From the Guidelines
The treatment of a femur fracture using Dynamic Hip Screw (DHS) plating involves several key steps, with the primary goal of restoring anatomical alignment and promoting bone healing while minimizing morbidity and mortality. The procedure typically begins with positioning the patient supine on a fracture table with the affected limb in slight adduction to facilitate access to the lateral aspect of the femur. After administering appropriate anesthesia (typically general or spinal) 1, the surgical site is prepped and draped. A lateral incision is made over the greater trochanter, extending distally along the femoral shaft. The vastus lateralis muscle is reflected anteriorly to expose the lateral femoral cortex.
Fracture reduction is then performed under fluoroscopic guidance to restore anatomical alignment. A guide wire is inserted from the lateral femur into the femoral head, positioned centrally in the head on both AP and lateral views, ideally in the lower half of the femoral head. After confirming proper guide wire placement, the femoral head is reamed to the appropriate depth for the lag screw. The lag screw is then inserted over the guide wire, followed by attachment of the side plate to the femoral shaft using cortical screws. Throughout the procedure, fluoroscopic imaging confirms proper implant positioning.
Some key considerations in the management of patients with hip fractures include:
- Protocol-driven, fast-track admission of patients with hip fractures through the emergency department 1
- Multidisciplinary care, led by orthogeriatricians 1
- Surgery within 48 hours of hospital admission 1
- High-quality communication between clinicians and allied health professionals 1
- Early mobilisation as a key part of the management of patients with hip fractures 1
Wound closure is performed in layers, and postoperative care includes:
- Prophylactic antibiotics (typically cefazolin 1-2g IV every 8 hours for 24 hours)
- Thromboprophylaxis (such as enoxaparin 40mg subcutaneously daily)
- Pain management
- Early mobilization is encouraged, though weight-bearing status depends on fracture stability, with protected weight-bearing for 6-12 weeks being common. The DHS procedure is effective because it allows controlled collapse at the fracture site while maintaining alignment, promoting bone healing through compression while providing rotational stability. This approach is supported by guidelines that emphasize the importance of timely and appropriate surgical intervention in the management of hip fractures 1.
From the Research
Steps for Treating a Fracture Femur using Dynamic Hip Screw (DHS) Plating
- Pre-operative preparation: The patient is prepared for surgery, and the fracture is assessed using imaging studies such as X-rays or CT scans 2.
- Reduction of the fracture: The fracture is reduced, and the bone fragments are aligned properly under image intensifier control 3.
- Insertion of the DHS plate: The DHS plate is inserted into the femur, and the screw is placed in the femoral head or neck 2.
- Fixation of the fracture: The fracture is fixed using the DHS plate and screw, and the stability of the fixation is checked using imaging studies 4.
- Post-operative care: The patient is monitored for complications, and post-operative care is provided to promote healing and prevent infection 2.
Potential Complications of DHS Plating
- Intra-operative complications: Insufficient reduction, broken tip of a K-wire, faulty technical procedure, and fracture of the distal fragment during surgery 2.
- Post-operative complications: "Cut-out" phenomenon, avascular necrosis of the femoral head, progression of coxarthrosis, screw breakage, femoral fracture under the plate, pseudoarthrosis, and late infection 2, 4.
- Factors affecting outcome: Fracture stability, osteoporosis, and technical mistakes made by surgeons can affect the outcome of DHS plating 2, 5.
Comparison with Other Fixation Methods
- Comparison with proximal femoral nail: DHS plating and proximal femoral nail have similar functional outcomes in the long term, but proximal femoral nail may have better outcomes in osteoporotic patients and weak bone mass 3.
- Comparison with cancellous screw fixation: There is no significant difference in outcomes between DHS plating and cancellous screw fixation for undisplaced subcapital hip fractures, but cancellous screw fixation may have better functional scores and quality of life in the early period 6.