Intertrochentric femur fracture by DR.NAVEEN RATHOR

Presented by-
DR.NAVEEN RATHOR
RESIDENT DOCTOR
DEPT. OF ORTHOPAEDICS
RNT MEDICAL COLLEGE,UDAIPR

 Completely Extracapsular fracture with variable
comminution
 Common in elderly osteoporotic patient
 Usually woman in eighth decade
 More common than I/C #NoF
 Unite easily and rarely cause avascular necrosis
 Some of the factors found to be associated
with a patient sustaining an intertrochanteric
rather than a femoral neck fracture include
 advancing age
 increased number of comorbidities
 increased dependency in activities of daily living
 history of other osteoporosis related fractures.
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 An intertrochanteric hip fracture occurs
between the greater trochanter, where the
gluteus medius and minimus muscles (hip
extensors and abductors) attach, and the
lesser trochanter, where the iliopsoas muscle
(hip flexor) attaches

FEMUR
Upper end consists of head, neck,
greater and lesser trochanters.
Head forms roughly 2/3 of sphere.
Shaft of femur is slightly twisted and
curved with convexity forward.
Neck extends inferolaterally from head
to meet shaft of femur at angle of about
125 degrees
(<120 : Coxa vara, >135 : Coxa vulga)
Angle varies with age, stature and width
of pelvis.
(less in adults, in persons with short limbs,
and in women)

 Occur in the region between the greater and
lesser trochanters of the proximal femur,
occasionally extending into the
subtrochanteric region
 Since they occur in cancellous bone with
abundant blood supply – no problems of non-
union and osteonecrosis

Abductors displace
Greater Trochanter
laterally and proximally
Iliopsoas displaces Lesser
Trochanter medially and
proximally
Hip flexors,
extensors and
adductors pull distal
fragment proximally

 Deforming muscle forces will usually produce
shortening, external rotation and varus
position at the fracture

 Intertrochanteric fractures in younger
individuals are usually the result of a high-
energy injury, such as a motor vehicle accident
(MVA) or fall from a height
 In the elderly, it results from a simple fall
(trivial trauma). The tendency to fall increases
with patient age and is exacerbated by several
factors including
 poor vision
 decreased muscle power
 labile blood pressure
 decreased reflexes
 vascular disease3/9/2017 8sridevirajeeve_orthopaedics_july2014

 Most fractures result from a direct impact to
the greater trochanter area
 Low energy falls from a standing height –
approximately 90% of community hip
fractures in patients more than 50 years of
age with a higher proportion of women

 History of pain and inability to ambulate after
a fall or other injury
 Pain is localized to the proximal thigh;
exacerbated by passive attempts at hip
flexion or rotation
 Drug use – contributing factor
 Nursing home and institutionalized patients –
potential neglect and abuse – previous
fractures, injuries in different states of repair
and decubiti (bedsores/skin peels)

 Pain
 Marked shortening of lower limb
 Patient cannot lift his/her leg
 Complete External Rotation Deformity
 Swelling, ecchymoses and Tenderness over the
Greater Trochanter
 Displaced fractures are clearly symptomatic,
such patients usually cannot stand, much less
ambulate
 Nondisplaced fractures may be ambulatory
and experience minimal pain, and there are yet
others who complain of thigh or groin pain but
have no history of antecedent trauma
 The amount of clinical deformity in patients
with an intertrochanteric fracture reflects the
degree of fracture displacement

 Shortening of the extremity and deformity of
rotation in resting position compared with
the other extremity
 Pain with motion/Crepitance testing – NOT
elicited unless there are no obvious physical
signs of deformity and radiographic studies
are negative for an obvious fracture.
 Pain with axial load on the hip – high
correlation with occult fracture

 Pelvis with both hips – AP, xray of the
affected hip – AP and cross-table lateral
 Traction films (with internal rotation) –
helpful in communited and high-energy
fractures and in determining implant
selection
 Subtrochanteric extension – Femur AP and
lateral

 Magnetic Resonance Imaging (MRI) –
currently the imaging study of choice in
delineating non-displaced or occult fractures
that may not be apparent on plain
radiographs – Preferred over CT due to higher
sensitivity and specificity for a more rapid
decision process

 Bone scans or CT – reserved for those who
have contradictions to MRI.Technetium bone
scans
 Technetium bone scan – when a hip fracture
is suspected but not apparent to standard
radiographs – requires 2-3 days to become
positive

i. Stable (Two part)
ii. Unstable with posteromedial communition
iii. Subtrochanteric extension into lateral shaft,
extension of the fracture distally at or just
below the lesser trochanter (the term
Reverse Obliquity was coined byWright)
iv. Subtrochanteric with intertrochanteric
extension with the fracture lying in atleast
two planes

1. Linear IT line #
2. Linear IT line # with comminution
3. Subtrochanteric #
4. Inter-/Subtrochanteric # with extension
into proximal femoral shaft
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 Type iii and iv are the most difficult types to
manage
 Account for one third of the trochanteric
fractures

 Type 1 : Two-part Undisplaced.
 Type 2 : Two-part Displaced.
 Type 3 : Three-fragment fracture without
posterolateral support (displaced GT
Fragment)
 Type 4 : Three fragment fracture without
medial support (displaced LT Fragment)
 Type 5 : Four fragment fracture without
posterolateral and posteromedial support
 Type 6 : Reverse oblique fracture.

 Because it distinguished stable from unstable
fractures and helped define the characteristics of
a stable reduction.
- Stable fracture patterns – posteromedial cortex
remains intact OR has minimal communition
- Unstable fracture patterns – characterised by
disruption or impaction of the posteromedial
cortex- can be converted into stable if medial
cortical opposition is maintained.
- Reverse Oblique – Inherently unstable due to
the tendency for medial displacement of the
femoral shaft

 The most quoted in recent scientific articles –
a derivative of the Muller classification
 Has been very useful in evaluating the results
of treatment of intertrochanteric fracture and
allowing comparisons among reports in
literature

 Group 1 fractures (31A1) – Pertrochanteric
simple (two-part) fractures, with the typical
oblique fracture line extending from the
greater trochanter to the medial cortex; the
lateral cortex of the greater trochanter
remains intact.
A1.1 – Along intertrochanteric line
A 1.2 –Through greater trochanter
A 1.3 – Below lesser trochanter

 Group 2 fractures (31A2) – Pertrochanteric
multifragmentary - comminuted with a postero-
medial fragment; the lateral cortex of the greater
trochanter however, remains intact. Fractures in this
group are generally unstable, depending on the size of
the medial fragment.
A2.1 –With one intermediate fragment
A2.2 –With several intermediate fragments
A2.3 – Extending more than 1cm below lesser
trochanter.

 Group 3 fractures (31A3) –TRUE
INTERTROCHANTERIC - are those in which
the fracture line extends across both the
medial and lateral cortices; this group also
includes the reverse obliquity pattern.
A3.1 – Simple oblique
A3.2 – Simple transverse
A3.3 - Multifragmentary

 Nonoperative Treatment
Indication
 Poor medical and surgical risk patients
 Terminally ill
Methods
 Very old patients - Buck’s traction
 Plaster/Hip spica
 Skeletal traction through distal femur or tibia
for 10 – 12 weeks with Bohler-Braun Splint

 Buck’s traction or extension
 Russell skeletal traction
 Balanced traction inThomas splint
 Plaster spica immobilization
 Derotation boot

 In elderly patients, this approach was associated
with high complication rates; typical problems
included
 Decubiti
 Urinary tract infection
 Joint contractures
 Hypostatic Pneumonia
 Thromboembolic complications
 Fracture healing was generally accompanied by varus
deformity and shortening because of the inability of
traction to effectively counteract the deforming
muscular forces = MALUNION!

 As soon as the general condition of this
patient is under control, internal fixation
should be carried out.
 The goal of surgical treatment is strong,
stable fixation of the fractured fragments

 Bone quality
 Fracture geometry
 Reduction
 Implant design
 Implant placement

 Plate Constructs
 Cephalomedullary nailing
 External Fixation
 Arthroplasty

 From the 1980s to 2000 – Sliding compression hip
screws became the gold standard for hip fracture
fixation.
 Historically the most commonly used device for both
stable and unstable fracture patterns. Available in
plate angles from 130deg to 150deg.
 The 135 degree plate is most commonly utilized; this
angle is easier to insert in the desired central position
of the femoral head and neck than higher angle
devices and creates less of a stress riser in the
subtrochanteric region.

 The most important technical aspects of
screw insertion are:
1. Placement within 1cm of subchondral bone
to provide secure fixation
2. Central position in the femoral head (Tip-
apex distance)

 Sum of distances from the tip of the lag screw
to the apex of the femoral head on both the
anteroposterior and lateral radiographic
views.
 The sum should be <25mm to minimize the
risk of lag screw cutout

 Inserted through the piriformis fossa OR lateral
greater trochanter OR medial greater trochanter
 Femoral head component – screw/blade
interlocked with nail component
 Dissatisfaction with use of a sliding hip screw in
unstable fracture patterns led to the
development of intramedullary hip screw
devices.

 Because of its location, theoretically provides more
efficient load transfer than does a sliding hip screw.
 The shorter lever arm of the intramedullary device can
be expected to decrease tensile strain on the implant,
thereby decreasing the risk of implant failure.
 Because the intramedullary fixation device
incorporates a sliding hip screw, the advantage of
controlled fracture impaction is maintained
 Shorter operative time and less soft-tissue dissection
than a sliding hip screw.

 The PFN nail has been shown to prevent the
fractures of the femoral shaft by having a
smaller distal shaft diameter which reduces
stress concentration at the tip.
 Due to its position close to the weight-
bearing axis the stress generated on the
intramedullary implants is negligible.

 PFN implant also acts as a buttress in
preventing the medialisation of the shaft.The
entry portal of the PFN through the
trochanter limits the surgical insult to the
tendinous hip abductor musculature only ,
unlike those nails which require entry through
the piriformis fossa.

 As reported by Moroni et. al. May be
indicated in osteoporotic hip fractures in
elderly patients who may be deemed at high
risk for conventional open reduction and
internal fixation
 Also for those who cannot receive blood
transfusions because of personal conviction
or religion (eg. Jehovah’s witnesses)

 Use was unsuccessful because of high rate of
pin-tract infection, subsequent pin loosing,
varus collapse, instability and failure
 Latest – new fixation designs and the
addition of hydroxyapatite coated pin
technology

 Neoplastic fractures, severe osteoporotic
disease, renal dialysis patients and pre-
existing arthritis under consideration for hip
replacement before the fracture occured
 Hemiarthroplasty reported to have a lower
dislocation rate when compared to total hip
arthroplasty

 Better salvage operation for failed internal
fixation rather than a first-line choice in
geriatric patient.
 No level-one evidence to show any difference
between compression hip screw and
arthroplasty except for a higher blood
transfusion rate with arthroplasty

 Morbidity associated with a more extensive
operative procedure
 Internal fixation problems with greater
trochanteric reattachment
 Risk of postoperative prosthetic dislocation

 AP and lateral radiographs while the patient
is still in the surgical area
 Patient mobilized to chair upright position
the day after the operative procedure
 Ambulation – under supervision with weight
bearing as tolerated with a walker or crutches
– emphasis on heel-strike and upright
balance exercises

 Multiple trauma/co-morbidities – difficulty in
early ambulation but must be done as soon as
possible to minimize secondary complications
 Weight bearing – for optimal recovery and to
reduce the fear of falling/lack of independence
 Good pain control

 Protein and caloric nutrition, osteoporotic
therapy includingVitamin D supplementation
 Hip abductor exercises bilaterally in
conjunction with proper balance and gait
training
 Patient to be counseled to report any
swelling or respiratory distress – risk of
thromboembolic disease

 ON DISCHARGE – fall prevention education
and safe home checks to be explained to the
family or social support group
 Re-evaluation of the patient in the OPD with
X-Rays at 2 weeks and then monthly
thereafter until fracture healing is
documented OR patient has maximum
ambulation (usually 6 months after injury)

 Loss of fixation
 Nonunion
 Malrotation deformity
 Osteonecrosis
 Medical, psychosocial, thromboembolic

 Commonly characterized by varus collapse of
the proximal fragment with cut-out of the lag
screw from the femoral head
 Occurs within 3 months of surgery due to
eccentric placement of lag screw within
femoral head, improper reaming, unstable
reduction, excessive fracture collapse which
exceeds the sliding capacity of the device

 Inadequate screw-barrel engagement which
prevents sliding and severe osteopenia
 Management – acceptance of the deformity,
revision ORIF with PMMA or conversion to
prosthetic replacement

 Uncommon. May follow internal fixation
more often than closed treatment
 Should be suspected with patients with
persistent hip pain that have radiographs
revealing a persistent radiolucency at the
fracture site 4-7 months after fracture fixation

 Managed by open reduction, renailing and
bone grafting

 Internal rotation of the distal fragment at
surgery
 Unstable fracture patterns – the proximal and
distal fragments may move independently –
such cases the distal fragment should be
placed in neutral/slight external rotation
during plate fixation

 Severe malrotation which interferes with
ambulation – revision surgery with plate
removal and rotational osteotomy of the
femoral shaft should be considered.
 Z-Effect – seen most commonly with dual
screw CM nails – most proximal screw
penetrates the hip joint and distal screw
backs out of the femoral head

 Rare
 Lag screw-side plate dissociation
 Occurs due to traumatic laceration of the
superficial femoral artery by a displaced
lesser trochanter fragment

 Cardiopulmonary complications most
frequent
 Other complications – GI bleeding, venous
thromboembolism, transient ischemic
attacks or stroke.
 Renal complications rare.

 Infection – seen in 1-2% postoperative
patients – can be minimized by preoperative
antibiotics – cephalosporins
 Vigilance with a high index of suspicion for
any signs of wound inflammation or drainage
 Oral antibiotics for 7-10 days if the infection is
superficial

 Rare – typically occur in older patients as a
result of an eccentric muscle contraction or
less commonly a direct blow
 Treatment – usually non-operative.Operative
considered in younger, active patients with a
widely displaced greater trochanter

 ORIF with tension band wiring of the
displaced fragment and the attached
abductor muscles or plate and screw fixation
with a “hook plate” are the preferred
techniques

 Most common in adolescence, typically
secondary to forceful iliopsoas contracture
 In elderly, isolated lesser trochanter fractures
have been recognised as pathognomonic for
pathologic lesions of the proximal femur
 Treatment – identifying the pathologic lesion
and treating accordingly. If no evidence of
pathologic lesion – symptomatic treatment to
gain ROM and ambulation.

Intertrochentric femur fracture by DR.NAVEEN RATHOR

Intertrochentric femur fracture by DR.NAVEEN RATHOR

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