Step-by-Step Procedure for Intertrochanteric Femur Fracture Fixation with Dynamic Hip Screw (DHS) Plating
The Dynamic Hip Screw (DHS) is the standard surgical treatment for intertrochanteric femur fractures, allowing for stable fixation and early mobilization to reduce morbidity and mortality. 1
Preoperative Preparation
- Position patient supine on a fracture table with the affected limb in slight adduction and internal rotation to facilitate reduction and provide good access to the lateral aspect of the proximal femur 1, 2
- Administer prophylactic antibiotics within one hour of skin incision to reduce infection risk 1
- Ensure appropriate anesthesia - either spinal/epidural or general anesthesia with consideration of peripheral nerve blocks for postoperative pain management 1
- Implement active warming strategies to prevent hypothermia, which is particularly important in elderly patients 1
Surgical Procedure
Step 1: Approach and Exposure
- Make a lateral incision starting approximately 2 cm below the greater trochanter and extending distally along the lateral thigh for 10-15 cm 2, 3
- Incise the fascia lata in line with the skin incision 3
- Split the vastus lateralis muscle along its fibers to expose the lateral femoral shaft 3
Step 2: Fracture Reduction
- Achieve anatomical reduction of the fracture under fluoroscopic guidance before proceeding with fixation 3
- Pay special attention to restore the posteromedial cortical contact to ensure stability 3
- Ensure proper reduction in both anteroposterior and lateral views 4
Step 3: Guide Wire Insertion
- Insert the guide wire through the lateral femoral cortex, aiming for the inferior central position in the femoral head (avoid anterior or superior positions which increase cut-out risk) 4
- Confirm proper guide wire position in both anteroposterior and lateral fluoroscopic views 4
- The guide wire should be placed at a distance of 5-10 mm from the subchondral bone of the femoral head 4
Step 4: Reaming and Screw Insertion
- Measure the required length of the lag screw using the measuring device over the guide wire 3
- Ream over the guide wire to the appropriate depth for the lag screw 3
- Insert the lag screw over the guide wire to the predetermined depth 3
- Remove the guide wire after lag screw placement 3
Step 5: Plate Attachment and Fixation
- Attach the appropriate length side plate to the lag screw (typically 2-4 holes depending on fracture pattern) 5
- Secure the side plate to the femoral shaft with bicortical screws 5
- For unstable fractures, consider adding a trochanter-stabilizing plate (TSP) to enhance stability 2
Step 6: Final Assessment
- Obtain final fluoroscopic images in multiple planes to confirm:
Step 7: Wound Closure
- Irrigate the wound thoroughly 3
- Close the vastus lateralis muscle, fascia lata, subcutaneous tissue, and skin in layers 3
- Apply sterile dressing 3
Postoperative Management
- Continue appropriate thromboprophylaxis (fondaparinux or low molecular weight heparin) 1
- Implement early mobilization protocols to reduce complications 1
- Provide adequate pain management with regular paracetamol and cautious use of opioids, especially in patients with renal dysfunction 1
- Monitor for potential complications including wound infection, varus deformity, and screw cut-out 3, 4
Technical Considerations and Pitfalls
- Lag screw position is critical: Inferior-central placement in the femoral head provides the best outcomes; anterior or superior positions increase cut-out risk 4
- Avoid varus reduction: Ensure anatomical reduction to prevent varus deformity which can lead to fixation failure 3
- Beware of iatrogenic fractures: Take care during reaming and screw insertion to prevent additional fracturing of the proximal femoral cortex 3
- Vascular injury risk: Be cautious with drill bits and screws to avoid injury to the profunda femoris artery, which can lead to pseudoaneurysm formation 6
- Consider bone quality: In osteoporotic bone, ensure optimal screw position and consider augmentation techniques 4