Surgery of Surgery of SUB TROCHANTERIC SUB TROCHANTERIC

FRACTURESFRACTURESon simple tableon simple table

Dr. B. Shivashankar.Iyer Orthopaedic Centre, Solapur

President 2008-09National Association of Interlocking Surgeons

ISO 9001:2008Certified Hospital

Ordinary Table

•Either•Radio Lucent – C arm compatible

•Radio Opaque – C arm IITV Non compatible

Hip AP Position of C ArmOn Ordinary Non Radio Lucent Table

Lateral Hip Position for C Arm

On Ordinary Non Radio Lucent Table

Hip abducted and made way for X ray beam

C arm position for Hip AP view

On Ordinary Radio Lucent Table

C arm Position for Cross Table hip lateral View

On Ordinary Radio Lucent Table

X Ray tube under the table, Image intensifierNear the operative hip to avoid too much zooming

C arm Pictures of Hip in Cross Table lateral view

Both hips seen, the one nearer the X ray tube (underneath table)will be magnified, the operative side hip will be seen comparatively smaller as the Camera is nearer to same, confirmed by Passing Steinmann pin passed into the pirifiormis fossa of operative hip. For Doing PFN Pass an anteversion Guide wire parallel to anterior cortex as marked with the arrow in next slide.

C arm Picture of Hip in Cross Table lateral view

Anteversion Guide wire

For Doing PFN Pass an anteversion Guide wire Parallel to anterior cortex as marked with the arrow in the slide and keep the jig parallel to the same while passing guide wires for neck fixation as shown on right.

Advantage – When surgeon inserts Guide Pin, he need not have to get out of the way just for C Arm pictures, He can manipulatethe Guide pin to best position!(seen here)IITV for Hip Lateral View IITV for Hip AP View

C arm monitor is towards foot end of the table . Surgeon, Assistant and the X ray technician, all of them can see the picture

Cross Table Lateral ViewSee the normal B and Operative side A (enlarged as the hip is nearerTo X ray tube underneath)

BA

Passing Anteversion Pin placed very anteriorly in the neck

Passing the anteversion pin AP

Passing Anteversion Pin placed very anteriorly in the neckFinal position- note it is parallel to anterior cortex marked with arrow

Entry with Guide PinNote entry medial to tip of Trochanteralmost from piriformis fossa

Guide pin in lateral viewNote it is in the centre of neck

Advancing the guide pinParallel to anterior cortex in lateral view

Advancing the guide pinParallel to lateral cortex in AP view

Enlarging the entry with centering Awl

Passing the beaded Guide Wire for reaming

Sequential Reaming with flexible reamers

Passing the nail and final seating

Inferior Cervical screw Guide Wire Passingafter making entry with a sharp Awl marked with an arrow

Superior Derotational screw Guide Wire Passingafter making entry with a sharp Awllmarked with an arrow

Both Guide Wires passedAs seen in AP view

Nail Blocking the view of Guide Wires in Lateral View, But both anterior and posterior cortex of the neck seen

By rotating the jig along with anteversion Guide wireGuide wires in the neck can be seen.Please do not rotate only the jig, that will causeBending of the guide wires, Rotate along with anteversionGuide wire to control the rotation of proximal fragment

First drill and pass superiorDerotation Screw

Then drill and pass Cervical screw

Final AP with jig in situ

Flex the knee to enable heel to touch ischeal tuberosity toAlign fragments rotationally correct and then do distal locking by free hand. Proximal jig not removedTo hold and keep the nail hole perpendicular to ground

Drill at the distal end of oblong hole to availDynamisation possible and pass distal IL Bolt

Final AP

Final Cross table lateral

Pre and immediate post operative Xrays

X ray at 6 weeks on 4-11-2011

Few More Cases

28 Year Male

Function at 8 Weeks

14-02-2011

ST fracture with Brachial Plexus ST fracture with Brachial Plexus InjuryInjury

30-1-2009

28-4-200913-3-2009

Scar of Nailing Scar of Nerve Graft donor site

Video Clip on You Tube

• Short Video Clip of 3.2 minutes on You Tube is available as

http://www.youtube.com/watch?v=o2v-ewedvWQ

Copy paste above link on your browser

Thank you

Any Query:

Contact: drbshivashankar@gmail.com

Dr. B. Shivashankar. Iyer Orthopaedic Centre

An ISO 9001 : 2008 Certified Hospital103, Railway Lines

SOLAPUR 413001, MaharashtraINDIA

Disclaimer• For educational purpose only for

use by Medical students and Orthopaedic Surgeons.

• View expressed are personal• If copied for presentation purpose

kindly give credit to the author.• No financial interest involved• Any Query Contact : Dr. B. Shivashankar on

<drbshivashankar@gmail.com>