Jul 16, 2015
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
Femur intertrochanteric (extracapsular)
They 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.
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.
Classification by Kyle
Diagnosis: 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
X-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.
TreatmentIntertrochanteric 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
TreatmentFracture 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.
TreatmentPositioning 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.
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.
PRIMARY PROSTHETIC REPLACEMENT Peritrochanteric fractures in the presence of severe arthritis of the hip, especially if the hip is stiffPathologic 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
ComplicationsEARLY1-DVT2-Pulmonary embolism3-Bed sores4-Hemorrhage as its occur in a region of ample blood supply
ComplicationsLATE1-Failed fixation Screws may cut out of the osteoporotic bone if reduction is poor or if the fixation device is incorrectly positioned2-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
Subtrochanteric FractureThey are common inIn elderly patient with osteoporosis, osteomalacia, pagets disease or secondary deposit Blood loss is greater than with femoral neck or trochanteric fracture
Subtrochanteric Fracture29.18 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 FractureSubtrochanteric 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 Fracture2. 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 FractureDiagnosis: Clinical featuresThe leg is externally rotated and shortThe thigh is markedly swollenMovement is excruciating painful
Subtrochanteric FractureX-rayThe fracture is through or below the lesser trochanter.It may be transverse, oblique or spiral, and is frequentlycomminuted. The upper fragment is flexedand appears deceptively short; the shaft is adductedand is displaced proximally
Subtrochanteric FractureOpen reduction and internal fixation is the treatmentof 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 FractureTreatmentTraction may help to reduce blood loss and pain. It isan interim measure until the patient, especially if elderlyand with multiple medical problems, is stabilizedand prepared for surgery
Malunion :Is Fairly common and may need operative correctionNon-union This occurs in about 5 per cent of cases; itwill require operative correction of any deformity,renewed fixation and bone grafting