Intertrochanteric fractures

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04/12/2023sridevirajeeve_orthopaedics_july2014 1

INTERTROCHANTERIC FRACTURES

By;

Sridevi Rajeeve

Intern

2008 Batch


BACK TO ANATOMY!


GENERAL FEATURES

Completely Extracapsular fracture with variable comminution

Common in elderly osteoporotic patient Usually woman in eighth decade More common than I/C #NoF Unite easily and rarely cause avascular necrosis Some of the factors found to be associated with a

patient sustaining an intertrochanteric rather than a femoral neck fracture include advancing age increased number of comorbidities increased dependency in activities of daily living history of other osteoporosis related fractures.


DEFINITION An intertrochanteric hip 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


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). 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


ACCORDING TO CUMMINGS 4 FACTORS CONTRIBUTE TO DETERMINING WHETHER A PARTICULAR FALL RESULTS IN A FRACTURE OF THE HIP

(a) Fall must be oriented so the person lands on or near the hip

(b) protective reflexes must be inadequate to reduce the energy of the fall below a certain critical threshold

(c) local shock absorbers (muscle and fat around the hip) must be inadequate.

(d) bone strength at the hip must be insufficient.


BONE MASS RELATED TO AGE IN CANCELLOUS BONE AND CORTICAL BONE

100 years50 years

Bone mass

Trochcanteric area

Neck of the femur

Age


SIGNS AND SYMPTOMS Pain Marked shortening of lower limb Patient cannot lift his/her leg Complete External Rotation Deformity Swelling, ecchymoses and Tenderness over the Greater

Trochanter Displaced fractures are clearly symptomatic, such

patients usually cannot stand, much less ambulate Nondisplaced 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 IMAGING1.(AP) view of the pelvis .2.AP and a cross-table lateral view of the involved proximal femur


When a hip fracture is suspected but not apparent on standard x-rays, a technetium bone scan or a magnetic resonance imaging (MRI) scan should be obtained. MRI has been shown to be at least as accurate as bone scanning in identification of occult fractures of the hip, and it will reveal a fracture within 24 hours of injury.


BOYD & GRIFFIN’S CLASSIFICATION

1. Linear IT line #2. Linear IT line # with comminution3. Subtrochanteric #4. Inter-/Subtrochanteric # with extension into

proximal femoral shaft



EVAN’S CLASSIFICATION

Type 1 : Two-part Undisplaced. Type 2 : Two-part Displaced. Type 3 : Three-fragment fracture without

posterolateral support (displaced GT Fragment) Type 4 : Three fragment fracture without medial

support (displaced LT Fragment) Type 5 : Four fragment fracture without

posterolateral and posteromedial support Type 6 : Reverse oblique fracture.


ORTHOPAEDIC TRAUMA ASSOCIATION (OTA) ALPHANUMERIC FRACTURE CLASSIFICATION


Group 1 fractures are simple (two-part) fractures, with the typical oblique fracture line extending from the greater trochanter to the medial cortex; the lateral cortex of the greater trochanter remains intact.

Group 2 fractures are comminuted with a postero-medial fragment; the lateral cortex of the greater trochanter, however, remains intact. Fractures in this group are generally unstable, depending on the size of the medial fragment.

Group 3 fractures are those in which the fracture line extends across both the medial and lateral cortices; this group also includes the reverse obliquity pattern.


TREATMENT OPTIONS

Nonoperative Treatment Indication 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 weeks with Bohler-Braun Splint


In elderly patients, this approach was associated with high complication rates; typical problems included Decubiti Urinary tract infection Joint contractures Hypostatic Pneumonia Thromboembolic complications Fracture healing was generally accompanied by varus

deformity and shortening because of the inability of traction to effectively counteract the deforming muscular forces = MALUNION!


OPERATIVE TREATMENT 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 with

prolonged recumbency

Fixed-angle nail-plate devices The first successful implants While these devices provided stabilization of the femoral head and

neck fragment to the femoral shaft, they did not allow fracture impaction

Sliding nail-plate devices The experience with fixed-angle nail-plate devices indicated the need

for a device that would allow controlled fracture impaction. This gave rise to sliding nail-plate devices

e.g., Massie nail, Ken-Pugh nail


MASSIE NAIL ,KEN-PUGH NAIL CONSISTING OF A NAIL THAT PROVIDED PROXIMAL FRAGMENT FIXATION AND A SIDE PLATE THAT ALLOWED THE NAIL TO “TELESCOPE” WITHIN A BARREL ALLOWING BONE ON BONE CONTACT


SLIDING HIP SCREW DEVICES

The sliding hip screw is the most widely used implant for stabilization of both stable and unstable intertrochanteric fractures. Sliding hip screw side plate angles are available in 5 degree increments from 130 to 150 degrees.

The 135 degree plate is most commonly utilized; this angle is easier to insert in the desired central position of the femoral head and neck than higher angle devices and creates less of stress


TROCHANTERIC STABILIZING PLATES The trochanteric stabilizing plate and the lateral

buttress plate are modular components that buttress the greater trochanter

These plates are placed over a four-hole sideplate and are used to prevent excessive slide (and resulting deformity) in unstable fracture patterns

These devices prevent telescoping of the lag screw within the plate barrel when the proximal head and neck fragment abuts the lateral buttress plate


PROXIMAL FEMORAL NAIL (PFN)

GAMMA NAIL

The PFN nail has been shown to prevent the fractures of the femoral shaft by having a smaller distal shaft diameter which reduces stress concentration at the tip.

Acts as a buttress in preventing the medialisation of the shaft

The main principle of this type of fixation is based on a sliding screw in the femoral neck-head fragment, attached to an intramedullary nail

In comminuted unstable trochanteric #, PFN preferred as it resists the deforming muscle forces (thus superior to DHS)


General Features Standard length – 24cm Distal part has dynamic and static locking holes Entry point – Pyriformis Fossa Central indication – excessively curved Femur

Advantages Can be inserted quickly Less blood loss Early ambulation Sliding and limb shortening is less More successful in Reverse Oblique fractures



COMPLICATIONS EARLY

Early complications are 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 implantitself may break. In either event, reduction and fixation may have to be re-done.

Malunion Coxa Vara and external rotation deformities are common Seldom severe and rarely interfere with function Non-union (uncommon, unlike #NoF) Traumatic Osteoarthritis Avascular Necrosis (quite rare)


THANK YOU!

Intertrochanteric fractures

Health & Medicine

Intertrochanteric fractures