Case Study of Subtrochanteric Femur

PREPARED BY: JOHN RESS A. ESCOBAL GROUP 1

SUBMITTED TO: TERESITA SAN JOSE RN, MAN

I. INTRODUCTION Subtrochanteric Femur Subtrochanteric fractures are fractures that occur in a zone extending from the lesser trochanter to 5cm distal to the lesser trochanter, however extension into the intertrochanteric region is common. These fractures are more difficult to treat as compared to intertrochanteric fractures due to the powerful muscle forces acting on the fragments as well as the tremendous stress that is normally placed through this region. When seen in young patients, they are due to high-energy trauma or pathologic fracture with 10% of high-energy fractures due to gun shot wounds. In the elderly, they are often low energy injuries involving osteoporotic bone. Pathologic fractures account for 17-35% of all subtrochanteric fractures. Fracture may also occur at the site of screw placement for a previous femoral neck fracture if the inferior screw is placed too low (below the lesser trochanter), as this creates a cortical defect and stress riser.

Risk Factors Any condition that generally (such as osteoporosis) or focally (such as metastatic disease) weakens the bone may predispose to such an injury with low-energy trauma or even without trauma.

Etiology In elderly patients, minor slips or falls that lead to direct lateral hip trauma are the most frequent mechanism of injury.5,3 This age group is also susceptible to metastatic disease that can lead to pathologic fractures. In younger patients, the mechanism of injury is almost always high-energy trauma, either from direct lateral trauma (eg, motor vehicle accident [MVA]) or from axial loading (eg, a fall from height). Gunshot wounds cause approximately 10% of high-energy subtrochanteric femur fractures. Two types of Subtrochanteric Femur:

Low subtrochanteric fracture Below lesser trochanter with piriformis fossa intact Treatment = standard locked IM nail
Proximal fragment is typically externally rotated and flexed due to the pull of the iliopsoas Distal fragment is displaced medially by the adductor magnus.

(Iliacus/ Psoas) and abducted by the short abductors inserting into the greater trochanter.

High subtrochanteric fracture Fractures with extention above the lesser trochanter Treatment = locked cephalomedullary nail. Beware of varus malreduction. The primary reason for this is failing to counteract the muscle forces acting on the proximal fragment combined with the adducted position of the distal femur during portal creation. Ensure anatomic reduction before guide wire and nail insertion. A clamp placed on the proximal fragment can be used to control proximal fragment movement and prevent eccentric reaming. In addition, excessive adduction of the distal fragment during reaming and nail placement should be avoided. (French BG, Tornetta P III: Clin Orthop 1998;348:95-100). Signs and Symptoms The clinical picture often is not subtle and resembles that in any patient with an intertrochanteric or a femoral shaft fracture. Pain and deformity are common, although nondisplaced fractures also are seen.Physical Exam Generally, a shortened extremity with a swollen thigh is most evident on examination. A complete neurovascular examination of the extremity should be performed. An open injury should be ruled out. Tests Laboratory
A complete blood count to evaluate the hematocrit is advisable in patients with any trauma.

Preoperative laboratory tests should be obtained in case operative treatment is necessary.

Urine and serum electrophoresis may be obtained if pathologic fracture is suspected. Imaging Radiography: AP radiographs of the pelvis and AP and lateral films of the hip and femur should be obtained with particular attention being paid to including the femoral neck to rule out concurrent, ipsilateral injury and to help dictate treatment options. The cross-table lateral hip view is advised rather than the frog-leg view. Classification Fielding Classification - This is an anatomic classification based on location of the fracture and is rarely used Type I - at level of lesser trochanter Type II - <2.5 cm below lesser trochanter Type III - 2.5-5cm below lesser trochanter Seinsheimer Classification - This system incorporates factors affecting stability and offers management guidelines. Type I - nondisplaced Type II - two part fractures Subtypes based on fracture pattern and displacement Type III - three part spiral fracture Subtypes based on type of fracture fragments Type IV - comminuted Type V - intertrochanteric extension Russell-Taylor Classification - This classification is based on integrity of the piriformis fossa. It was designed to guide treatment of intramedullary nails using a piriformis fossa starting point. This system may not be as important as it used to be, due to changes in entry point techniques and improved implant designs. Type I - intact piriformis fossa A - lesser trochanter attached to proximal fragment B - lesser trochanter detached from proximal fragment Type II - fracture extends into piriformis fossa A - stable posterior-medial buttress B - comminution of lesser trochanter Orthopaedic Trauma Association Classification - Based on degree of comminution and mainly used for research purposes. Treatment Initially, the limb should be stabilized with Hare traction, Buck's traction or skeletal traction. If there will likely be a delay in surgical stabilization, femoral or tibial skeletal traction should likely be employed. Nonoperative treatment in 90-90 skeletal traction followed by hip spica casting should only be employed in those whom surgery is deemed very high risk. 90-90 traction attempts to counteract the deforming muscular forces. Traction usually is required for 12-16 weeks. Surgical stabilization is the standard of care. The treatment option include: Intramedullary nail fixation is the preferred treatment. In general, intramedullary devices

have been found to be almost twice as strong as extramedullary implants. First generation interlocking nails (centromedullary) are indicated when both trochanters are intact as the oblique locking screw is able to obtain adequate purchase. Second generation interlocking nails with a locking screw that extends into the femoral neck (cephalomedullary) offer more stable fixation and are indicated when the lesser trochanter is displaced or comminuted. Advantages of intramedullary fixation include 1) Potential for closed treatment with preservation of fracture hematoma and blood supply to fracture fragments, 2) Decreased the moment arm on the implant compared to a lateral plate and thus decreases the tensile stress on the implant, 3) Reaming the canal in preparation of the implant provides internal bone graft, 4) intramedullary implants have been found to be twice as strong as traditional extramedullary implants. Disadvantages include 1) the implant cannot be used to help facilitate reduction and the fracture site may need to be opened to affect a reduction and guide pin insertion, thus lessening benefits of closed intramedullary fixation. It is nonetheless critical to achieve reduction and to maintain this reduction (using instruments, an incision or both as needed) while the nail is being placed. Failure to do so will result in varus displacement during implantation. Obtainment of proper nail starting point can be eased by lateral/lazy lateral patient positioning or the use of a trochanteric starting nail. If a trochanteric nail is chosen, it is imperative that a very medial starting point is chosen, again to avoid varus deformity. Russell et al have reported decreased rates of malalignment using the Minimally Invasive Nail Insertion Technique (MINIT) 4 . Ninety-five degree fixed-angle devices Historically this was the most common device used for operative fixation. This is a fixed angle construct that provides rigid fixation. Advantages include 1) Offers a treatment option for fractures with comminution of the trochanters that may make intramedullary implant insertion difficult, 2) Provides for multiple points of proximal fixation. Disadvantages include 1) Technically very demanding, 2) Extensive soft-tissue dissection, 3) High risk of implant failure due to tremendous stress applied to the plate laterally. Sliding hip screw This device is indicated only for very proximal fractures. The sliding of the screw allows medialization of the distal fragment, which reduces bending moment on fracture and implant. The sliding mechanism must cross the fracture site to lessen the risk of implant failure and the posteromedial cortex must be reconstructed to decrease the stress on the device. Post-Operative Care Rehab: Weight bearing is guided by fracture pattern. Protected weight bearing can be started early in fractures with posteromedial bony contact. Most patients should not fully bear weight for the first 6-8 weeks.

II. PERSONAL PROFILE Name: Manny agus Address:5262 Guyabano st. brgy 178 Camarin, Caloocan Age: 5 y/o Gender: Male Birthday: January 22, 2006 Name of Mother: Ellen Agus Name of Father: Robert Agus

General Information: CH: 631624 Date admitted: February 14, 2011 Attending Physician: Dr. Vinluan Ward: CW Chief complaint: Pain and deformities Right Thigh Diagnosis: FX CL Comp. Spiral Disp. Subtrochanteric Femur Right

III. HISTORY OF PRESENT ILLNESS: -3 days PTA, patient slipped while walking performing a split Left IE slipped forward while the Right IE was left behing.

IV. LABORATORY RESULT CBC

Component Hemoglobin Hematocrit

S/S Pain Swelling Breakage of the bone in complete fracture redness

Slipped on the floor Inflammation Trauma to the femur

Result 99 0.32

Normal result 127-183 g/L 0.37-0.54

V. ANATOMY

Subtrochanteric fractures are fractures that occur in a zone extending from the lesser trochanter to 5cm distal to the lesser trochanter. The medial and posteromedial cortices of the subtrochanteric femur experience the highest compressive stresses in the body. The lateral cortex is under a high degree of tensile stress. These fractures occur at the cortico-cancellous junction. The high composition of cortical bone and subsequently the decreased vascularity impairs the capacity for healing of these fractures when compared to the abundant cancellous bone of the intertrochanteric region of the hip. The proximal fragment is usually flexed and externally rotated by the pull of the iliopsoas and short external rotators, and abducted by the pull of the gluteus medius and minimus. The distal fragment is adducted and shortened by the pull of the adductors leading to a varus and procurvatum fracture alignment. These factors should be considered when attempting reduction. VI. PATHOPHYSIOLOGY

deformity Bone will be displace Fracture of the subtrochanteric femur

VII. Nursing Management

Provide emergency care if requires (hemostasis, respiratory care, prevention of shock). Provide fracture fixation to prevent following injury of tissues. Always stretch the linen to avoid bed sores Observe signs of fat embolism (especially during first 48 hours after the fracture). Monitor clients vital signs. Monitor clients laboratory tests results for abnormal values. Prepare client and his family for surgical intervention if required. Provide care to client in traction (check the weights are hanging freely, observe skin for irritation and site of skeletal traction insertion for signs of infection; use aseptic technique when cleaning the site of insertion). Provide respiratory exercises to prevent lung complications. Observe for signs of thrombophlebitis, report immediately. Provide appropriate skin care to prevent pressure sores. Encourage fluid intake and high-protein, high-vitamin, high-calcium diet. Provide emotional support to client, explain all procedures to decrease anxiety and to obtain cooperation.

Instruct client regarding fracture healing process, diagnostic procedures, treatment and its complications, home care, daily activities, diet, restrictions and follow-up.

DIAGNOSIS

PLANING

INTERVENTION

RATIONALE

EVALUATION

S>Nahihirapan siyang gumalaw as verbalized by the SO. O>presence of Balance skeletal traction >limited range of motion >inability to move purposely

Impaired physical mobility related to muscoskeletal impairement

After 4 hours of nursing intervention the S.O. will verbalize understanding of situation, risk factor, individual regimen treatment, and safety measure.

>Esstablished rapport >encourage patient to do divertional activity such as reading pocket books and coloring book. >encourage patient to eat foods reach in calcium and vit. C. >instruct patient to use overhead trapeze >encourage patient proper exercise >instruct the SO to maintain the linen free

ASSESSMENT

After 4 hours of nursing intervention the SO was able to verbalized understanding of situation, risk factor, individual regimen treatment, and safety measure.

from wrinkles

IX. NURSING CARE PLAN

VIII. DRUG STUDY

Brandname/Generic name 1. Paracetamol Classification Antipyretics, analgesics Indication for fever and pain Dosage
125 mg/5ml 5ml q 6hrs PRN for pain.

Adverse reactions Nausea and vomiting

Contraindication Hypersensitivity

Nursing Management If have fever check the temperature 30mins before and after giving the medication.

2. Ferrous Sulfate

Fe Sulfate

for iron deficiency

5ml TID

Black stool

Tetracycline, antacid

Take after meal