![]() Furthermore, the femur should be visualized distally to assess the inner diameter of the intramedullary canal and antecurvation of the femur. Traction-internal rotation radiographs may further delineate the calcar region and hint at ease of fracture reduction. To adequately assess whether intramedullary nailing is necessary, the medial calcar region of the proximal femur should be clearly visible on at least one plane. An additional ap pelvic view is advantageous for guiding intra-operative reduction based on the contralateral side, especially in severely displaced and comminuted fractures. Standard anterior-posterior (ap) and lateral views of the fracture are usually enough to adequately diagnose and classify however, due to severe pain, sometimes only one view can be achieved (Fig. ![]() However, if the piriformis fossa approach is used as an entry point for the intramedullary nail, injuries to the anterior branch of the medial femoral artery have been described. Intertrochanteric fractures are extracapsular fractures by definition and thus rarely compromise the femoral head perfusion. To allow axial placement of the nail, however, adduction prior to nail insertion is necessary, depending on the entry point and patient body habitus. To counteract the displacement forces, the typical reduction maneuver thus requires traction, internal rotation, and abduction. Understanding the resulting muscle forces is a key prerequisite for assuring correct intra-operative reduction (Fig. The distal main fragment is commonly adducted through the adductor and hamstring muscles and externally rotated. If the lesser trochanter is intact, the adherent main fragment is further flexed and externally rotated. The gluteal muscles abduct the proximal main fragment. After an intertrochanteric fracture, the resulting muscle forces lead to a typical displacement pattern. In intertrochanteric fractures, the gluteal musculature and the iliotibial band cannot neutralize this force. As a mechanical axis runs medial to the lesser trochanter, the fracture typically displaces in a varus direction. ![]() In intertrochanteric fractures requiring intramedullary nail fixation, four main fragments are commonly found: head-neck, greater trochanter, lesser trochanter, and shaft, corresponding to AO fracture types A2 and A3. The lesser trochanter is the insertion point for the iliopsoas muscle and an important cortical stabilizer (Calcar). gemelli, obturatorius internus and obturatorius externus). The greater trochanter is an apophysis and insertion point for several important muscles: the piriformis muscle inserts on its tip, and the gluteus medius and minimus fan around the dorsolateral and ventrolateral side, while the intertrochanteric fossa is the insertion point for the short external rotators (Mm. In general, stage I and II are stable fractures and can be treated with internal fixation (head-preservation), and stage III and IV are unstable fractures and hence treated with arthroplasty (either hemi- or total arthroplasty) 3.The intertrochanteric femur region is one of the four distinct regions of the proximal femur (femoral head, neck, intertrochanteric, and sub-trochanteric regions). Garden stage IV: complete fracture, completely displacedįemoral head aligned normally in the acetabulum and its medial trabeculae are in line with the pelvic trabeculae Garden stage III: complete fracture, incompletely displacedįemoral head tilts into a varus position causing its medial trabeculae to be out of line with the pelvic trabeculae Medial group of femoral neck trabeculae may demonstrate a greenstick fracture Garden stage I: undisplaced incomplete, including valgus impacted fractures Garden described particular femoral neck and acetabular trabeculae patterns which can assist in recognizing differences within this classification system 2. It is simple and predicts the development of osteonecrosis 1,2. The Garden classification of subcapital femoral neck fractures is the most widely used.
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