Orthopedics 5th year, 5th lecture (Dr. Ali A.Nabi)

Intertrochanteric fracturesIntertrochanteric fractures


Extracapsular fracture.Extracapsular fracture. Common in elderly osteoporotic Common in elderly osteoporotic

patient.patient. Usually woman in eighth decade.Usually woman in eighth decade. Unite easily and rarely cause Unite easily and rarely cause

avascular necrosis. avascular necrosis.


The siteThe site The proximal femur consists of the The proximal femur consists of the

femoral head, femoral neck, and the femoral head, femoral neck, and the trochanteric region. An intertrochanteric trochanteric region. An intertrochanteric hip fracture occurs between the greater hip fracture occurs between the greater trochanter, where the gluteus medius and trochanter, where the gluteus medius and minimus muscles (hip extensors and minimus muscles (hip extensors and abductors) attach, and the lesser abductors) attach, and the lesser trochanter, where the iliopsoas muscle trochanter, where the iliopsoas muscle (hip flexor) attaches.(hip flexor) attaches.


Mechanism Mechanism

1.1. fall directly onto greater trochanter.fall directly onto greater trochanter.

2.2. indirect twisting injury.indirect twisting injury.


EtiologyEtiology The etiology of intertrochanteric The etiology of intertrochanteric

fractures is the combination offractures is the combination of

1.1. increased bone fragility of the increased bone fragility of the intertrochanteric area of the femur.intertrochanteric area of the femur.


2.2. decreased muscle tone of the muscles in decreased muscle tone of the muscles in the area secondary to the aging process. the area secondary to the aging process. The increasing bone fragility results from The increasing bone fragility results from osteoporosis and osteomalacia secondary osteoporosis and osteomalacia secondary to a lack of adequate ambulation or to a lack of adequate ambulation or antigravity activities, as well as decreased antigravity activities, as well as decreased hormone levels, increased levels of hormone levels, increased levels of demineralizing hormones, decreased demineralizing hormones, decreased intake of calcium and/or vitamin D, and intake of calcium and/or vitamin D, and other aging processes. other aging processes.


3.3. Benign and malignant tumors, Benign and malignant tumors, along with metastases such as along with metastases such as multiple multiple myelomamyeloma and other and other malignancies, can also lead to malignancies, can also lead to weakened bony structure. weakened bony structure.

http://emedicine.medscape.com/article/1256274-overview



Types Types

1.1. stable fracture.stable fracture.


2.2. unstable fracture in which there is unstable fracture in which there is poor contact between fracture poor contact between fracture fragments. There will be displaced fragments. There will be displaced fragment from the weight bearing fragment from the weight bearing area ( the Calcar or the area ( the Calcar or the inferomedial part of the femoral inferomedial part of the femoral neck).neck).


Unstable factors:Unstable factors:1.1. four part fracture.four part fracture.

2.2. reverse oblique fracture.reverse oblique fracture.

3.3. calcar fracture.calcar fracture.

4.4. shattered postero-medial cortex.shattered postero-medial cortex.

5.5. displaced large fragment including the displaced large fragment including the lesser trochanter.lesser trochanter.


Clinical featuresClinical features

1.1. usually old unfit female.usually old unfit female.

2.2. H/O fall or just twisting.H/O fall or just twisting.

3.3. unable to stand or walk.unable to stand or walk.

4.4. the leg is short and externally the leg is short and externally rotated.rotated.

5.5. the patient cannot left her leg.the patient cannot left her leg.


X-RayX-Ray

1.1. undisplaced stable fracture only undisplaced stable fracture only show crack line along with the show crack line along with the interrochanteric line.interrochanteric line.

2.2. displaced with comminution or displaced with comminution or displaced lesser trochanter are displaced lesser trochanter are usually obvious.usually obvious.


Treatment Treatment The current treatment of The current treatment of

intertrochanteric fractures is surgical intertrochanteric fractures is surgical intervention. Despite an acceptable intervention. Despite an acceptable healing rate with nonsurgical methods, healing rate with nonsurgical methods, surgical intervention for surgical intervention for intertrochanteric fractures has replaced intertrochanteric fractures has replaced previous nonsurgical methods ofprevious nonsurgical methods of


1.1. Prolonged bed rest.Prolonged bed rest.

2.2. Prolonged traction in bed.Prolonged traction in bed.

3.3. Prolonged immobilization in a full-Prolonged immobilization in a full-body (spica) cast.body (spica) cast.


Though healing rates for previous Though healing rates for previous nonsurgical methods may have been nonsurgical methods may have been acceptable, they were accompanied by acceptable, they were accompanied by unacceptable morbidity and mortality unacceptable morbidity and mortality rates because of frequent rates because of frequent nonorthopedic complications nonorthopedic complications associated with prolonged associated with prolonged immobilization or inactivity. immobilization or inactivity. Complications included the following:Complications included the following:


1.1. Pulmonary complications of Pulmonary complications of pneumonia resulting from inactivity. pneumonia resulting from inactivity.

2.2. Pulmonary emboli from Pulmonary emboli from deep vein thrombosisdeep vein thrombosis (DVT) caused (DVT) caused by immobilization of an extremity. by immobilization of an extremity.

3.3. Bedsores from prolonged bed rest. Bedsores from prolonged bed rest.



4.4. Loss of motion of the lower extremity Loss of motion of the lower extremity joints and muscle atrophy due to joints and muscle atrophy due to prolonged immobilization. prolonged immobilization.

5.5. Union of the fracture in an unacceptable Union of the fracture in an unacceptable position resulting in a deformity. (Known position resulting in a deformity. (Known as a malunion, the fracture heals with as a malunion, the fracture heals with unacceptable shortening, rotation, and/or unacceptable shortening, rotation, and/or angulation of the extremity, resulting in angulation of the extremity, resulting in decreased mobility and subsequent decreased mobility and subsequent handicap, impairment, and disability.)handicap, impairment, and disability.)


Surgical optionsSurgical options

1.1. close reduction and internal close reduction and internal fixation.fixation.

2.2. Open reduction and internal Open reduction and internal fixation.fixation.


Types of internal fixationTypes of internal fixation

1.1. sliding nail or screw.sliding nail or screw.

2.2. fixed angle 95° or 135° L-plate.fixed angle 95° or 135° L-plate.

3.3. DHS and side plate.DHS and side plate.

4.4. intramedullary device and hip screwintramedullary device and hip screw


ComplicationsComplications EarlyEarly the same of the femoral neck the same of the femoral neck

fractures.fractures.


Late Late

1.1. failed fixation either the screw cut out failed fixation either the screw cut out the osteoporotic bone or the screw the osteoporotic bone or the screw itself breaks because of nonunion.itself breaks because of nonunion.

2.2. malunion which is usually follow malunion which is usually follow conservative treatment.conservative treatment.

3.3. non-union which is rare complication.non-union which is rare complication.

Subtrochanteric Subtrochanteric fracturesfractures

Subtrochanteric fracturesSubtrochanteric fractures

The subtrochanteric region of the femur, The subtrochanteric region of the femur, arbitrarily designated as the region arbitrarily designated as the region between the lesser trochanter and a point 5 between the lesser trochanter and a point 5 cm distal, consists predominantly of cortical cm distal, consists predominantly of cortical bone. Healing in this region is bone. Healing in this region is predominantly through a primary cortical predominantly through a primary cortical healing. Thus, the fracture is quite slow to healing. Thus, the fracture is quite slow to consolidate. During normal activities of consolidate. During normal activities of daily living, up to 6 times the body weight is daily living, up to 6 times the body weight is transmitted across the subtrochanteric transmitted across the subtrochanteric region of the femur.region of the femur.


MechanismMechanism

1.1. In In elderlyelderly patients, minor slips or falls patients, minor slips or falls that lead to direct lateral hip trauma are that lead to direct lateral hip trauma are the most frequent mechanism of injury. the most frequent mechanism of injury. This age group is also susceptible toThis age group is also susceptible to

a.a. metastatic disease that can lead to pathologic metastatic disease that can lead to pathologic fractures.fractures.

b.b. Osteoporosis and osteomalaciaOsteoporosis and osteomalacia

c.c. Paget’s disease.Paget’s disease.

http://www.medscape.com/resource/geriatric


2.2. In younger patients, the mechanism In younger patients, the mechanism of injury is almost always high-of injury is almost always high-energy trauma, either from direct energy trauma, either from direct lateral trauma (eg, motor vehicle lateral trauma (eg, motor vehicle accident [MVA]) or from axial accident [MVA]) or from axial loading (eg, a fall from height).loading (eg, a fall from height).


3.3. Gunshot wounds cause Gunshot wounds cause approximately 10% of high-energy approximately 10% of high-energy subtrochanteric femur fractures.subtrochanteric femur fractures.


Clinical featuresClinical features Physical findings at the time of injury Physical findings at the time of injury

often include often include 1.1. a shortened extremity on the a shortened extremity on the

fractured side.fractured side.2.2. Significant swelling is frequently Significant swelling is frequently

present, with tenderness to palpation present, with tenderness to palpation in the proximal thigh region.in the proximal thigh region.


3.3. The leg may lie in internal or The leg may lie in internal or external rotation. external rotation.

4.4. The patient cannot flex the hip or The patient cannot flex the hip or abduct the leg. abduct the leg.

5.5. Hemorrhage into the injured thigh Hemorrhage into the injured thigh may be substantial, and the patient may be substantial, and the patient should be monitored for systemic should be monitored for systemic shock and compartment syndrome. shock and compartment syndrome.


6.6. In high-energy fractures, a complete In high-energy fractures, a complete system examination must be system examination must be performed. Associated injuries to the performed. Associated injuries to the cranium, thorax, and abdomen must cranium, thorax, and abdomen must be recognized. Pelvic, spine, and be recognized. Pelvic, spine, and long bone injuries are also common, long bone injuries are also common, especially on the ipsilateral side, and especially on the ipsilateral side, and these should be identified early to these should be identified early to optimize treatment and outcomes.optimize treatment and outcomes.


X-Ray X-Ray 1.1. Fracture through or below the lesser Fracture through or below the lesser

trochanter can be seen, the fracture trochanter can be seen, the fracture could be transverse, oblique or could be transverse, oblique or spiral.spiral.

2.2. the upper fragment is flexed and the upper fragment is flexed and appear short.appear short.

3.3. the shaft adducted and displaced the shaft adducted and displaced proximally.proximally.


TreatmentTreatment The goals of treatment includesThe goals of treatment includes

1.1. anatomic alignment.anatomic alignment.

2.2. early mobilization. early mobilization.

3.3. effective rehabilitation.effective rehabilitation.


With the improvements in surgical With the improvements in surgical techniques and implants, most of techniques and implants, most of these goals can be achieved with these goals can be achieved with surgical treatment.surgical treatment.


indicationsindications Current indications for surgical Current indications for surgical

treatment include treatment include

1.1. displaced. displaced.

2.2. nondisplaced fractures in adults. nondisplaced fractures in adults.


3.3. fractures in patients with multiple fractures in patients with multiple traumatic injuries. traumatic injuries.

4.4. open fractures, severe ipsilateral open fractures, severe ipsilateral extremity injuries.extremity injuries.

5.5. pathologic fractures.pathologic fractures.


Open reduction and internal fixation Open reduction and internal fixation is the treatment of choice.is the treatment of choice.


Types Types

1.1. For fractures at the level of lesser For fractures at the level of lesser trochanter, DHS and plate is trochanter, DHS and plate is satisfactory.satisfactory.

2.2. for fractures below the level of the for fractures below the level of the lesser trochanter, interlocking nail lesser trochanter, interlocking nail is suitable.is suitable.


3.3. for fractures extended to piriformis for fractures extended to piriformis fossa, 95° angled L-plate is safer.fossa, 95° angled L-plate is safer.

4.4. if there is comminution or cortical if there is comminution or cortical defect, bone graft added to the defect, bone graft added to the above procedures.above procedures.


ComplicationsComplications

1.1. malunion.malunion.

2.2. non-union.non-union.

Date post:	07-May-2015
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Orthopedics 5th year, 5th lecture (Dr. Ali A.Nabi)

Health & Medicine