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Pearls & Pitfalls of Managing Intertrochanteric Fractures with SHS

Oct 17, 2015

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Sliding Hip Screw

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    PEARLS & PITFALLS OF MANAGINGINTERTROCHANTERIC FRACTURES

    WITH D.H.S

    DR. ZAKRIA TARIQPGR, ORTHOPEDICS

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    INTERTROCHANTERIC FRACTURES

    Intertrochanteric or Pertrochanteric orPeritrochanteric

    Accounts for nearly 50% of all proximal femurfractures

    Average patient age of incidence is 66-76yrs

    In females, annual incidence is 63/100,000population per year while it is 34/100,000 in

    males (USA) Female to male ratio 2:1 to 8:1, likely because of

    postmenopausal metabolic changes in bone

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    Some factors found to be associated with

    intertrochanteric rather than femoral neckfractures

    Advancing age

    Increased number of comorbidities

    Increased dependency in activities of daily living

    A history of other osteoporosis related (fragility)

    fractures

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    ANATOMY Intertrochanteric fracture occurs in the region between G.T

    and L.T of proximal femur Occasionally extend into subtrochanteric area

    Extracapsular fractures

    Occur in cancellous bone with an abundant blood supply

    Nonunion and osteonecrosis are not major problems Deforming forces produce shortening, ER and varus

    position at the fracture. Abductorsdisplace GT laterally & proximally

    Iliopsoasdisplace LT medially & proximally

    Hip Flexors, Extensors & Adductors- pull distal fragment proximally

    Fracture stability determined by presence of posteromedialbony contact, which acts as a buttress against fracturecollapse

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    MECHNISM OF INJURY

    IN YOUNGER INDIVIDUALS

    Usually high energy trauma such as RTA or fall

    from height

    IN ELDERLY

    90%result from a simple fall

    Most fractures from a direct impact to GT area

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    MECHNISM OF INJURY

    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 disease, and

    coexisting musculoskeletal pathology.

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    CLINICAL EVALUATION

    Patients presentation vary depending upon

    displacement

    Displaced fractures are non ambulatory on

    presentation, with shortening and ER of lower

    extremity

    Pain is evident on attempted range of hip

    motion

    Nondisplaced fractures may go unnoticed

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    CLINICAL EVALUATION

    Patient may experience delay beforepresentation at hospital

    Mostly are dehydrated with nutrition

    depletion at presentation Potential for VTE, pressure ulceration as well

    as hemodynamic instability

    Intertrochanteric fractures may be associatedwith as much as a full unit of hemorrhage intothe thigh.

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    RADIOGRAPHIC EVALUATION AP view of Pelvis

    Allows comparison of involved with contralateral side

    Can help to identify nondisplaced fractures

    Lateral view

    Assess posterior communition of proximal femur AP & Cross Table View of the involved proximal femur

    Preferred over frog leg lateral as latter requires FABERof

    the affected leg and involves risk of fracture displacement

    Physician assisted IR view of injured hip (10-15 degree)

    IR offsets the anteversion of femoral neck

    Provides true AP view of the Proximal femur

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    RADIOGRAPHIC EVALUATION

    MRI imaging study of choice

    Delineates nondisplaced or occult fractures that are not

    apparent on plain radiographs

    Reveals fracture within 24 hours of injury

    CT Scan & Bone Scan

    where MRI contraindicated

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    BOYD AND GRIFFIN CLASSIFICATION

    Type I:A single fracture along the intertrochanteric line, stable and easily reducible.

    Type II:

    Major fracture line along the intertrochanteric line with comminution in thecoronal plane.

    Type III:Fracture at the level of the lesser trochanter with variable comminution and

    extension into the subtrochanteric region (reverse obliquity).

    Type IV:Fracture extending into the proximal femoral shaft in at least two planes.

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    TYPE I TYPE II

    TYPE III TYPE IV

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    EVANS CLASSIFICATIONType I:

    (A) Stable:

    - Undisplaced fractures.

    - Displaced but after reduction overlap of the medial cortical

    buttress make the fracture stable.

    (B) Unstable:

    - Displaced and the medial cortical buttress is not restored by

    reduction of fracture.

    - Displaced and comminuted fractures in which the medial corticalbuttress is not restored by reduction of the fracture.

    Type II: Reverse obliquity fractures.

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    UNDISPLACED

    DISPLACED

    but reduced

    DISPLACED

    not Reduced

    REVERSEDOBLIQUITY

    COMMUNITED

    Trochanteric fractures. (Reproduced with permission and copyright of the British Editorial Society

    of Bone and Joint Surgery. Ewans EM. The treatment of trochanteric fractures of the femur.J Bone

    Joint Surg 1949;31-B:190

    203.)

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    OTA CLASSIFICATION31-A Femur, proximal trochanteric

    31-A1 Peritrochanteric simple

    31-A1.1 Along intertrochanteric line

    31-A1.2 Through greater trochanter

    31-A1.3 Below lesser trochanter

    31-A2 Peritrochanteric multifragmentary

    31-A2.1 With one intermediate fragment

    31-A2.2 With several intermediate fragments

    31-A2.3 Extending more than 1 cm below lesser trochanter

    31-A3 Intertrochanteric

    31-A3.1 Simple oblique

    31-A3.2 Simple transverse

    31-A3.3 Multifragmentary

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    Otota CLASSIFICATION

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    UNUSUAL FRACTURE PATTERNS

    BASICERVICAL FRACTURES located just proximal to or along the intertrochanteric

    line

    Anatomically included in femoral neck fractures

    Usually extracapsular Behave and treated as intertrochanteric fractures

    At greater risk for AVN than the more distalintertrochanteric fractures

    Lack the cancellous interdigitation seen with fracturesthrough intertrochanteric region

    More likely to sustain rotation of femoral head duringimplant

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    UNUSUAL FRACTURE PATTERNS

    REVERSE OBLIQUITY FRACTURES

    Unstable fractures.

    An oblique fracture line extending from medial

    cortex proximally to lateral cortex distally.

    Location and direction of fracture line results in a

    tendency to medial displacement from the pull of

    adductors. Treated as subtrochanteric fractures.

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    TREATMENT

    NONOPERATIVE INDICATIONS

    Patients who are at extreme medical risk for surgery

    Demented nonambulatory patients with mild hip pain

    Nondisplaced fractures can be considered for nonoperative

    because displacement changes neither operation type nor

    outcome

    Early bed to chair mobilization

    Avoid complications like poor pulmonary toilet,

    atelectasis, venous stasis, pressure sores.

    Resultant hip deformity is both expected and accepted in

    cases of displacement

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    TREATMENT

    OPERATIVE GOAL

    Stable internal fixation to allow early mobilization and fullweight bearing ambulation.

    STABILITY OF FRACTURE FIXATIONdepends on Bone quality Fracture pattern

    Fracture reduction

    Implant design

    Implant placement

    TIMING OF SURGERY Should be performed in timely fashion once the patient is

    medically stabilized

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    OPTIONS

    Available options for treating intertrochanteric

    fractures include -

    SLIDING HIP SCREW

    INTRAMEDULLARY HIP SCREW NAIL

    EXTERNAL FIXATION

    PROSTHETIC REPLACEMENT

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