Case presentation Failed DHS in cervicotrochanteric fracture

1
Case presentation Failed DHS in
cervicotrochanteric fracture

• R2 Wu Meng Huang
• VS Won Yi Zhen

2
General data

• Age 84 y/o
• Gender Female
• Occupation Retired (Past house-keeper)

3
Chief complaint

• Left hip pain and disability after fall injury 4
  months ago

4
Past history

• Multiple T-L compression fracture s/p T11/12
  vertebroplasty on 2006/04/19
• Old pulmonary TB
• Chronic gastritis and sessile polyp

5
Present illness-1

• Low back pain for years
• Fall injury on 2007/5/24
• Left hip contusion
• No other associated injury

• Physical exam
• Bogy height138.5CM BW46KG
• Conscious Clear
• No pale conjunctiva, no icteric sclera, Neck
  supple
• Chest Symmetrical expansion, breathing sound
  clear
• AbdomenSoft and flat
• Extremities left leg shortening
• Left hip Swelling
• Deformity External rotation, ROM limitated,
• Tenderness, Neurovascular deficit(-)

6
5/24
Lt femoral basal neck/ trochanteric fracture
7
Intertrochanteric fracture

• Most common hip fracture
• Osteoporosis, old age, multiple cormobidities
• Nonoperative treatment
• UTI, pneumonia, bedsore
• Operative treatment

8
5/25
ORIF with DHS and derotation screw 135 degrees,
4H/ 4S, 90 mm cannulated screw for stability
9
Present illness-2

• Fall again at home after discharge
• Frequent hip pain afterward and visit ER for
  several times
• OPD on 6/9
• Still severe hip pain
• PE
• Left hip wound clean, no discharge
• No local heat, mild swelling
• ROM limited, pain during weight bearing

10
6/6
Lt femoral greater trochanteric avulsion fracture
11
Greater trochanter fracture

• Abduction gluteus medius and gluteus minimus
• Rotation piriformis, obturator internus, and
  gemelli muscles
• Young vs. elderly
• Treatment
• Displacement is less than 1 cm and no further
  displace Conservatively with protected weight
  bearing
• Screws, cable devices, and tension band
  techniques to reattach muscle insertions

12
6/10
ORIF with cable wire/ clip good stability after
fixation no loosening of previous implant
13
Present illness-3

• Fall again on 7/7
• ER

14
7/7
Futher displacement of intertrochanteric fracture
and greater tochanteric avulsion fracture
15
Present illness-4

• Admission
• Buck traction
• Non weight bearing
• Augmentation was suggested but patient hesitated
• F/u X-ray on 8/29 OPD

16
8/29
DHS screw penetration and head collapse
17
DHS complication

• Screw penetration
• Loss reduction
• Nonunion
• Hemorrhage

18
9/3
Cemented Moore hemiarthroplasty