LESSER

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LESSER TUBEROSITY
AP pelvis and AP hip of an elderly patient with
a three-part intertrochanteric hip fracture.
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LATERAL RADIOGRAPH
FEMUR
ISCHIUM
LESSER TROCHANTER
The set up on the fracture table does not require
the uninjured leg to be placed in hyperflexion
and abduction. The legs may be scissored to
allow for good lateral radiographs of the
affected side without putting the opposite hip at
risk.
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This image demonstrates the position of the
fracture table with the patients affected arm
over the chest and well padded.
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SCDs ON DURING PROCEDURE
This image demonstrates the scissoring of the
legs with the affected side slightly flexed and
the unaffected side slightly extended. Notice
that sequential compression devices remain on the
legs during the procedure.
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A view from below demonstrates the position of
the arm.
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The C-arm is brought in from an angle
approximately 30 degrees distal to the patient.
The AP radiograph is taken with the C-arm
slightly over rotated to give a more perfect AP
view with respect to the anatomy of the proximal
femur and the lateral view.
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The incision should begin proximally at the
trochanteric ridge and need extend approximately
10 centimeters down the thigh.
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ITB
The incision brought down to the level of
the iliotibial band and fascia lata.
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ITB
The iliotibial band is incised with a knife. A
Metzenbaum scissors is used to dissect under the
band, which is divided in line with the incision.
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The iliotibial band is incised with a knife. A
Metzenbaum scissors is used to dissect under the
band, which is divided in line with the incision.
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ITB
VASTUS LATERALIS
With retraction of the iliotibial band, the
vastus lateralis fascia is visualized.
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A sharp rake is introduced anteriorly and is used
to retract the vastus lateralis anteriorly. An
incision is then made in the fascia just anterior
to the most posterior aspect of the femur.
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A sharp rake is introduced anteriorly and is used
to retract the vastus lateralis anteriorly. An
incision is then made in the fascia just anterior
to the most posterior aspect of the femur.
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A periosteal elevator can be used to elevate the
lateralis off the femur with care taken to avoid
perforating branches.
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A Bennett retractor can be placed over the
anterior surface of the femur, exposing the
lateral edge of the femur.
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AP x-ray demonstrating abduction of the proximal
fragment and displacement of the posteromedial
fragment.
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A bone hook can be used, as can a clamp or
other technique, to reduce the abduction in the
proximal fragment.
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Once a reduction is obtained and confirmed on the
AP and lateral radiographs, the angle guide is
placed against the lateral surface of the femur
in order to place the guidewire for the lag screw.
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The natural anteversion of the hip requires
commensurate external rotation of the jig in
order to drive the wire into the center of the
head.
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X-rays demonstrating the position of the
guidewire through the jig in the AP and lateral
planes.
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After the appropriate measurement for the lag
screw is made, the femur is prepared by reaming.
In this case, a long barrel was chosen and the
appropriate reamer is selected.
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If the bone is of good quality, a tap may be used.
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AP radiograph of the lag screw being terminally
seated.
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When using a small incision, the side plate must
be slid from proximal to distal along the
femoral shaft, then drawn back up proximally such
that it is within the wound.
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In order to seat the side plate, its distal end
must be held gently off bone, such that the side
plate is parallel with the femur in order to
engage the lag screw.
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Once the plate is terminally seated and tapped in
place, it is affixed to the cortex using standard
screw fixation.
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AP radiograph of the lag screw and side plate in
position.
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In this particular situation, the posteromedial
fragment was rather large, thus it was elected to
fix it with a lag screw. This must be done from a
position anterior to the side plate.
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This is the case because the side plate must be
slightly posterior to the midline in order to
direct the lag screw into the center of the head,
given the normal anteversion of the neck.
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The posteromedial fragment cannot be lagged
through the plate because the angle of the screw
through the plate would be too great. Thus, the
screw is placed from anterior to the plate as
seen in this figure.
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Lateral view of the posteromedial fragment
reduction with a clamp.
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The image shows the drill that is placed into the
lesser trochanter.
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Final AP radiograph demonstrating excellent
fixation and compression across the
intertrochanteric fracture as well as lag screw
fixation of the lesser trochanter.
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VASTUS LATERALIS
ITB
The closure is then performed with a running
stitch of the vastus lateralis.
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ITB
The iliotibial band is repaired using interupted
sutures the skin will then be closed in layers.
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