Intertrochanteric fracture

Intertrochanteric fracture

Definition :

These fractures are ‘ extracapsular ’ and occur in the wide metaphyseal region between the two trochanters of the femur.

Why such fractures tend to unite without difficulty and seldom cause avascular necrosis?Because the blood supply to the fracture is adequate

ExtracapsularExtracapsular

Femur – intertrochanteric (extracapsular)

Intertrochanteric fractureThey are common in Elderly, osteoporotic people; most of the patients are women in the 8th decade.

Risk factors -Age (>70 years)-Sex (female>male)-Rheumatoid arthritis-Pathologic fractures may occur in the presence of tumor or metastatic bone lesions.

Intertrochanteric fracture

Mechanism of injuryThe fracture is caused either by a fall directly onto the greater trochanter or by an indirect twisting injury.The crack runs up between the lesser and greater trochanter and the proximal fragment tends to displace in varus.

Intertrochanteric fractureClassification by Kyle

Intertrochanteric fractureDiagnosis: Clinical features1-pain 2-unable to stand. 3-The leg is shorter andmore externally rotatedthan with a transcervical fracture (because the fracture is extracapsular) 4- The patient cannot lift his or her leg.5- Swelling in the hip region

Intertrochanteric fractureX-rayUndisplaced, stable fracturesmay show no more than a thin crack along the intertrochanteric line; indeed,there is often doubt as to whether the bone is fractured and the diagnosis may

have to be confirmed by MRI.

Intertrochanteric fractureTreatmentIntertrochanteric fractures are almost always treated by early internal fixationnot because they fail to unite with conservative treatment but (a) to obtain the best possible position and (b) to get the patient up and walking as soon as possible and there by reduce the complications associated with prolonged lying down

Intertrochanteric fractureTreatmentFracture reduction at surgery is performed on a fracture table that provides slight traction and internal rotation;the position is checked by x-ray and the fracture is fixed with an angled device preferably a sliding screw in conjunction with a plate or intramedullary nail.

Intertrochanteric fractureTreatmentPositioning the screw is important if it is to be Prevented from cuttingout of the osteoporotic bone. It should pass up the femoral neck to end within the centreof the femoral head, with the tip resting about 5 mm from the subchondral bone plate.

Intertrochanteric fracture

TreatmentNon-operative treatment may be appropriate for a small group who are too ill to undergo anaesthesia; traction in bed until there is sufficient reduction of pain to allow mobilization can yield reasonable results but much depends on the quality of nursing care and physical therapy.

Intertrochanteric fracturePRIMARY PROSTHETIC REPLACEMENT

Peritrochanteric fractures in the presence of severe arthritis of the hip, especially if the hip is stiff

Pathologic fractures in which the bone stock preclude internal fixation

Unstable, severely comminuted fractures in the very elderly, whose bone is so osteoporotic that internal fixation, even with cement augmentation, is expected to fail

Intertrochanteric fracture

ComplicationsEARLY1-DVT2-Pulmonary embolism3-Bed sores4-Hemorrhage as it’s occur in a region of ample blood supply

Intertrochanteric fracture

ComplicationsLATE1-Failed fixation Screws may cut out of the osteoporotic bone if reduction is poor or if the fixation device is incorrectly positioned

2-Malunion Varus and external rotation deformities are common. Fortunately they are seldom severe and rarely interfere with function.

3-Non-union Intertrochanteric fractures seldom fail to unite

Intertrochanteric fracture

Subtrochanteric Fracture

They are common in In elderly patient with osteoporosis,

osteomalacia, paget’s disease or secondary deposit

Blood loss is greater than with femoral neck or trochanteric fracture

Subtrochanteric Fracture

29.18 Subtrochanteric fractures of the femur –warning signs on the x-ray X-ray findings that shouldcaution the surgeon: (a) comminution, with extension intothe piriform fossa; (b) displacement of a medial fragmentincluding the lesser trochanter and, (c) lytic lesions in thefemur.

)a( )b( )c(

Subtrochanteric Fracture

Subtrochanteric fractures have several featureswhich make them interesting (and challenging totreat):1. Blood loss is greater than with femoral neck ortrochanteric fractures – the region is covered withanastomosing branches of the medial and lateralcircumflex femoral arteries which come off theprofunda femoris trunk

Subtrochanteric Fracture

2. There may be subtle extensions of the fractureinto the intertrochanteric region, which mayinfluence the manner in which internal fixationcan be performed.3. The proximal part is abducted and externallyrotated by the gluteal muscles, and flexed by thepsoas. The shaft of the femur has to be broughtinto a position to match the proximal part or elsea malunion is created by internal fixation

Subtrochanteric Fracture

Diagnosis: Clinical features

The leg is externally rotated and short The thigh is markedly swollen Movement is excruciating painful

Subtrochanteric Fracture

X-ray The fracture is through or below the lesser trochanter.

It may be transverse, oblique or spiral, and is frequently

comminuted. The upper fragment is flexed

and appears deceptively short; the shaft is adducted

and is displaced proximally

Subtrochanteric Fracture

Open reduction and internal fixation is the treatment

of hoice Two main types of implant are usedFor fracture fixation:(a ) an intramedullary nail with aproximal interlocking

screw.

(b) a 95 degree hip screw-and-plate device.

Subtrochanteric Fracture

)a()b(

Subtrochanteric Fracture

TreatmentTraction may help to reduce blood loss and pain. It is

an interim measure until the patient, especially if elderly

and with multiple medical problems, is stabilized

and prepared for surgery

Malunion :Is Fairly common and may need operative correction

Non-union This occurs in about 5 per cent of cases; itwil l require operative correction of any deformity,renewed f ixation and bone graft ing