Proximal Femoral Nail for the treatment of Unstable Trochanteric Fracture

Shabi, A V (2010) Proximal Femoral Nail for the treatment of Unstable Trochanteric Fracture. Masters thesis, Madurai Medical College, Madurai.


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INTRODUCTION: Inter trochanteric fracture is one of the most devastating injuries in the elderly. The incidence of these fractures increases with advancing age. These patients are more limited to home ambulation and are dependent in basic and instrumental activities of daily living. 50 % of fracture around hip patients in elderly is of trochanteric fracture and these 50 % of fracture are unstable type of trochanteric fractures. The sliding hip screw device has been used for more than a decade for the treatment of these fractures. Though Zickel introduced his nail long ago, it was not a very popular fixation device due to higher incidence of complications. So was the case with Enders nail. The Zickel nail was later modified and renewed interest is being given to intramedullary fixation with devices like the Proximal Femoral Nail, Intramedullary Hip Screw and Gamma Nail due to shorter operating time, less blood loss and earlier mobilization with these devices. Side plate devices when used for unstable trochanteric fracture which are commonly associated with lateral wall communition results in excessive collapse of the proximal fragment and gross medialisation of distal fragment resulting in implant failure and delayed union or non union at fracture site. Intramedullary position of the PFN prevents the excessive collapse of proximal fragment & medialisation of distal fragment. Being a intramedullary load sharing device, PFN helps in early post operative mobilization ,weight bearing and ultimately the early fracture union. Being done as a closed nailing procedure PFN preserve the fracture haematoma and associated with less blood loss and short operating time. AIM OF THE STUDY: To assess the clinical, radiological and functional out come of unstable trochanteric fracture when treated with PFN. MATERIALS AND METHODS: At our institution we selected 12 cases (13 hips – one patient had bilateral unstable trochanteric fracture) of unstable trochanteric fractures for this prospective study. All (12 patients) 13 hips were treated with Proximal Femoral Nail in which (11 patients) 12 hips came for regular follow up and they were included in the study. The age group varied from a minimum of 22 years to a maximum of 70 years and average age was 42.8 years. Duration of the study was from June 2007 to May 2009. Mean follow up was 10 months of the 11 patients 9 were male and three were female. Right side involved in 8 cases Left side involved in 4 patients. 9 patients were manual laborers, two were sedentary workers. All the fractures were classified according to Boyd & Griffin classification for Inter- trochanteric fractures. Only type III & Type IV were included in the study. RESULTS: Patients were evaluated clinically and radiologically at 3 weeks interval for first 3 months and there after monthly for the next 3 months and bimonthly for next 12 months. During follow up the Harris Hip Score was evaluated at 3 months and 6 months post operatively. Various parameter like pain, limp, use of support, distance walked, stair climbing, sitting, absences of deformity, range of motion were evaluated using Harris Hip Score. Average operating time was 67.6 minute for patient treated with the PFN. Blood loss has varied from 150ml to 325ml with an average of 227 ml. Mean usage of image intensifier was 117 sec. Abductor lurch was seen in two patients. Average union time in weeks is 13.3 weeks. All the patient were allowed for partial weight bearing from the 2-3rd pod with aids. Harris hip Score at the end of 3 month is 73.8 and at end of 6 months is 84.3. Seven patients who were manual laborers went back to their original work None of the patients developed thigh pain. Screw back out occurred in one patient, but the # united by 16 weeks. Two patients treated with PFN developed abductor lurch. One patient developed Superficial wound infection which settled down with antibiotics. There was no case of deep infection . We don’t have encountered post operative ‘Z’ effect which is due to sliding of screws and femoral shaft # at the tip of the nail in our follow up. CONCLUSION: Intramedullary nailing with the PFN has distinct advantages over DHS like shorter operating time and lesser blood loss for unstable trochanteric fractures. Early mobilization and weight bearing is allowed in patients treated with PFN thereby decreasing the incidence of bedsores, uraemia and hypostatic pneumonia. The incidence of preoperative and postoperative femoral shaft fractures in PFN can be reduced by good preoperative planning and correct technique, adequate reaming of the femoral canal, insertion of implant by hand and meticulous placement of distal locking screws. PFN is a significant advancement in the treatment of unstable trochanteric fractures which has the unique advantage of closed reduction, preservation of fracture hematoma, less tissue damage during surgery, early rehabilitation and early return to work.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Proximal femoral nail ; treatment ; unstable trochanteric fracture.
Subjects: MEDICAL > Orthopaedics
Depositing User: Subramani R
Date Deposited: 16 Sep 2017 15:53
Last Modified: 17 Sep 2017 06:33

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