InterTrochanteric Fractures

INTERTROCHANTERIC FRACTURE

Dr. Kevin Joseph Ambadan

DEFINITION

• An InterTrochanteric 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.

GENERAL FEATURES

• Completely ExtraCapsular fracture with variable comminution

• Common in elderly osteoporotic patient, usually women in their 80’s

• More common than IntraCapsular # - Neck of Femur

• Unites easily

• Rarely causes avascular necrosis

MECHANISM OF INJURY

• 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).

SIGNS AND SYMPTOMS

• Pain

• Marked shortening of lower limb

• Patient cannot lift their leg

• Complete External Rotation Deformity

• Swelling, ecchymosis and tenderness over the Greater Trochanter

• Displaced fractures are clearly symptomatic, such patients usually cannot stand, much less ambulate

• Non-displaced 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

ASSOCIATED INJURIES

• Older individuals who sustain an intertrochanteric fracture as a result of a low-energy fall occasionally have an associated osteoporosis related fracture, such as a distal radius or proximal humerus fracture.

• Intertrochanteric fractures in younger individuals are usually the result of a high-energy injury, such as a motor vehicle accident or fall from a height. In these instances, assessment must be made of possible associated head, neck, chest, and abdominal injuries.

DIAGNOSTIC IMAGING

• X-ray is the standard diagnostic tool.

• When a hip fracture is suspected but not apparent on standard x-rays, a technetium bone scan or a MRI scan should be obtained.

• MRI has been shown to be at least as accurate as bone scanning inidentification of occult fractures of the hip, and it will reveal afracture within 24 hours of injury.

BOYD & GRIFFIN’S CLASSIFICATION

1. Linear IT line #

2. Linear IT line # with comminution

3. Subtrochanteric #

4. Inter-/Subtrochanteric # with extension into proximal femoral shaft

CLASSIFICATION OF KYLE

EVAN’S CLASSIFICATION

TREATMENT

Nonoperative TreatmentIndications

• 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 weekswith Bohler-Braun Splint

BUCKS TRACTION

HIP SPICA

• In elderly patients, this approach was associated with highcomplication rates; typical problems included• Decubiti

• Urinary tract infection

• Joint contractures

• Hypostatic Pneumonia

• Thromboembolic complications

• Fracture healing was generally accompanied by varus deformity andshortening because of the inability of traction to effectivelycounteract the deforming muscular forces = MALUNION!

OPERATIVE TREATMENT

Intertrochanteric fractures are almost always treated

by early internal fixation – not because they fail to

unite with conservative treatment (they unite quite

readily), but • Obtain the best possible position

• Early ambulation to reduce the complications associated with prolonged recumbency.

SLIDING HIP COMPRESSION SCREW

Indications• stable intertrochanteric fractures

Outcomes• equal outcomes when compared to

intramedullary hip screws for stable fracture patterns

• The sliding hip screw is the most widely used implant for stabilizationof both stable and unstable intertrochanteric fractures.

• Sliding hip screw side plate angles are available in 5 degreeincrements from 130 to 150 degrees.

• The 135 degree plate is most commonly utilized; this angle is easierto insert in the desired central position of the femoral head and neckthan higher angle devices and creates less of stress

TROCHANTERIC STABILIZING PLATES

• The trochanteric stabilizing plate and thelateral buttress plate are modularcomponents that reinforces the greatertrochanter

• These plates are placed over a four-holesideplate and are used to preventexcessive slide (and resulting deformity)in unstable fracture patterns

• These devices prevent telescoping of thelag screw within the plate barrel whenthe proximal head and neck fragmentabuts the lateral buttress plate

INTRAMEDULLARY HIP SCREWAlso known as the Proximal Femoral Nail (PFN).

Indications

• stable fracture patterns

• unstable fracture patterns

• reverse obliquity fractures (56% failure when treated with sliding hip screw)

• subtrochanteric extension

• lack of integrity of femoral wall

Outcome

• equivalent to sliding hip screw for stable fracture patterns

• use has significantly increased in last decade

COMPLICATIONS

EARLY

• The same as with femoral neck fractures, reflecting the fact that most of these patients are in poor health.

LATE

• Failed fixation Screws may cut out of the osteoporotic bone if reduction is poor or if the fixation device is incorrectly positioned. If union is delayed, the implant itself may break. In either event, reduction and fixation may have to be re-done.

• Malunion

• Coxa Vara and external rotation deformities are common

• Non-union (uncommon, unlike # NoF)

• Traumatic Osteoarthritis

• Avascular Necrosis (rare)

PATHOLOGICAL FRACTURE

• Due to metastatic disease or myeloma.

• Unless patients are terminally ill, fracture fixation is essential in order to ensure an acceptable quality of life for their remaining years.

• In addition to internal fixation, methylmethacrylate cement may be packed in the defect to improve stability.

THANK YOU