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Intertrochanteric fractures

Jun 02, 2015


All you wanted to know about ITF

  • 1. By;Sridevi RajeeveIntern2008 Batchsridevirajeeve_orthopaedics_july2014 8/28/2014 1

2. sridevirajeeve_orthopaedics_july2014 8/28/2014 2 3. Completely Extracapsular fracture with variablecomminutionCommon in elderly osteoporotic patientUsually woman in eighth decadeMore common than I/C #NoFUnite easily and rarely cause avascular necrosisSome of the factors found to be associated with apatient sustaining an intertrochanteric rather thana femoral neck fracture includeadvancing ageincreased number of comorbiditiesincreased dependency in activities of daily livinghistory of other osteoporosis related fractures.sridevirajeeve_orthopaedics_july2014 8/28/2014 3 4. An intertrochanteric hip fracture occurs betweenthe greater trochanter, where the gluteus mediusand minimus muscles (hip extensors andabductors) attach, and the lesser trochanter,where the iliopsoas muscle (hip flexor) attachessridevirajeeve_orthopaedics_july2014 8/28/2014 4 5. Intertrochanteric fractures in younger individuals areusually the result of a high-energy injury, such as amotor vehicle accident (MVA) or fall from a heightIn the elderly, it results from a simple fall (trivialtrauma). The tendency to fall increases with patientage and is exacerbated by several factors includingpoor visiondecreased muscle powerlabile blood pressuredecreased reflexesvascular diseasesridevirajeeve_orthopaedics_july2014 8/28/2014 5 6. (a) Fall must be oriented so the person lands on ornear the hip(b) protective reflexes must be inadequate toreduce the energy of the fall below a certaincritical threshold(c) local shock absorbers (muscle and fat aroundthe hip) must be inadequate.(d) bone strength at the hip must be insufficient.sridevirajeeve_orthopaedics_july2014 8/28/2014 6 7. 50 years 100 yearsBone massTrochcanteric areaNeck of the femurAgesridevirajeeve_orthopaedics_july2014 8/28/2014 7 8. PainMarked shortening of lower limbPatient cannot lift his/her legComplete External Rotation DeformitySwelling, ecchymoses and Tenderness over the GreaterTrochanterDisplaced fractures are clearly symptomatic, suchpatients usually cannot stand, much less ambulateNondisplaced fractures may be ambulatory andexperience minimal pain, and there are yet others whocomplain of thigh or groin pain but have no history ofantecedent traumaThe amount of clinical deformity in patients with anintertrochanteric fracture reflects the degree offracture displacementsridevirajeeve_orthopaedics_july2014 8/28/2014 8 9. Older individuals who sustain anintertrochanteric fracture as a result of a low-energyfall occasionally have an associatedosteoporosis related fracture, such as a distalradius or proximal humerus fracture.Intertrochanteric fractures in younger individualsare usually the result of a high-energy injury, suchas a motor vehicle accident or fall from a height.In these instances, assessment must be made ofpossible associated head, neck, chest, andabdominal injuries.sridevirajeeve_orthopaedics_july2014 8/28/2014 9 10. 1.(AP) view of the pelvis .2.AP and a cross-table lateral view of the involved proximal femursridevirajeeve_orthopaedics_july2014 8/28/2014 10 11. When a hip fracture is suspected but not apparenton standard x-rays, a technetium bone scan or amagnetic resonance imaging (MRI) scan shouldbe obtained. MRI has been shown to be at least asaccurate as bone scanning in identification ofoccult fractures of the hip, and it will reveal afracture within 24 hours of injury.sridevirajeeve_orthopaedics_july2014 8/28/2014 11 12. 1. Linear IT line #2. Linear IT line # with comminution3. Subtrochanteric #4. Inter-/Subtrochanteric # with extension intoproximal femoral shaftsridevirajeeve_orthopaedics_july2014 8/28/2014 12 13. sridevirajeeve_orthopaedics_july2014 8/28/2014 13 14. Type 1 : Two-part Undisplaced.Type 2 : Two-part Displaced.Type 3 : Three-fragment fracture withoutposterolateral support (displaced GT Fragment)Type 4 : Three fragment fracture without medialsupport (displaced LT Fragment)Type 5 : Four fragment fracture withoutposterolateral and posteromedial supportType 6 : Reverse oblique fracture.sridevirajeeve_orthopaedics_july2014 8/28/2014 14 15. sridevirajeeve_orthopaedics_july2014 8/28/2014 15 16. Group 1 fractures are simple (two-part) fractures, withthe typical oblique fracture line extending from thegreater trochanter to the medial cortex; the lateralcortex of the greater trochanter remains intact.Group 2 fractures are comminuted with a postero-medialfragment; the lateral cortex of the greatertrochanter, however, remains intact. Fractures in thisgroup are generally unstable, depending on the size ofthe medial fragment.Group 3 fractures are those in which the fracture lineextends across both the medial and lateral cortices;this group also includes the reverse obliquity pattern.sridevirajeeve_orthopaedics_july2014 8/28/2014 16 17. Nonoperative TreatmentIndication Poor medical and surgical risk patients Terminally illMethods Very old patients - Bucks traction Plaster/Hip spica Skeletal traction through distal femur or tibia for10 12 weeks with Bohler-Braun Splintsridevirajeeve_orthopaedics_july2014 8/28/2014 17 18. In elderly patients, this approach was associatedwith high complication rates; typical problemsincludedDecubitiUrinary tract infectionJoint contracturesHypostatic PneumoniaThromboembolic complicationsFracture healing was generally accompanied by varusdeformity and shortening because of the inability oftraction to effectively counteract the deformingmuscular forces = MALUNION!sridevirajeeve_orthopaedics_july2014 8/28/2014 18 19. Intertrochanteric fractures are almost always treatedby early internal fixation not because they fail tounite with conservative treatment (they unite quitereadily), but(a) Obtain the best possible position(b) Early ambulation to reduce the complications associated withprolonged recumbencyFixed-angle nail-plate devicesThe first successful implantsWhile these devices provided stabilization of the femoral headand neck fragment to the femoral shaft, they did not allowfracture impactionSliding nail-plate devicesThe experience with fixed-angle nail-plate devices indicated theneed for a device that would allow controlled fracture impaction.This gave rise to sliding nail-plate devicese.g., Massie nail, Ken-Pugh nailsridevirajeeve_orthopaedics_july2014 8/28/2014 19 20. sridevirajeeve_orthopaedics_july2014 8/28/2014 20 21. The sliding hip screw is themost widely used implant forstabilization of both stable andunstable intertrochantericfractures. Sliding hip screwside plate angles are availablein 5 degree increments from130 to 150 degrees.The 135 degree plate is mostcommonly utilized; this angleis easier to insert in thedesired central position of thefemoral head and neck thanhigher angle devices andcreates less of stresssridevirajeeve_orthopaedics_july2014 8/28/2014 21 22. The trochanteric stabilizing plate and the lateralbuttress plate are modular components thatbuttress the greater trochanterThese plates are placed over a four-hole sideplateand are used to prevent excessive slide (andresulting deformity) in unstable fracture patternsThese devices prevent telescoping of the lag screwwithin the plate barrel when the proximal headand neck fragment abuts the lateral buttress platesridevirajeeve_orthopaedics_july2014 8/28/2014 22 23. The PFN nail has been shown to prevent the fractures ofthe femoral shaft by having a smaller distal shaft diameterwhich reduces stress concentration at the tip.Acts as a buttress in preventing the medialisation of theshaftThe main principle of this type of fixation is based on asliding screw in the femoral neck-head fragment, attachedto an intramedullary nailIn comminuted unstable trochanteric #, PFN preferred as itresists the deforming muscle forces (thus superior to DHS)sridevirajeeve_orthopaedics_july2014 8/28/2014 23 24. General FeaturesStandard length 24cmDistal part has dynamic and static locking holesEntry point Pyriformis FossaCentral indication excessively curved FemurAdvantagesCan be inserted quicklyLess blood lossEarly ambulationSliding and limb shortening is lessMore successful in Reverse Oblique fracturessridevirajeeve_orthopaedics_july2014 8/28/2014 24 25. sridevirajeeve_orthopaedics_july2014 8/28/2014 25 26. EARLYEarly complications are the same as with femoral neck fractures,reflecting the fact that most of these patients are in poor health.LATEFailed fixation Screws may cut out of the osteoporotic bone ifreduction is poor or if the fixation device is incorrectly positioned. Ifunion is delayed, the implantitself may break. In either event,reduction and fixation may have to be re-done.MalunionCoxa Vara and external rotation deformities are commonSeldom severe and rarely interfere with functionNon-union (uncommon, unlike #NoF)Traumatic OsteoarthritisAvascular Necrosis (quite rare)sridevirajeeve_orthopaedics_july2014 8/28/2014 26 27. sridevirajeeve_orthopaedics_july2014 8/28/2014 27

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