Patterns and management of musculoskeletal injuries in attempted suicide by jumping from a height: a single, regional level I trauma center experience.

BACKGROUND: Suicide is a common cause of death in Brazil, with an overall increase of 62.5% during the last 30-year period. The study aims to determine overall patient characteristics and symptomatic indicators of complications among survivors. METHODS: In this retrospective cross-sectional study, we collected and analyzed clinical information of all patients aged > 10 years who presented to our hospital with a history of attempted suicide by jumping from a height in a 7-year period. Records were searched for primary demographic data, radiographs and CT scans were reviewed to determine injury characteristics, and records and operative notes were searched to look for symptomatic indicators of complications among survivors. Baseline demographics and the distribution on skeletal injuries were compared between the survivor and non-survivor patients using the Chi-squared for categorical variables and the Student's t-test for continuous variables. Among survivors, univariate and multivariate analysis were performed to investigate independent risk factors of attempted suicide and complications. RESULTS: A total of 222 patients attempted suicide by jumping from a height. At multivariate analysis, the middle-aged patient was the unique identified risk factor for suicide by jumping from a height. Overall mortality was 67.6%. The main independent cause for death was traumatic brain injury. Among survivors, there was a higher incidence of foot and ankle fractures, and pelvic ring injuries. The overall complication rate for survivor patients was 51.4%, with acute infection being the most prevalent complication. At multivariate analysis, middle-aged men, foot and ankle injuries, open pelvic injuries, and open fractures were identified as risk factors for acute complications. CONCLUSION: Middle-aged people are at significant risk for attempting suicide by jumping from a height in Brazil, independently of gender, with 67.6% deaths. Traumatic brain injury, higher ISS, and more than 3 skeletal injuries are independent variables related to this fatal outcome. Acute complications occur in approximately 50% of survivors. Middle-aged men, foot and ankle injuries, open pelvic injuries, and open fractures are risk factors for complications.

Operative treatment of transverse acetabular fractures: is it really necessary to fix both columns?

OBJECTIVE: we prospectively evaluated clinical and radiographic outcomes in patients with displaced combined transverse-posterior wall acetabular fractures managed at our Institution over a period of seven years by posterolateral single approach, direct posterior wall and posterior column reduction and plating, and indirect reduction of anterior column controlled by fluoroscopic images with or without lag-screw fixation. The aim was to identify if the obtained immediate postoperative Matta radiographic roof-arc angles after fracture reduction and fixation alters in the postoperative period when comparing posterior plating alone versus posterior plate and anterior column lag-screw fixation. PATIENTS AND METHODS: 35 skeletally mature patients (31 male and four female, with mean age of 39.9 years old [range, 23.3 to 66.7 y/o]) with combined transverse-posterior wall acetabular fractures surgically treated by a posterolateral single approach were enrolled in this prospective investigation. Nineteen patients had associated orthopaedic injuries. The first part of the acetabular fracture management was similar to all patients and consisted in anatomical reduction and fixation of the transverse posterior component followed by anatomical reduction and fixation of the posterior wall component. The transverse anterior component reduction was controlled by fluoroscopic images (anteroposterior (AP), iliac oblique, and obturator oblique views) and digital palpation through the greater sciatic notch. Fifteen of the 35 patients had an additional lag-screw fixation from the posterior to the anterior columns with an extra-long small-fragment cortical screw. AP and Judet oblique radiographic views were taken at the end of the procedure and roof-arc angles were measured. Clinical results were assigned according to the grading system of Merle D'Aubigne and Postel as modified by Matta et al. Radiographic roof-arc angles were checked and compared between the two groups of patients to the same data collected both at the time of the surgical procedure and at three months postoperatively. Statistical analysis was done by either using chi-square (clinical outcome) and Mann-Whitney (roentgenographic outcome) tests, with a level of significance of alpha = 5%. RESULTS: at final follow-up examination 18 to 84 months postoperatively (mean, 46.8 months), the clinical results were considered satisfactory in 31 (88.6%) patients (excellent in nine (25.7%) and good in 22 (62.9%) patients). There was no difference between patients with (n = 15) and without (n = 20) fixation of the transverse anterior component of the acetabular fracture (p = 0.67). Radiographic roof-arc angles measured at discharge, at three months postoperatively and at the last follow-up consultation didn't changed significantly (p > 0.05). There was no statistically significant difference between patients treated with (n = 15) and without (n = 20) fixation of the anterior component of the transverse acetabular fracture in terms of medial displacement of the femoral head. CONCLUSION: the authors suggest that associated transverse-posterior wall acetabular fractures can be managed by a single posterior approach. Direct reduction and fixation of the posterior wall and column components is an adequate option for these injuries. If there is adequate indirect reduction of the anterior column, as checked by digital palpation and fluoroscopy, we feel that it is not necessary to fix the anterior column component of the transverse acetabular fracture.

The role of the medial plate for Pauwels type III femoral neck fracture: a comparative mechanical study using two fixations with cannulated screws.

BACKGROUND: The biomechanical behavior of Pauwels type III fractures should be taken into consideration when performing internal fixation, since this repair should resist the shear force inherent in the vertical fracture line to the greatest extent possible. Recently, the use of a small fragment plate on the medial face of the femoral neck has been proposed by some authors, with satisfactory initial results. In the current study we analyze the mechanical role a medial plate used as a buttress plate for Pauwels type III femoral neck fractures, comparing the resistance of two fixation configurations using three cannulated screws. METHODS: Pauwels type III fractures were simulated in synthetic bones models and two groups were created, one of those using two parallel screws at the bottom of the femoral neck and the third screw crossing the fracture horizontally (G1), and the other fixed in the same arrangement as G1, but with the addition of a medial side plate at the apex of the fracture (G2). The constructs were subjected to axial loading until catastrophic failure. RESULTS: The addition of a medial plate buttressing the femoral neck increased significantly the resistance to maximum loading (p = 0.003). CONCLUSION: Use of a medial buttress plate results in a mechanically superior construction for Pauwels type III fractures fixed with multiple cannulated screws. LEBEL OF EVIDENCE: Level IV. Biomechanical comparative study.

Use of Nonvascularized Autologous Fibular Strut Graft in the Treatment of Major Bone Defect after Periprosthetic Knee Fracture.

We present the case of a patient who suffered a comminuted supracondylar periprosthetic femur fracture. The patient was an 86-year-old lady who suffered a minor fall at home and presented at our hospital with a right comminuted distal femur fracture around a total knee arthroplasty. The patient was submitted to a cruciate-sacrificing total knee replacement 6 years before at the same institution. Despite severe metaphyseal fragmentation and short distal fragment, the prosthesis was stable; thus, open fracture reduction and stabilization with internal fixation were performed. The surgical technique included the use of a nonvascularized autologous fibular strut graft as an augmentation technique in conjunction with double plating fixation. Clinically, patient presented a painless aligned knee 12 months after femur fixation, although she was not able to return to an independent level of activity. No pain involving the donor graft site was reported at the time of the most recent follow-up examination. This case study demonstrates the use of free nonvascularized autogenous fibular strut bone graft as an option to bridge major bone defects. This proved to be a relatively simple, not expensive procedure that can be done percutaneously and does not need high-quality training.

Outcome evaluation of staged treatment for bicondylar tibial plateau fractures.

BACKGROUND: The universal accepted strategy for treating high-energy tibial plateau fractures remains a topic of ongoing debate. The challenge for the practicing orthopaedic trauma surgeon is to provide anatomical articular fracture reduction, with successfully managing the complex soft-tissue injury that is commonly present at patient admission. The primary aim of the actual study was to evaluate the results of a staged protocol for the treatment of high-energy bicondylar tibial plateau fractures. The secondary aim was to describe the technique used for the definitive fixation of this complex fracture pattern. METHODS: Thirty patients with unstable high-energy closed bicondylar tibial plateau fractures (17 Schatzker V and 13 Schatzker VI) were managed. There were 24 men (80%) and six women (20%). All of them were skeletally mature with their age ranging from 19 to 67 years (mean of 33.1±3.4 years). Treatment involved a two-stage procedure with appropriate emergency care, preoperative planning, and definitive fixation. Initial treatment, named 'damage control on complex articular fracture elements', consisted on temporary bridging external fixation. Definitive treatment was delayed in a mean of 10 days (ranging from seven to 13 days) and was performed when the soft-tissue conditioning demonstrated either complete or almost complete remission of the inflammatory reaction due to the 'first hit'. Conventional implants were used in the 30 patients. All patients were evaluated clinically and radiographically. RESULTS: Twenty-six (86.7%) patients had a moderate level of activity, three (10%) patients had a very light level of activity, and one (3.3%) patient was unable to have any kind of work activity and is currently supported by the Brazilian Welfare. Using the visual analog scale mean pain score was 30 (ranging from 10 to 60); even the patient with the workers' compensation had no severe pain. All patients except three have no difficulty with stairs, giving way, locking, swelling, and squatting, but were unable to run. Three (10%) patients had problems with stairs and could not bend the operated knee more than 90°. One of them had a varus knee but no instability. Ninety percent of the patients were either very satisfied or somewhat satisfied with their outcome. The three dissatisfied patients suffered postoperative complications, most commonly wound infections. Four (13.4%) patients with former anatomical reduction had a residual articular step-off or diastasis of less than 3mm after fracture healing. All patients had no or mild arthrosis at the time of the last outpatient consultation. CONCLUSIONS: The two-staged procedure presented herein showed to be an effective strategy for managing bycondilar tibial plateau fractures. The protocol used for these complex traumatic injuries follows very well defined steps, which means acute stabilization with a linear bridging external fixation, adequate soft tissue handling, preoperative planning, and definitive surgical fixation after seven to 14 days. The model presents a more biological approach to optimizing functional outcome with an acceptable complication rate and minimal risk of loss of reduction in these high-energy tibial plateau fractures.

Open Pelvic Fractures: Review of 30 Cases.

BACKGROUND: Open pelvic fractures are rare but usually associated with a high incidence of complications and increased mortality rates. The aim of this study was to retrospectively evaluate all consecutive open pelvic fractures in patients treated at a single Level-1 Trauma Center during a 10-year interval. PATIENTS AND METHODS: In a 10-year interval, 30 patients with a diagnosis of open pelvic fracture were admitted at a Level-1 Trauma Center. A retrospective analysis was conducted on data obtained from the medical records, which included patient's age, sex, mechanism of injury, classification of the pelvic lesion, Injury Severity Score (ISS), emergency interventions, surgical interventions, length of hospital and Intensive Care Unit stay, and complications, including perioperative complications and death. The Jones classification was used to characterize the energy of the pelvic trauma and the Faringer classification to define the location of the open wound. Among the survivors, the results were assessed in the last outpatient visit using the EuroQol EQ-5D and the Blake questionnaires. It was established the relationship between the mortality and morbidity and these classification systems by using the Mann-Whitney non-parametric test, with a level of significance of 5%. RESULTS: Twelve (40%) patients died either from the pelvic lesion or related injuries. All of them had an ISS superior to 35. The Jones classification showed a direct relationship to the mortality rate in those patients (p = 0.012). In the 18 (60%) other patients evaluated, the mean follow-up was 16.3 months, ranging from 24 to 112 months. Eleven (61%) patients had a satisfactory outcome. The Jones classification showed a statistically significant relationship both to the objective and subjective outcomes (p < 5%). The Faringer classification showed a statistically significant relationship to the subjective, but not to the objective outcome. In addition, among the 18 patients evaluated at the last outpatient visit, the Faringer classification showed statistical significance on the need of colostomy (p = 0.001) in the acute phase of treatment. CONCLUSION: We suggest the routine use of the Jones classification for the emergency room assessment and management of all open fractures of the pelvic ring. We believe the Faringer classification seems to be useful for the abdominal surgeons for the indication of gut transit derivation but not for the acute management of the bony component of an open pelvic fracture.

WhatsApp Messenger is useful and reproducible in the assessment of tibial plateau fractures: inter- and intra-observer agreement study.

OBJECTIVE: The aim of this study was to evaluate the inter- and intra-observer agreement in the initial diagnosis and classification by means of plain radiographs and CT scans of tibial plateau fractures photographed and sent via WhatsApp Messenger. BACKGROUND: The increasing popularity of smartphones has driven the development of technology for data transmission and imaging and generated a growing interest in the use of these devices as diagnostic tools. The emergence of WhatsApp Messenger technology, which is available for various platforms used by smartphones, has led to an improvement in the quality and resolution of images sent and received. METHODS: The images (plain radiographs and CT scans) were obtained from 13 cases of tibial plateau fractures using the iPhone 5 (Apple Inc., Cupertino, CA, USA) and were sent to six observers via the WhatsApp Messenger application. The observers were asked to determine the standard deviation and type of injury, the classification according to the Schatzker and the Luo classifications schemes, and whether the CT scan changed the classification. The six observers independently assessed the images on two separate occasions, 15 days apart. RESULTS: The inter- and intra-observer agreement for both periods of the study ranged from excellent to perfect (0.75<κ<1.0) across all survey questions. When asked if the inclusion of the CT images would change their final X-ray classification (Schatzker or Luo), the inter- and intra-observer agreement was perfect (k=1) on both assessment occasions. CONCLUSION: We found an excellent inter- and intra-observer agreement in the imaging assessment of tibial plateau fractures sent via WhatsApp Messenger. The authors now propose the systematic use of the application to facilitate faster documentation and obtaining the opinion of an experienced consultant when not on call. Finally, we think the use of the WhatsApp Messenger as an adjuvant tool could be broadened to other clinical centres to assess its viability in other skeletal and non-skeletal trauma situations.

Is the surgical knot tying technique associated with a risk for unnoticed glove perforation? An experimental study.

BACKGROUND: The issue of safety in the surgical procedure has recently been widely and openly discussed at the World Health Organization. The use of latex gloves is the current standard of protection during surgery, as they remain intact throughout the procedure. The present study was designed to evaluate the rate of glove perforation during a two-hand technique using polyester sutures in a controlled experimental study. METHODS: Hypothesis was that the gloves used during a two-hand technique using polyester suture suffer punctures. We used 150 pairs of gloves during the experiment. Each investigator performed 30 tests always using double gloving. They made five surgical knots on each test over a custom-made table specifically developed for the experiment. Ten tests were done at a time with a week- interval. The Control Group (CG) has 30 pairs of intact surgical gloves. The gloves were tested to impermeability by water filling and leaking was observed at three different times. Statistics relating to the perforation rate were analyzed using the chi-square test. A P value less than 0.05 was considered statistically significant. RESULTS: During the experiment there was no loss of gloves by drilling or inadvertent error in performing the impermeability test. No perforations were detected at any time during the impermeability test with the gloves used for sutures. Also, the CG presented no leakage of the liquid used for the test. There was no statistical difference between the groups underwent suture nor between them and the GC. CONCLUSION: Under the studied conditions, the authors' hypotheses could not be proved. There was no damage to the surgical gloves during the entire experiment. The authors believe that the skin abrasions observed in the ulnar side of the little finger, constant throughout the experiment, must be caused by friction. We feel there is no risk of perforation of surgical gloves during a two-hand technique using polyester suture.

Radiographic analysis of factors predisposing toward tendon tears in the knee extensor mechanism.

OBJECTIVES: to review radiographs of patients who suffered tendon tears of the knee extensor apparatus and observe alterations that might be factors predisposing toward this type of injury. METHODS: we retrospectively analyzed 60 cases of injury to the knee extensor mechanism that were treated surgically at the Miguel Couto Municipal Hospital between March 2004 and March 2011. Four patients were excluded due to poor quality of the examination. RESULTS: of the 56 patients evaluated, 23 were considered to be normal and 33 presented radiographic alterations. Among these, eight (24.3%) presented suprapatellar osteophytes alone; seven (21.2%), infrapatellar calcification; seven (21.2%), suprapatellar calcification; six (18.2%), supra- and infrapatellar osteophytes; and five (15.1%), infrapatellar osteophytes alone. CONCLUSION: radiographic alterations were frequently observed in patients with extensor mechanism tears.

OBJETIVOS: revisar radiografias de pacientes vítimas de rupturas tendinosas do aparelho extensor do joelho e observar alterações que possam ser um fator predisponente a esse tipo de lesão. MÉTODOS: analisamos, retrospectivamente, 60 lesões do mecanismo extensor do joelho, tratadas cirurgicamente no Hospital Municipal Miguel Couto, de março de 2004 a março de 2011, e quatro pacientes foram excluídos por má qualidade do exame. RESULTADOS: dos 56 pacientes avaliados, 23 foram considerados normais e 33 apresentaram alterações radiográficas, oito (24,3%) com presença de osteófito suprapatelar isolado, sete (21,2%) com calcificação infrapatelar, sete (21,2%) com calcificação suprapatelar, seis (18,2%) com osteófitos supra e infrapatelares e cinco (15,1%) com osteófito infrapatelar isolado. CONCLUSÃO: as alterações radiográficas foram frequentes em pacientes com ruptura do mecanismo extensor.

Epidemiological study on tibial plateau fractures at a level I trauma center.

OBJECTIVES: To review the epidemiological aspects of fractures of the tibial plateau in a level one hospital. METHODS: We retrospectively analyzed 239 tibial plateau fractures treated surgically. We took into account age, gender, trauma mechanism, classification of the injuries, associated injuries and affected side. RESULTS: 168 were male, the fifth decade has been the most affected, the mechanism of trauma, car accident was the main causal fator, 128 cases were on the left side and 22,6% had associated injuries. CONCLUSIONS: Most patients were male, in the fifth decade of life, and victim of traffic accidents, and the depression and shear fractures of the tibial plateau are the most frequent. Associated lesions were infrequent in our study. Level of Evidence II, Prognostic Studies. Investigating the Effect of a Patient Characteristic on the Outcome of Disease.

SIMULTANEOUS BILATERAL AVULSION FRACTURE OF THE TIBIAL TUBEROSITY IN A TEENAGER: CASE REPORT AND THERAPY USED.

Simultaneous bilateral avulsion fracture of the tibial tuberosity in teenagers is a rare lesion. We describe the first case in the literature, in a teenage girl who sustained a fall while jumping during a volleyball match. No predisposing factors were iden tified. The lesions were treated with open surgical reduction and internal fixation. The aim of the present study was to present a case of simultaneous bilateral avulsion fracture of the tibial tuberosity in a teenage girl and the therapy used.

SIMULTANEOUS BILATERAL TEAR OF THE KNEE EXTENSOR MECHANISM IN A PRE-ADOLESCENT: CASE REPORT.

Unilateral tearing of a patellar tendon and a contralateral sleeve fracture in a pre-adolescent are rare lesions. We report a case in which a pre-adolescent sustained a fall while jumping during a soccer match. No predisposing risk factors were identified. The injuries were treated with surgical repairs and transosseous suturing. The aim of this study was to present a case of spontaneous concurrent tearing of the extensor mechanism of the knee in a pre-adolescent.

Supplementary vitamin C does not accelerate bone healing in a rat tibia fracture model.

OBJECTIVE: To investigate the role of ascorbic acid supplementation on bone healing after rat tibia fracture. METHODS: Thirty male Wistar rats were randomly divided into Vitamin C (Group A) and sham (Group B) groups (15 rats each). Group A received 200 mg intraperitoneally per kg per day of ascorbic acid and Group B was given saline 5 ml per kg per day intraperitoneally once a day. The animals were caged in pairs and allowed free access to tap water and a standard rodent chow ad libitum. Fractures were produced manually, they were not stabilized, and unprotected weight-bearing was allowed. At two, four, and six weeks post-fracture, the rats in both groups were anesthetized and sacrificed by cervical dislocation. Callus tissue was dissected, prepared, and analyzed histologically. Histomorphological analysis was performed at six weeks post-fracture and the extent of fracture healing was determined using a five-point scale. RESULTS: There were no histological and histomorphological differences between drug-treated animals and the sham in the three different stages studied. By six weeks post-fracture, the five animals of each group had a complete bone union. CONCLUSION: Under the studied conditions, intraperitoneal Vitamin C supplementation does not accelerate the fracture healing process after experimental tibia fracture in rats. LEVEL OF EVIDENCE: Level 2, individual study with experimental design.

ANALYSIS ON THE MODIFIED LYSHOLM FUNCTIONAL PROTOCOL AMONG PATIENTS WITH NORMAL KNEES.

OBJECTIVE: To evaluate the modified Lysholm protocol among patients with knees that were considered to be normal (without previous complaints or pathological conditions in this region). METHOD: Between January 2010 and March 2010, a prospective study was conducted on 300 patients with orthopedic complaints in other regions of the body who came to the emergency service of our hospital. The inclusion criterion among these patients was the absence of complaints or previous surgery in the knee that was considered to be dominant. The age range was from 16 to 40 years, with an average of 28.8 years. Our study group consisted of 153 males and 147 females. In the modified Lysholm system, the maximum score is 100 points and this includes functional and objective criteria. Altogether, 50% of the total score is based on symptoms of pain and instability. RESULTS: The average score using the Lysholm protocol was 95 points in the knees that were considered normal. Males had higher scores than females. CONCLUSION: These patients with knees that were considered normal did not achieve the maximum score when evaluated using the modified Lysholm protocol. This study suggests that this line of research on functional evaluation systems for the knee is open for further evaluations. Moreover, creation and development of new forms of functional assessment for the knee should be investigated in order to achieve a worldwide consensus.

[Comparative study between different radiographic plans in knee osteoarthritis]. / Estudo comparativo entre incidências radiográficas para a osteoartrose do joelho.

UNLABELLED: Perform a comparative analysis (with the criteria of Ahlbäck original classification) of the anteroposterior (AP) weight-bearing radiograph of knee in extension and of Rosenberg(2) view, in symptomatic arthritic knees. The analysis aims at revealing agreement or disagreement between (AP) view and Rosenberg view and the degree of articular degeneration and the advantages of these views. PATIENTS AND METHODS: From January 2005 to March 2007, a prospective study was conducted with 76 selected patients (111 arthritic knees) attending the outpatient clinic, at the knee unit, and subjected to the radiographs proposed in the present study. Of the total number of patients (76), 52 were females and 24 males, having an average age of 62 (range, 50- 82 years). 41 patients had unilateral degeneration and 35 patients had bilateral degeneration. Of the total number of assessed knees (111), 66 were right knees and 45 were left knees. The study used the Kappa statistical analysis, which assesses interobserver agreement of qualitative data. RESULTS: According to the Ahlbäck score, there was agreement between the orthopedist and the radiologist in 98.2% of cases in the AP weight-bearing view, and in 88.3% in the Rosenberg view. A highly significant agreement on both views between the orthopedist and the radiologist was noticed. However, the degree of agreement was higher for the AP weigh-bearing view than for the Rosenberg view. According to the Ahlbäck score, the AP weight-bearing view agreed with the Rosenberg view in only 27% of the cases for the orthopaedist, and in 31.5% for the radiologist. No significant agreement was found between the AP weight-bearing view and the Rosenberg view for the orthopedist and the radiologist. CONCLUSIONS: There is no significant disagreement between experts concerning the classification of knee osteoarthritis, according to the Ahlbäck score, both for the AP weight-bearing view and the Rosenberg view. There is no agreement between the views, concerning the classification of knee osteoarthritis, both for the orthopedist and the radiologist, the Rosenberg view having shown more clearly the degree of articular degeneration. The posteroanterior view of Rosenberg provided a better assessment of degeneration of the articular surface, which in some cases led to a change in the classification of knee osteoarthritis and was routinely used.

ANALYSIS OF THE REPRODUCIBILITY OF TIBIAL PLATEAU FRACTURES' CLASSIFICATION.

OBJECTIVE: To assess the inter-observer agreement of three tibial plateau fracture classifications: Schatzker, AO Group, and Hohl. METHODS: Nine physicians of different levels of expertise (six Orthopaedic Residents - OR - and three Orthopaedic Attendings - OA) classified 50 tibial plateau fractures. RESULTS: There was a low to moderate agreement between OR and OA on the three classification systems. A straight correlation was found between the year of Residence and an increase on the level of agreement on the AO group and Hohl classifications. This was partially seen on the Schatzker classification. Kappa ranged from 0.344 to 0.577, 0.36 to 0.499, and 0.278 to 0.465 for the Hohl, AO group, and Schatzker systems, respectively. CONCLUSION: With a level of 0.1, there was a significant agreement on the three classifications among the physicians. When comparing ORs to OAs, the three studied classifications show low to moderate consistency, with the Hohl classification showing the highest level of agreement between OR.

ENTRY POINT FOR THE ANTEGRADE FEMORAL INTRAMEDULLARY NAIL: A CADAVER STUDY.

OBJECTIVE: To analyze the natural exit of the wire guides in major trochanter through retrograde femoral approach, in cadaver specimens. MATERIAL AND METHOD: 100 femurs had been perforated between the femoral condyles, at 1.2 cm of the intercondylar region. A 3-mm straight wire guide was introduced, through retrograde approach, until the proximal extremity of femur was reached. Femurs were assessed for posterosuperior and anterosuperior portions of major trochanter, pear-shaped cavity, and upper median line between the head-neck and the major trochanter. RESULTS: in 62%, the straight wire guides exited at the anterior surface of major trochanter. In the pear-shaped cavity, the median distance found was 1.0 cm and the interquartile range was 0.5 cm, initially expressing, in relation to pear-shaped cavity, better accuracy. CONCLUSION: the central axis of the medullar canal, at coronal plane, projected better accuracy in the region of the pear-shaped cavity.