[Medical Case Studies
Minimally invasive surgery for intertrochanteric fracture of femur
I. Percutaneous PFNA internal fixation for intertrochanteric fracture of femur
Patient’s name: Zhu×× Sex: Female Date of birth: 85 years old
Date of consultation：2013/06/20 Initial consultation Season：Mangkat
Complaint: right hip pain and limitation of movement for 1 day due to a fall.
History: The patient complained of a fall at home one day ago. After the injury, she developed pain and swelling in her right hip and had limited movement, unable to stand or walk. After the injury, the patient consulted “Zhangping City Hospital”, the film suggested: right femur intertrochanteric fracture, no special treatment, for further treatment, today visited our hospital, the outpatient physician gave a physical examination and film after the proposed “Chinese medicine diagnosis: right femur intertrochanteric fracture (cis trochanteric fracture stasis blood blockage); Western medicine diagnosis: right femur intertrochanteric fracture”. Right femoral intertrochanteric fracture”. The pain was of a stabbing nature, and the right hip movement was limited, and he could not stand or walk.
Past history: history of “hypertension” for 10 years, with regular oral antihypertensive medication and unknown blood pressure control; history of “diabetes” for 1 year, with oral hypoglycemic medication and unknown blood glucose control; denied “hepatitis History of infectious diseases such as “hepatitis” and “tuberculosis”, history of major surgery and trauma, history of poisoning and blood transfusion were denied. History of drug and food allergy denied, history of vaccination unknown.
Allergy history: not found
Specialized conditions: bedridden position, right lower limb externally rotated shortening deformity, shortening of about 2M, right hip and upper right thigh swelling obvious, no obvious bruising and petechiae, localized percussion pain at the greater trochanter, right lower limb longitudinal percussion pain obvious, right hip joint movement restricted, right knee and ankle joint movement normal, right dorsalis pedis artery pulsation present, right lower limb extremity sensory blood flow normal.
Auxiliary examination: X-ray (Longyan Hospital 2013-06-20) showed that the right femoral intertrochanteric fracture, the fracture line from the greater trochanter to the right femoral lesser trochanter, the distal fracture end was displaced outward and upward, the lesser trochanter was split and free medially, the neck stem angle became smaller, about 125 degrees, and the pelvic bones showed osteoporotic changes.
TCM diagnosis:
1, intertrochanteric fracture of the right femur (cis trochanteric fracture Stasis of blood obstruction).
2, thirst.
3, bone impotence.
Western medical diagnosis.
1, intertrochanteric fracture of the right femur.
2, hypertensive disease.
3, diabetes mellitus.
4, osteoporosis.
Admission treatment plan.
1, TCM orthopedic care routine secondary care, diabetic diet, low-salt diet, bed rest, and one escort.
2, improve the admission routine examination, such as three major routine, biochemical full set, four coagulation, electrocardiogram, chest X-ray, etc.
3. According to the principle of “treating the symptoms of blood stasis and diarrhea of the symptoms of blood stasis”, we adopted the treatment method of “activating blood stasis, promoting blood circulation and relieving pain”.
1.The treatment was based on the combination of movement, tendon and bone, internal and external treatment, and cooperation between the doctor and the patient, and the left tibial tuberosity traction brake was performed under local anesthesia immediately.
2.Static drops of ShuXinNing to activate blood circulation and remove blood stasis, and Ginseng and Mai to benefit Qi and nourish Yin.
3.Chinese medicine: Yu’s “Earth Turtle Compound” for internal use
Minimally invasive PFNA internal fixation surgery management.
After admission, he was treated by systemic adjustment and medical consultation, and was prepared for surgery on 2013-07-08 under anesthesia for closed reduction of right femoral intertrochanteric fracture with percutaneous PFNA internal fixation. The surgical procedure is as follows
1. After the onset of anesthesia, the patient was placed on the orthopedic traction bed with the healthy limb fixed in the abducted neutral position, the hip of the affected limb was padded about 20 degrees, and the foot of the orthopedic traction bed was fixed in the straightened position. C-arm fluoroscopy showed good alignment of the fracture end.
2, routine disinfection and towel laying in the operating area, from the apex of the greater trochanter to the proximal end of the skin incision of 4cm, cut the skin subcutaneous tissue, and deep fascia, bluntly separate the gluteus medius muscle, touch the apex of the greater trochanter, choose the apex of the greater trochanter as the nail entry point, with a sharp cone opening, insert the guide needle, c-arm fluoroscopy to see the correct nail entry point, the guide needle is located in the medullary cavity, bone cone to expand the entrance of the guide needle, and this is the nail entry point, with the medullary enlarger gradually The insertion point is enlarged, the 11×200 mm PFN is attached to the insertion handle, the intramedullary nail is inserted from the entry point along the guide needle until the caudal end is level with the bone at the entry point, the fluoroscopic view shows a good fracture alignment, the intramedullary nail is in place, the insertion depth and length are appropriate, a sighting device and the Sanwei positioning rod are installed on the insertion handle, a skin incision of about 3 cm in length is made on the lateral side of the proximal femur, the barrel is bluntly separated and the barrel is jacked to the bone cortex. The bone hole is drilled through the barrel, the depth is measured, and the 85 mm screwdriver is inserted to 1 cm below the femoral head under the supervision of the C-arm machine, and the screwdriver is locked. A distal sight and a positioning rod were installed, and a 30 mm long locking nail was screwed into the distal femur in the same way as above. After the fluoroscopy, the fracture end was well aligned, the internal fixation was in place, and the length was appropriate, the insertion handle was removed, and a screw cap was screwed into the caudal end. After the operation, the incision was closed layer by layer.
3. Intraoperative anesthesia was good and bleeding was low.
Postoperative treatment.
1. Postoperative treatment such as rehydration, prevention of infection, blood circulation and promotion of fracture healing were given.
2. Postoperative review X-ray showed that the fracture end was well aligned.
3. 9 days after surgery, the stitches were removed.
4. The patient recovered well after surgery and could sit up two days after surgery.
Follow-up examination.
On July 20, 2013, the patient was in good spirits and could walk on the ground with two crutches.
【Experience
Femoral intertrochanteric fracture is a common fracture and often occurs in elderly patients, with the development of aging society, we will face more and more elderly patients with high-risk femoral intertrochanteric fracture. However, the traditional conservative Chinese medicine treatment is bed-rest for a long time under traction and medication, because the elderly patients are often combined with many medical diseases and long-term bed-rest is easy to combine with many fatal complications. This method uses percutaneous minimally invasive PFNA internal fixation to treat femoral trochanteric fractures with simple operation, less trauma, less bleeding, and shorter operation time, and modern research has concluded that the PFNA nail is a new intramedullary fixation instrument consisting of the PFNA main nail, spiral blade, distal locking and locking nut, with the following characteristics (1) the main nail is specially designed with a 5-degree external deviation angle, which can be smoothly inserted from the top of the greater trochanter during surgery and passed through the femoral trochanter. (2) Wide contact surface between the PFNA spiral blade and the bone, which compresses the cancellous bone when inserting the spiral blade and improves the anchoring force of the spiral blade in the femoral head, significantly improving the stability of rotation and collapse, thus avoiding the cut-out phenomenon: (3) Relatively flexible tip design, which makes insertion easier and avoids local stress concentration in the bone: (4) Single spiral blade design at the proximal end The proximal single spiral blade design makes the procedure simpler and reduces the risk of disrupting the blood flow of the femoral head. Because of the above features, PFNA internal fixation is especially suitable for elderly patients with intertrochanteric femoral fractures.
B. Percutaneous combined external fixation brace under local anesthesia for treatment of intertrochanteric fracture of femur
Patient’s name: Huang ×× Sex: Female Date of birth: 92 years old
Date of admission: January 12, 2013, Xinluo District, Longyan City, China Season of illness: Mango
Complaint: right hip pain and limitation of movement due to fall for 1 hour.
History: One hour ago, the patient fell down accidentally while walking in his own house, and felt pain in his right hip and limitation of movement, unable to stand and walk. There was no numbness and abnormal sensation in both lower limbs, and no urinary or fecal incontinence. Family members were sent to the hospital by car. Outpatient radiographs showed that the right femur was fractured between the trochanter. For further diagnosis and treatment, the outpatient clinic proposed “Chinese medicine diagnosis: right femoral intertrochanteric fracture (Shun intertrochanteric fracture with blood stasis obstruction); Western medicine diagnosis: right femoral intertrochanteric fracture”. The pain was of a stabbing nature, and the right hip movement was limited, and he could not stand or walk.
Past history: history of “hypertension” for more than 10 years, irregular medication, blood pressure control unknown; denied history of “hepatitis”, “tuberculosis” and other infectious diseases, denied Denies any history of chronic diseases such as “diabetes, kidney disease”. Denies history of major surgery and trauma, denies history of poisoning and blood transfusion. Deny history of drug and food allergy.
Specialized conditions.
Bedridden position, right lower extremity externally rotated deformity, unequal length of both lower extremities, right lower extremity shortened 2M compared to left lower extremity, right hip and upper right thigh slightly swollen, no obvious cyanotic petechiae, local percussion pressure pain at the greater trochanter, right lower extremity longitudinal percussion pain obvious, knee and ankle reflexes of both lower extremities normal, muscle strength and sensation of both lower extremities normal. The tongue is red, with yellow coating at the base of the tongue, and the pulse is sunken and stringent.
Auxiliary examination.
Pelvic plain film showed (Longyan City Hospital of Traditional Chinese Medicine 2013-01-12): right femoral intertrochanteric fracture, fracture line from the greater trochanter obliquely splitting inward to the lesser trochanter of the right femur, the lesser trochanter splitting, distal end of the fracture rotating outward and inward, visible shortening displacement, neck stem angle becoming smaller, about 100 degrees, Shentong line discontinuity, bone cortex thinning, bone trabeculae sparse.
TCM diagnosis:
1, intertrochanteric fracture of the right femur.
2, bone impotence.
Diagnosis: Shun intertrochanteric fracture Stasis and blood obstruction
Western medical diagnosis.
1, intertrochanteric fracture of the right femur.
2, osteoporosis.
3, hypertensive disease (grade II, very high risk).
Treatment plan.
I. conventional level I care in TCM orthopedics, low-salt diet, bed rest, and one escort.
(b) Improve the routine admission examinations, such as three major routine, biochemical complete set, four coagulation items, electrocardiogram, chest X-ray, etc.
According to the principle of “treating the symptoms of blood stasis and diarrhea of the symptoms of blood stasis”, we adopt the treatment method of “activating blood stasis, promoting blood circulation and relieving pain”, and give oral administration of Daqili tablets.
1.Take the combination of movement, tendon and bone, internal and external treatment, and cooperation between the doctor and the patient as the treatment principle, and immediately perform traction brake on the right tibial tuberosity under local anesthesia, with a traction weight of 7Kg, and observe the blood flow and sensory movement of the affected limb.
2. Sedative drip of Lanjian flower powder to activate blood circulation and remove blood stasis, and ginseng to benefit Qi and return Yang.
4, improve the relevant examination, internal medicine to assist in consultation and treatment, stable situation on the next day for minimally invasive surgical treatment (PFNA, or external fixation stent)
Case record.
After the patient was admitted to the hospital, the relevant tests were completed and the internal medicine department consulted on January 16, 2013.
Consultation opinion: 1, hypertension grade 2, very high risk, poor blood pressure control; 2, coronary artery disease, arrhythmia, cardiac function grade 3; 3, pulmonary infection. Suggestions: 1, improve cardiopulmonary function; 2, control blood pressure, do glucose tolerance, insulin release test, glycated hemoglobin; 3, if the family agrees, transfer to internal medicine.
Thereafter, the patient was actively treated for related conditions and stabilized, but the patient was at high risk due to the coexistence of multiple medical diseases, and the anesthesiologist consultation was not appropriate under anesthesia, and the patient’s family strongly requested to be able to actively treat the patient after intra-departmental discussion and finalized the surgical treatment plan of percutaneous needle external fixation stent under local anesthesia.
2013-01-24 Surgical record Closed reduction external stenting of right femoral intertrochanteric fracture under local anesthesia
The patient was placed in a supine position on an orthopedic traction bed with the right lower limb in an abducted neutral position. The fracture end was injected with 0.5% lidocaine 10 ml local anesthesia under fluoroscopy, and then the fracture was repositioned by manipulation, and the fracture alignment was acceptable, the neck stem angle was good, and the small trochanter was misaligned medially. After successful local anesthesia with 10 ml of 0.5% lidocaine at the puncture site, a 4.0-mm Kirschner needle was drilled under fluoroscopy in the direction of the tension and pressure trabeculae at 3 cm and 6 cm below the greater trochanter of the femur, respectively, until it reached about 1.0 cm below the femoral head, which was confirmed by fluoroscopy, and one 4.0-mm diameter Kirschner needle was drilled from lateral to medial at 20 cm and 25 cm above the condyle, respectively, according to the length of the brace. After installing the stent, the fluoroscopy confirmed that the fracture end was well aligned, the joints were tightened, the excess pinhole was cut out, and the pinhole was wrapped. The operation was smooth, and the patient did not complain of any special discomfort during and after the operation, which lasted about 20 minutes, and there was basically no bleeding during the operation, and the patient was basically pain-free. The patient returned to the ward afterwards.
Postoperative condition record
After the operation, the patient was discharged from the hospital in good general condition 4 days after the operation, except for the bed-bound bone traction, that is, semi-recumbent sitting, and the patient was in good spirits, after observation and nutrition and other treatment.
【Experience
With the gradual aging of society, the number of elderly hip fracture patients is increasing, which is inseparable from the elderly, with osteoporosis, reduced bone strength and increased bone fragility. Because of the declining function of the elderly body and often accompanied by multi-system disease comorbidities, complications are prone to occur and the morbidity and mortality rate is also higher. Proper and reliable surgery and early functional exercise after surgery are the keys to prevent complications and reduce the morbidity and mortality rate. There are many treatment methods for geriatric femoral trochanter fractures, and traction and surgery are often used. Due to traction treatment, bed rest for a long time, the elderly are prone to bed sores, urinary tract infections, pulmonary infections, deep vein thrombosis and other complications. Deep vein thrombosis causing pulmonary disorders is an important complication that causes death of hip fracture in the elderly, and long time traction, the knee and hip joints do not get effective functional exercise, prone to dysfunction and other complications, so for the treatment of elderly femoral trochanter fracture, patients who can tolerate surgical treatment should be given surgical treatment as much as possible to reduce the time of bed rest and avoid the occurrence of long-term bed rest complications. There are various internal fixation methods commonly used for surgery, such as plate, power hip, PFNA, especially PFNA is now becoming a more recognized minimally invasive and effective internal fixation method, but all these procedures need anesthesia to be performed with surgery. In our existing clinic, we often encounter elderly patients with multiple medical diseases, and the anesthesia consultation often cannot be implemented with anesthesia, resulting in the inability to perform internal fixation, therefore, we are able to perform closed reduction external brace fixation of femoral intertrochanteric fracture under local anesthesia for such patients after full discussion and communication with the family. The procedure is fluoroscopically closed and repositioned, which is less traumatic, shorter, basically non-bleeding, less disturbing to the body, and can be tolerated by elderly and frail patients with cardiopulmonary insufficiency. Therefore, we believe that the choice of the specific surgical approach for elderly patients with intertrochanteric fractures is not fixed, and it is not possible for one surgical approach to solve all problems, but the final surgical approach should be decided according to the different conditions of each patient.