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AbstractSubtrochanteric femur fracture fixationremains one of the most challenging procedures to orthopedic surgeons. Apart ofthe choices of implant used, patient positioning for intramedullary nailing ofsubtrochanteric femoral fracture plays a crucial role in fracture reduction andshould be considered during preoperative planning. It is partly contributed tothe deforming muscle forces acting one the proximal fragment of femur. Ascompared to supine position, intramedullary fixation in lateral decubitus withtraction of affected leg is believed achieve to easier reduction of proximalfemur fragments due to the deforming muscle forces, easier attainment ofintramedullary fixation entry point due to les interference of the thorax andchest wall especially in obese patient.  Wereport the case of a 28-year-old male patient who underwent intramedullaryfixation of right subtrochanteric fracture in lateral decubitus with tractionof the affected leg.  Keywords: Subtrochanteric femur fracture,lateral decubitus, traction IntroductionSubtrochanteric fracture accounts for 25% ofproximal femur fracture and their distribution is bimodal which involves youngmade adults and old females predominantly3.  Subtrochanteric fracture is unstable as resultof the high compressive and tensile forces of muscle that separate the fracturesegments. Therefore surgery is the optimal option for the patients with noabsolute contraindication.

 Intramedullary fixation has been gaining popularity for the past decadesdue to its unique advantage- short force arm which can better distribute thestress compared to extramedullary fixation5.Intramedullary fixation in supine traction position has been well described.However the literature describing intramedullary fixation in lateral decubitusposition with traction is scarce1. This is partlycontributed to its drawback as the positioning set up is more timeconsuming.  Otherwise performingintramedullary fixation in lateral decubitus position with traction tableprovides an alternative to orthopedic surgeons for easier access to entry pointand fracture reduction. We reported a 28-year-old man who underwentintramedullary fixation for subtrochanteric fracture in lateral decubitusposition in traction table.

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   CaseReportA 28-year-old man had injured his right lowerlimb after a motor vehicle accident. Post trauma, he complained of pain over rightproximal thigh and was unable to lift up his right leg. Physical examinationrevealed a deformity over right thigh with intact neurovascular function.Standard pelvis and right femur radiographs show a fracture over rightsubtrochanteric femur (Figure 1). Otherwise lesser trochanter and piriformisfossa were intact.  The patient underwent intramedullary fixationunder general anesthesia using cephalomedullary nail. He was positioned inlateral position on traction table, with the operative leg over the top of theperineal post (Figure 2).

Boot was attached to the table with traction applied;hip was slightly adducted and moderately flexed. The leg was then internallyrotated 10-15 degrees.  Contra-lateralknee was flexed with boot attached. Padding was placed over fibular neckprominence over non operative leg. Closed reduction was achieved under C-armfluoroscopy guidance. C-arm was brought in perpendicular to the long axis ofthe femur.

When moving proximally and distally, the entire C-arm was moved, tostay perpendicular to the long axis. To visualize the proximal femur and thehead, C-arm was rotated 15° over the top and tilted 45° cephalad. Afterprepping and draping, 3-5cm of skin incision was made with greater trochanteras the center. Entry point was identified following by guide wire insertion. Theforce line of the limbs and fracture position were properly maintained followedby intramedullary reaming and intramedullary nail insertion. Afterwards theproximal and distal locking screws were inserted and fracture position wasconfirmed under C-arm fluoroscopy.  Postoperatively patient was given intravenousprophylactic antibiotics for 3 doses. He was initiated on the exercise ofmuscle strength of lower limbs and functional exercises of hip jointimmediately after operation.

He was discharged uneventfully post operative day2. Weight bearing over operative leg was prohibited 8-12 weeks.   DiscussionIntramedullary fixation of subtrochantericfracture remains one of the most challenging procedures to orthopedic surgeons.

It is partly due to the several deforming forces subjected to the proximalfemur fragments: flexion (provoked by the iliopsoas), abduction (by the gluteusmedius), and external rotation (by the external rotators). The adductors,inserted in the distal region of the femur, are responsible for the varus deformity4. Delayed union ornon union has been reported as a common complication of subtrochantericfracture as a result of limited contact surface area, decreased vascularity,and high mechanical stresses which might impair the bone healing2.

 Therefore proper reduction prior tofixation is detrimental to correct the rotation and flexion of proximal femurfragments and hence to achieve satisfactory bone consolidation.  Several surgical techniques especially patient’sposition during intramedullary fixation have been described in literatures toease the reduction of subtrochanteric fracture. Patient may be placed in eithersupine or lateral position with or without traction table. Previous literaturedescribed placing patient in lateral decubitus position on traction table;operative hip was flexed, adducted and knee was flexed with traction applied totake account of any flexion of the proximal fracture fragment. Instead ofapplying traction over flexed knee, we applied traction over the operative legwith knee extended.

     Positioning patient in lateral decubitus withtraction of the operative leg offers several advantages to orthopedic surgeons.Firstly it improves access to the entry point especially in obese patient asthe trunk is shifted away from surgical site which minimizes the interferenceof entry point by the torso. Second there is a good control of proximalfragment with less interference from the flank, chest wall or ribs. Thirdly, placingpatient in lateral decubitus with traction of affected leg could neutralize theproximal femur fragment which tends to angulate in varus in supine position.

Howeverfixation of subtrochanteric fracture in lateral position is without itsdisadvantages. The techniques might compromise the pulmonary function. Secondlyvenous congestion could be caused from the perineal post compressing the medialthigh and femoral vessels. Apart from that sciatic nerve over the operated legmight be at risk due to prolonged traction and hip flexion.  Finally many believe positioning in lateraldecubitus is more time consuming.

However we believe that once familiarity isgained the set-up time might not be different from the supine position.  ConclusionThe key point to reduce the complication ofsubtrochanteric fracture fixation is the quality of the reduction. Deformingmuscle forces make treatment of subtrochanteric fractures challenging.Therefore patient positioning is crucial to achieve satisfactoryreduction.  Intramedullary fixation inlateral decubitus with traction of the affected leg offers an alternative toorthopedic surgeons for easier attainment of reduction and intramedullary nailentry point.

 

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