mlroutt at u
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Aug 22, 2006, 6:57 AM
Post #5 of 5
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Re: X-IMail-SPAM-Connection RE: [ORT-L] fem head fx in obese pt
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OK.
> the posted image is pre-fixation. if and when this pt gets a repeat CT scan,
> post ORIF fem head
> CT scan, I will post images. I say if and when b/c the radiology dept is
> starting to say the pt
> is too heavy for the scanner. thanks
> dan schlatterer
>
> --- Chip Routt <mlroutt@u.washington.edu> wrote:
>
>> The non-concentric joint is due to malreduction of the head fracture
>> according to your CT image.
>>
>> With a malreduced or excised femoral head fracture fragment, the wall
>> fracture IS now potentially clinically relevant...when the head reduction is
>> accurate the head is smooth and spherical and the hip is almost always
>> stable without repair of the peripheral wall...when the head fragment is
>> excised or malreduced "out of round", then head has an altered surface for
>> potential "skid" thru the peripheral posterior wall fracture defect.
>>
>> Chip
>>
>>
>>
>>
>>
>>
>>
>>
>>
>>> I have been away for a few days, so I am sorry for not giving an update
>>> sooner
>>> on the obese pt
>>> with fem head fx/dislocation. we proceeded with an anterior approach last
>>> week. very time
>>> consuming. most retractors were too short for him. at one point we used the
>>> buckwalter retractor
>>> ring! the ulnar aspect of my left wrist was sore by the end of the case
>>> from
>>> trying to retract.
>>> anyhow, medial head fragment was completely attached to lig.teres. the lig
>>> was released to permit
>>> full dislocation and reduction/fixation. dislocation was equally tough.
>>> fragment was secured
>>> with 4 minifrag/countersunk screws. unfortunately, the small fragment
>>> between
>>> the two major
>>> fragments (which was causing the displacement, see attachment)was from the
>>> superior aspect of the
>>> head and could not be salvaged. repaired head then reduced, but never
>>> completely concentric.
>>> joint was checked several times for foreign body. obviously the anterior
>>> approach contributed to
>>> the instability, but the joint should have fit better. the posterior wall
>>> fragment was noted to
>>> be larger and more displaced than the static CT scan revealed. we closed
>>> the
>>> approach and plan to
>>> re-CT scan and possibly perform KL approach for post/wall. so far this pt
>>> has
>>> had;
>>> DHS for right fem neck fx,
>>> ORIF pubic symphysis
>>> Right SI screws
>>> ORIF left fem head.
>>> this seems to be a never ending case! thanks to everyone for their input.
>>> dan schlatterer
>>> atlanta medical center
>>>
>>> --- "Gruenwald, Johannes M" <JG@uams.edu> wrote:
>>>
>>>> The fracture is anteriomedial, quite typically, and the surgeon cannot see
>>>> it
>>>> through Smith
>>>> Peterson, or any other anterior approach without dislocation, and detaching
>>>> the capsular/
>>>> ligamentous attachments. Also, anterior approaches may result in more poor
>>>> outcomes, as the have
>>>> a higher rate of HO formation.
>>>>
>>>> I am happy to read that in your opinion this discussion is over, it
>>>> continues
>>>> to go on however,
>>>> hopefully also on this board.
>>>>
>>>> Regards
>>>>
>>>> Michael
>>>>
>>>>
>>>> Swing and a miss...strike 3.
>>>>
>>>> The femoral head injury as shown is an anteromedial articular fracture and
>>>> does not "indirectly reduce", nor should it be indirectly reduced...it
>>>> should be directly reduced...it's as articular as an articular fracture
>>>> gets.
>>>>
>>>> The fracture is anteromedial...the surgeon cannot see it thru a KL.
>>>>
>>>> The wall fracture is peripheral and very very rarely has impact on hip
>>>> instability after the head fragment is anatomically reduced and stabilized.
>>>>
>>>> We've been thru all of these issues extensively and enough times already on
>>>> the list...please refer to the archives.
>>>>
>>>> Chip
>>>>
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>>>
>>>
>>> __________________________________________________
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>>
>> M.L. Chip Routt, Jr.,M.D.
>> Professor-Orthopedic Surgery
>> Harborview Medical Center
>> 325 Ninth Avenue
>> Box 359798
>> Seattle, WA 98104-2499
>> phone 206-731-3658
>> FAX 206-731-3227
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M.L. Chip Routt, Jr.,M.D.
Professor-Orthopedic Surgery
Harborview Medical Center
325 Ninth Avenue
Box 359798
Seattle, WA 98104-2499
phone 206-731-3658
FAX 206-731-3227
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