, structured answer with numbers 2. "Why does superior placement increase cut-out?" - Understand biomechanics 3. "Short vs long nail - how do you decide?" - Know specific indications 4. "What are complications?" - Know rates and how to prevent each **Examiner Expects**: - Understand evidence behind TAD less than 25mm - Know lateral wall significance (less than 20mm threshold) - Describe reduction goals specifically (valgus acceptable, varus not) - Systematic approach to preventing cut-out ### Common Pitfalls in Exam **Mistakes to Avoid**: - Saying "varus reduction is acceptable" - IT IS NOT - Not mentioning TAD or saying "somewhere less than 30mm" - Not checking lateral view for entry point - Burying nail below GT tip - Not having systematic approach to final check **Buzz Words Examiners Want to Hear**: - "Tip-apex distance less than 25mm" - "Center-center or inferior-center position" - "Lateral wall thickness less than 20mm" - "Medial cortical support" - "Varus is unacceptable" ## Australian Context **Implant Availability**: - Multiple systems available (Synthes PFNA, Stryker Gamma3, Smith+Nephew TRIGEN, DePuy Synthes TFN) - PBS does not cover implants - hospital supply - Choice based on hospital contract and surgeon familiarity **Indications in Australia**: - CMN increasingly used as first-line for all intertrochanteric fractures - SHS still option for stable patterns in some centers - Evidence supports CMN for unstable patterns **Outcomes Data**: - ANZHFR (Australian and New Zealand Hip Fracture Registry) tracks outcomes - 30-day mortality approximately 7-8% for intertrochanteric fractures - Early surgery (within 48 hours) associated with improved outcomes ## References 1. Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am. 1995;77(7):1058-1064. [Landmark study establishing TAD <25mm as critical predictor of cut-out] 2. FAITH Investigators. Fracture fixation in the operative management of hip fractures (FAITH): an international, multicentre, randomised controlled trial. Lancet. 2017;389(10078):1519-1527. [Level I RCT comparing sliding hip screw vs CMN for intertrochanteric fractures] 3. Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev. 2010;(9):CD000093. [Level I meta-analysis of CMN vs SHS] 4. Hsu CE, Shih CM, Wang CC, Huang KC. Lateral femoral wall thickness. A reliable predictor of post-operative lateral wall fracture in intertrochanteric fractures. Bone Joint J. 2013;95-B(8):1134-1138. [Level III study establishing lateral wall <20mm threshold] 5. Palm H, Jacobsen S, Sonne-Holm S, Gebuhr P; Hip Fracture Study Group. Integrity of the lateral femoral wall in intertrochanteric hip fractures: an important predictor of a reoperation. J Bone Joint Surg Am. 2007;89(3):470-475. [Level III prognostic study on lateral wall significance] 6. Kaufer H. Mechanics of the treatment of hip injuries. Clin Orthop Relat Res. 1980;(146):53-61. [Classic biomechanical analysis of hip fracture fixation] 7. Streubel PN, Moustoukas MJ, Obremskey WT. Mechanical failure after intramedullary screw fixation of unstable intertrochanteric femur fractures. J Orthop Trauma. 2013;27(1):e1-e6. [Level IV case series analyzing mechanical failures and TAD] 8. Australian and New Zealand Hip Fracture Registry (ANZHFR) Steering Group. Australian and New Zealand Guideline for Hip Fracture Care: Improving Outcomes in Hip Fracture Management of Adults. Sydney: Australian and New Zealand Hip Fracture Registry Steering Group; 2014. [Australian clinical practice guideline] 9. Mereddy P, Kamath S, Ramakrishnan M, Malik H, Donnachie N. The AO/ASIF proximal femoral nail antirotation (PFNA): a new design for the treatment of unstable proximal femoral fractures. Injury. 2009;40(4):428-432. [Level IV case series on helical blade design] 10. National Institute for Health and Care Excellence (NICE). Hip fracture: management. Clinical guideline [CG124]. London: NICE; 2011 (updated 2017). [Clinical practice guideline on hip fracture management including orthogeriatric care]

Proximal Femoral Nail (Cephalomedullary Nail) for Intertrochanteric Fracture

Proximal Femoral Nail (Cephalomedullary Nail) for Intertrochanteric Fracture