extern ortho maharat conference 26 dec 2016
TRANSCRIPT
EXTERNCONFERENCE
26 DEC 2016
Korranit Pansritum
A 77-year-old female with a history of slipping and falling in the toilet 4 hours PTA
HISTORYA 77-year-old female with a history of slipping and falling in the toilet 4 hours PTA
• Her right hip hit the floor with sudden right hip pain
• Unable to get up or move her right leg
PHYSICAL EXAMINATIONVital signs: T 36.7 C PR 84 bpm BP 200/89 mmHg RR 16/min
General appearance: An old Thai woman, good consciousness, alert, awake, active
HEENT: No pale conjunctivae, anicteric sclerae
Lungs: Equal chest expansion, equal breath sound, clear both lungs
Heart: Pulse full and regular, normal S1, S2, no murmur
Abdomen: flat, no wound, normoactive bowel sound, soft, not tender, no hepatosplenomegaly
HIP EXAMINATION
HIP EXAMINATIONInspection:• No wound• No ecchymosis• Right leg in external rotation positionPalpation:• Tenderness at right groin area• No leg shortening• Unable to do active & passive right hip flexion• Tenderness at right hip when internal rotate• Can flex & extend right toes, ankle• Right radial pulse 2+
HIP EXAMINATIONSpecial tests:• Log roll test +ve
PROBLEM LISTAn elderly with right hip tenderness with history of
simple fall
APPROACH TO HIP PAIN IN ELDERLY• Femoral head fracture• Femoral neck fracture• Trochanteric fracture• Intertrochanteric fracture• Sub trochanteric fracture
INVESTIGATION
DIAGNOSISClose fracture right intertrochanteric fracture
INTERTROCHANTERICFRACTURE
INTRODUCTION• Extracapsular fractures of the proximal
femur between the greater and lesser trochanters
• Mechanism:• Elderly > low energy falls in osteoporotic patients• Young > high energy trauma
INTRODUCTION• Prognosis:• Nonunion and malunion rates are low• 20 – 30% mortality risk in the first year
following fracture• Factors that increase mortality
• Male (25 – 30%) VS Female (20%)• Operative delay of > 2 days• Age > 85 years• 2 or more pre-existing medical conditions
• Surgery within 48 hours decreases 1 year mortality
CLASSIFICATION• Stable• Definition: Intact posteromedial cortex• Clinical significance: will resist medial
compression loads once reduced• Unstable• Definition: Comminution of the posteromedial
cortex• Clinical significance: will collapse into varus
and retroversion when loaded
In 1949, Evans published his classification on intertrochanteric (IT) fractures as follows:Type I:Stable: (Intact or minimally communited posteriomedial cortex)• Undisplaced fractures.• Displaced but after reduction overlap of the medial
cortical buttress make the fracture stable.Unstable:• Displaced and the medial cortical buttress is not
restored by reduction of fracture.• Displaced and comminuted fractures in which the
medial cortical buttress is not restored by reduction of the fracture.
Type II: Reverse obliquity fractures (Inheritably unstable fracture)
Clinical importance: • Better understanding of intertrochanteric fractures
based on stability of fracture after close reduction and skeletal traction
• Posterior-medial cortex continuation is important for restoring stability
Jensen’s Modification of the Evans Classification [3] (Fig. 2):Jansen (1975 ) later modified Evans classification into three groups.Displaced or undisplaced stable 2-fragment fractures, Unstable 3-fragment fractures with greater or lesser trochanter fracture and 4-fragment fractures
Clinical Importance:• Reduced the number of types from 6 to 5 by
including the extremely rare fracture with a reversed oblique fracture line and large greater trochanter fragment into Type 3
• Best prediction of the possibility of obtaining reliable anatomical reduction and the risk of secondary fracture dislocation
Kyle’s Classification [4] (Fig. 3): Type I fractures consist of nondisplaced stable intertrochanteric fractures without comminution.Type II fractures represent stable, minimally comminuted but displaced fractures; these are the fractures that, once reduced, allow a stable construct. Stable fractures are not a problem and hold up well with any type of fixation device.Type III intertrochanteric fracture is a problem fracture and has a large posteromedial comminuted area.Type IV fracture is uncommon and consists of an intertrochanteric fracture with a subtrochanteric component. This is the most difficult type of fracture to fix because of the great forces imposed by muscle forces and weight bearing on the subtrochanteric region of the femur.
Clinical Importance: Addition of new variant (type 4) extension of intertrochanteric fracture in neck.
A1: 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.A2: fractures are comminuted with a posteromedial 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 fragmentA3: fractures are those in which the fracture line extends across both the medial and lateral cortices; this group includes the reverse obliquity pattern or subtrochanteric extensions.
31-A Femur, proximal trochanteric31-A1 Peritrochanteric simple31-A1.1 Along intertrochanteric line31-A1.2 Through greater trochanter31-A1.3 Below lesser trochanter31-A2 Peritrochanteric multifragmentary31-A2.1 With one intermediate fragment31-A2.2 With several intermediate fragments31-A2.3 Extending more than 1 cm below lesser trochanter31-A3 Intertrochanteric31-A3.1 Simple oblique31-A3.2 Simple transverse31-A3.3 Multifragmentary.Clinical importance: This helps in predicting prognosis and suggests treatment for the entire spectrum of IT fractures. Fractures A1.1 through A2.1 are commonly described as stable, and fractures A2.2 through A3.3 usually are unstable.
PRESENTATIONPainful, shortened, externally rotated lower
extremity
IMAGINGRadiographs:• AP pelvis• AP of hip, lateral cross table• Full length femurCT or MRI:• Useful if radiographs are negative but physical
exam consistent with fracture
TREATMENTNon operative (Non weight bearing with early out of bed to chair):• Indications
• Non ambulatory patients
• Patients at high risk of perioperative mortality• Outcome
• High rates of pneumonia, UTI, DVTOperative:• Sliding hip compression screw• Intramedullary hip screw (Cephalomedullary screw)• Arthroplasty
COMPLICATIONS• Implant failure and cutout
• Incidence• Most common complication• Usually occurs within first 3 months
• Treatment• Young > Corrective osteotomy and/or revision open reduction and
internal fixation• Elderly > Total hip arthroplasty
• Anterior perforation of the distal femur• Following intramedullary screw fixation
• Nonunion• Malunion
REFERENCEORTHO BULLETS
AOTRAUMA foundation
Sonawane DV. Classifications of Intertrochanteric fractures and their Clinical Importance. Trauma International July-Sep 2015;1(1):7-11