DHS and DCS

Q: What is DHS and what are its various names?

DHS means Dynamic Hip Screw. It is described as dynamic hip system by AO group.
It is designed primarily for fixation of intertrochanteric fractures, basicervical femoral
neck fractures and certain subtrochanteric fractures.
It has several names, e.g.
1. Richardson’s screw 2. Sliding screw
3. Compression screw 4. Dynamic screw
Q: What is the principle of mechanism of DHS?
DHS has sliding nail principle which allows controlled collapse of the fracture
fragments, thus stimulating osteosynthesis and enhance union.
Q: What are the parts of DHS?
DHS has three parts or components. These are –
1. Lag screw 2. Side plate and 3. Compression screw
Q: What are the components of DHS operation set?
Components of DHS operation set are as follows –
 Guide pin/ guide wire  230mm in length, 2.5mm in diameter, graduated and the
tip portion threaded 1-2cm.
 Angle guide  allows placement of guide pin at desired angle. 135 o angle guide is
mostly used.
 Direct measuring device  read off directly the inserted depth of guide pin.
 Triple reamer  has three elements –
1. 8mm drill bit – for lag screw.
2. Reamer head – for barrel and conical barrel plate junction.
3. A locking nut – for adjusting the reaming distance.
 Tap  thread diameter 12.5mm, core diameter 8mm; tapped length can be read
on the calibrated shaft.
 Centering sleeve  centers the tap during tapping.
 Wrench  for insertion and extraction of DHS screw.
 Coupling screw  short screw for insertion, long screw for extraction.
 Impactor  used to set the DHS plate finally by gentle blow with hammer.
 Guide wire introducer.
Q: Describe the lag screw of DHS.
Length – available from 50mm to 145mm with 5mm increment.
Thread length – 22mm, thread diameter – 12.5mm.
Shaft diameter – 8mm.
Q: How the required length of the lag screw is determined?
Preoperatively – measuring the distance from flare of the greater trochanter to most
distal part of the femoral head in A/P view X-ray of normal hip. Then 10% is
deduced for imaging magnification.
Per-operatively – introducing the guide pin in proper place and confirmed by image
intensifier. The remaining length of the guide pin is measured either by (i)
comparing with another similar guide pin and then deducting from the total length,
or by (ii) measuring with a direct measuring device.
Q: What is the ideal point and method for guide pin insertion in case of
DHS operation?
1. 2cm away (distal) from the flare of greater trochanter and mid-cortical point of
the lateral surface of upper femoral shaft in antero-posterior plane for 135 o plate.
2. Thereafter for each degree increment in the angle of the DHS plate, 1mm further
away will be the point of insertion from the flare of greater trochanter.
3. The pin is directed upwards and medially at 135 o angle toward the opposite
antero-superior iliac spine and with 10-15o anteversion.
4. The pin should pass through the center of the neck or its postero-inferior part.
5. The tip of the pin should reach within 5mm of the subchondral area of femoral
head so that the TAD (Tip-apex distance) should be <25mm.
Q: Why DHS is chosen in trochanteric fracture?
1. Controlled collapse mechanism of DHS causes osteosynthesis and accelerates
union of fracture.
2. Variation in angle of DHS plate increases its acceptability as it can be applied to
femurs with wide range of neck-shaft angle.
Q: What are the advantages and disadvantages of DHS over Jwette nail?
DHS Jwette nail
Advantages:
1 Controlled collapse mechanism. Has no collapse mechanism.
2 Available in various angle plates. Fixed angle at 135o
3 Early weight bearing can be allowed. Weight bearing delayed.
Disadvantages:
1 Operation is expertise oriented and Operation is easy.
needs image intensifier.
2 Jamming of sliding mechanism may No sliding, no jamming.
occur.
3 Rotation of proximal fragment over the Rotation is not possible.
screw is possible.
4 Controlled collapse is more effective in No controlled collapse
higher angle, e.g. 150o; but most of the mechanism.
neck-shaft angles are around 135o. So
it does not work properly.
Q: What are the advantages of DCS over DHS in reverse oblique
trochanteric fracture?
1. DCS prevents medial displacement of distal fragment.
2. Two additional screws of DCS hold the proximal fragments and gives better
fixation.
Q: What is TAD? What is its significance?
Tip-apex distance (TAD) is the sum of distance from the apex of the femoral head to
the tip of the lag screw on both anteroposterior and lateral views X-rays, correcting
for magnification. It should be <25mm ideally.
If TAD is <25mm, the purchase of the screw is good and there is less chance of
failure caused by cutting out the lag screw.
Q: What is the ideal point and method of insertion of DCS screw in
trochanteric fracture?
1. 1.5cm below the tip of the greater trochanter; at the junction of anterior 1/3rd and
posterior 2/3rd of the lateral surface of the trochanter.
2. Tip of the guide pin should be 2cm away from the articular surface and in the
lower half of the head, 10mm below the upper border of the neck.
3. Tip of the screw should be in the inner and medial quadrant of the head.
4. TAD should be <20mm.
Q: What are the differences between DHS and DCS?
Sl. DHS DCS
1 Dynamic hip screw is designed for Dynamic condylar screw is for distal
proximal femoral fractures. femoral as well as proximal fractures.
2 Indicated in trochanteric, basal Indicated in condylar femoral
neck and some subtrochanteric fractures and reverse oblique
fractures. trochanteric fractures.
3 Controlled collapse mechanism is Less evident.
more.
4 Barrel plate angle is not fixed. 135 o Fixed barrel plate angle at 95o
to 150o
5 Plate is straight, 46mm to 260mm Plate is curved, 100mm to 260mm
length. length.
6 No additional screws for proximal Two additional cancellous screws for
fragment proximal fragment
7 Barrel length is 25mm and 38mm Only 25mm
Q: What are the factors that are responsible for displacement of fragments
in reverse oblique trochanteric fracture?
A. Lesser trochanter with proximal fragment:
1. Proximal fragment is flexed by iliopsoas and abducted by abductors and
externally rotated by short rotators.
2. Distal fragment is proximally driven and medially displaced by the action of
adductors.
B. Lesser trochanter with distal fragment:
1. The proximal fragment is only abducted and externally rotated.
Q: What are the complications of DHS operation?
A. Peroperative:
1. Haemorrhage
2. Failure to insert the lag screw in proper place.
B. Postoperative:
1. Infection – Early
2. Malunion with varus deformity
3. Nonunion
4. Implant failure – e.g. cutting out of lag screw, jamming.
Q: Why we choose 135o angled DHS?
Angle of neck-shaft angle of femur in adult is 124 o to 136o. Controlled collapse
mechanism of DHS functions better at greater angles. So we take the maximum of
the normal range. If further wider angle is selected, insertion of lag screw is difficult
in the neck from a far distance from trochanteric flare.
Q: How plate of the DHS is fixed?
Distal screw of the plate should be fixed first to maintain the alignment of the plate
in proper place.
Q: What is the postoperative care after DHS removal?
Partial weight bearing is allowed for 6-8 weeks.