What is the step-by-step procedure for treating an intertrochanteric femur fracture using Dynamic Hip Screw (DHS) plating?

Step-by-Step Procedure for Intertrochanteric Femur Fracture Treatment with DHS Plating

Dynamic Hip Screw (DHS) fixation is the standard procedure for stable intertrochanteric femur fractures, providing effective stabilization with lower blood loss compared to other techniques. 1

Preoperative Preparation

1. Imaging Assessment

   • Obtain AP pelvis and lateral hip radiographs to confirm intertrochanteric fracture 1
   • Assess fracture pattern for stability (stable vs. unstable/comminuted) 1
   • Consider CT scan for complex fractures to better visualize fracture pattern

2. Patient Preparation

   • Administer prophylactic antibiotics within one hour of skin incision 1
   • Consider multimodal pain management including peripheral nerve block (iliofascial block) 1
   • Administer tranexamic acid at the start of the case to reduce blood loss 1
   • Position patient on fracture table with the affected limb in slight adduction

Surgical Procedure

1. Anesthesia and Positioning

   • Administer spinal or general anesthesia 1
   • Position patient supine on fracture table
   • Apply traction to achieve fracture reduction
   • Prepare and drape the surgical site using standard aseptic technique

2. Fracture Reduction

   • Achieve closed reduction under fluoroscopic guidance
   • Confirm adequate reduction in both AP and lateral views
   • Ensure proper alignment of the medial cortex

3. Surgical Approach

   • Make a lateral incision starting 2 cm below the greater trochanter, extending distally 6-8 cm
   • Incise the fascia lata in line with the skin incision
   • Split the vastus lateralis muscle along its fibers to expose the lateral femoral shaft

4. Guide Wire Insertion

   • Identify the entry point on the lateral femoral cortex
   • Insert guide wire at the appropriate angle (135° for standard DHS)
   • Position the guide wire in the center or slightly posterior-inferior position in the femoral head on both AP and lateral views 2
   • Ensure the tip of the guide wire is 5-10 mm from the subchondral bone

5. Reaming and Screw Insertion

   • Measure the required length of the lag screw
   • Ream over the guide wire to the appropriate diameter
   • Insert the lag screw to the measured depth
   • Ensure proper position of the lag screw in the femoral head

6. Plate Attachment

   • Select appropriate length of DHS plate (typically 4-6 holes)
   • Slide the plate over the lag screw barrel
   • Secure the plate to the femoral shaft with cortical screws
   • For unstable fractures, consider adding a trochanteric buttress plate to prevent lateralization of the greater trochanter 3

7. Fixation of Lesser Trochanter Fragment

   • In comminuted fractures, ensure proper fixation of the lesser trochanter and posteromedial bone fragment to prevent varus collapse 4

8. Final Assessment

   • Confirm proper hardware placement with fluoroscopy in both AP and lateral views
   • Ensure the lag screw can slide within the barrel
   • Check for fracture reduction and stability

9. Wound Closure

   • Irrigate the wound thoroughly
   • Close the vastus lateralis and fascia lata with absorbable sutures
   • Close subcutaneous tissue and skin in standard fashion
   • Apply sterile dressing

Postoperative Management

1. Immediate Care

   • Monitor for postoperative anemia; transfuse if symptomatic 1
   • Provide adequate pain control with multimodal analgesia including regular paracetamol 1
   • Administer supplemental oxygen for at least 24 hours 1
   • Implement thromboprophylaxis with low molecular weight heparin or fondaparinux 1

2. Early Mobilization

   • Begin physical therapy on postoperative day 1 5
   • Allow weight-bearing as tolerated for stable fractures 1
   • Progress from assisted to independent ambulation based on patient ability 5

3. Follow-up Care

   • Schedule follow-up at 2-4 weeks, then at 3 months, 6 months, and annually 5
   • Obtain radiographs to assess fracture healing and implant position
   • Evaluate for complications such as screw cut-out, varus collapse, or infection 4
   • Arrange bone health assessment and osteoporosis treatment 1

Common Pitfalls and Prevention

1. Technical Complications

   • Screw cut-out: Ensure proper lag screw placement in center or posterior-inferior position of femoral head 2
   • Varus collapse: Achieve anatomic reduction and consider cephalomedullary nail for unstable fractures 1, 4
   • Femoral cortex fracture: Use careful surgical technique during reaming and screw insertion 4
   • Infection: Maintain strict aseptic technique and administer appropriate antibiotics 4

2. Patient-Related Complications

   • Delayed mobilization: Implement early physical therapy and appropriate pain management 5
   • Excessive blood loss: Consider tranexamic acid administration and monitor hemoglobin 1
   • Delayed union: Ensure proper reduction and fixation of posteromedial fragments 4

Remember that for unstable intertrochanteric fractures (comminuted, reverse obliquity), a cephalomedullary nail may be more appropriate than DHS fixation 1, 6.