INTERTROCHANTERIC FRACTURES OF THE FEMUR

Presented by- DR.NAVEEN RATHOR RESIDENT DOCTOR DEPT. OF ORTHOPAEDICS RNT MEDICAL COLLEGE,UDAIPR

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.

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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

FEMUR

Upper end consists of head, neck, greater and lesser trochanters.

Head forms roughly 2/3 of sphere.

Shaft of femur is slightly twisted and curved with convexity forward.

Neck extends inferolaterally from head to meet shaft of femur at angle of about 125 degrees

(<120 : Coxa vara, >135 : Coxa vulga)

Angle varies with age, stature and width of pelvis.

(less in adults, in persons with short limbs, and in women)

ANATOMY

Occur in the region between the greater and lesser trochanters of the proximal femur, occasionally extending into the subtrochanteric region

Since they occur in cancellous bone with abundant blood supply – no problems of non-union and osteonecrosis

Abductors displace Greater Trochanterlaterally and proximally

Iliopsoas displaces Lesser Trochanter medially and proximally

Hip flexors, extensors and adductors pull distal fragment proximally

ANATOMY

ANATOMY

Deforming muscle forces will usually produce shortening, external rotation and varus position at the fracture

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

MECHANISMS OF INJURY

Most fractures result from a direct impact to the greater trochanter area

Low energy falls from a standing height – approximately 90% of community hip fractures in patients more than 50 years of age with a higher proportion of women

HISTORY AND PHYSICAL EXAMINATION History of pain and inability to ambulate

after a fall or other injury Pain is localized to the proximal thigh;

exacerbated by passive attempts at hip flexion or rotation

Drug use – contributing factor Nursing home and institutionalized patients

– potential neglect and abuse – previous fractures, injuries in different states of repair and decubiti (bedsores/skin peels)

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

EXAMINATION

Shortening of the extremity and deformity of rotation in resting position compared with the other extremity

Pain with motion/Crepitance testing – NOT elicited unless there are no obvious physical signs of deformity and radiographic studies are negative for an obvious fracture.

Pain with axial load on the hip – high correlation with occult fracture

IMAGING STUDIES - XRAYS Pelvis with both hips – AP, xray of the

affected hip – AP and cross-table lateral

Traction films (with internal rotation) – helpful in communited and high-energy fractures and in determining implant selection

Subtrochanteric extension – Femur AP and lateral

OTHER IMAGING STUDIES Magnetic Resonance Imaging (MRI) –

currently the imaging study of choice in delineating non-displaced or occult fractures that may not be apparent on plain radiographs – Preferred over CT due to higher sensitivity and specificity for a more rapid decision process

OTHER IMAGING STUDIES

Bone scans or CT – reserved for those who have contradictions to MRI. Technetium bone scans

Technetium bone scan – when a hip fracture is suspected but not apparent to standard radiographs – requires 2-3 days to become positive

BOYD AND GRIFFIN CLASSIFICATION

i. Stable (Two part)ii. Unstable with posteromedial

communition iii. Subtrochanteric extension into

lateral shaft, extension of the fracture distally at or just below the lesser trochanter (the term Reverse Obliquity was coined by Wright)

iv. Subtrochanteric with intertrochanteric extension with the fracture lying in atleast two planes

Boyd & griffin’s classification

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

into proximal femoral shaft

BOYD AND GRIFFIN CLASSIFICATION Type iii and iv are the most difficult

types to manage

Account for one third of the trochanteric fractures

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.

WHY WAS EVAN’S CLASSIFICATION IMPORTANT? Because it distinguished stable from unstable

fractures and helped define the characteristics of a stable reduction.- Stable fracture patterns – posteromedial cortex remains intact OR has minimal communition- Unstable fracture patterns – characterised by disruption or impaction of the posteromedial cortex- can be converted into stable if medial cortical opposition is maintained. - Reverse Oblique – Inherently unstable due to the tendency for medial displacement of the femoral shaft

OTA/AO CLASSIFICATION

The most quoted in recent scientific articles – a derivative of the Muller classification

Has been very useful in evaluating the results of treatment of intertrochanteric fracture and allowing comparisons among reports in literature

OTA/AO CLASSIFICATION

Group 1 fractures (31A1) – Pertrochanteric 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.

A1.1 – Along intertrochanteric lineA 1.2 – Through greater trochanterA 1.3 – Below lesser trochanter

OTA/AO CLASSIFICATION

Group 2 fractures (31A2) – Pertrochanteric multifragmentary - 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.

A2.1 – With one intermediate fragmentA2.2 – With several intermediate fragmentsA2.3 – Extending more than 1cm below lesser trochanter.

OTA/AO CLASSIFICATION

Group 3 fractures (31A3) – TRUE INTERTROCHANTERIC - are those in which the fracture line extends across both the medial and lateral cortices; this group also includes the reverse obliquity pattern.A3.1 – Simple obliqueA3.2 – Simple transverseA3.3 - Multifragmentary

OTA/AO CLASSIFICATION

OTA/AO CLASSIFICATION

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

TREATMENT OPTIONS – NON OPERATIVE Buck’s traction or extension Russell skeletal traction Balanced traction in Thomas splint Plaster spica immobilization Derotation boot

Buck’s traction

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

As soon as the general condition of this patient is under control, internal fixation should be carried out.

The goal of surgical treatment is strong, stable fixation of the fractured fragments

OPERATIVE TREATMENT – FACTORS THAT DETERMINE THE STRENGTH OF THE FRACTURE FRAGMENT-IMPLANT ASSEMBLY Bone quality

Fracture geometry

Reduction

Implant design

Implant placement

OPERATIVE METHODS

Plate Constructs Cephalomedullary nailing External Fixation Arthroplasty

PLATE CONSTRUCTS – DYNAMIC COMPRESSION PLATING From the 1980s to 2000 – Sliding compression hip

screws became the gold standard for hip fracture fixation.

Historically the most commonly used device for both stable and unstable fracture patterns. Available in plate angles from 130deg to 150deg.

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 a stress riser in the subtrochanteric region.

SLIDING HIP SCREW

PLATE CONSTRUCTS – DYNAMIC COMPRESSION PLATING

The most important technical aspects of screw insertion are:

1. Placement within 1cm of subchondral bone to provide secure fixation

2. Central position in the femoral head (Tip-apex distance)

TIP-APEX DISTANCE

Sum of distances from the tip of the lag screw to the apex of the femoral head on both the anteroposterior and lateral radiographic views.

The sum should be <25mm to minimize the risk of lag screw cutout

CEPHALOMEDULLARY DEVICES Inserted through the piriformis fossa OR

lateral greater trochanter OR medial greater trochanter

Femoral head component – screw/blade interlocked with nail component

Dissatisfaction with use of a sliding hip screw in unstable fracture patterns led to the development of intramedullary hip screw devices.

CEPHALOMEDULLARY NAILS - ADVANTAGES Because of its location, theoretically provides more

efficient load transfer than does a sliding hip screw.

The shorter lever arm of the intramedullary device can be expected to decrease tensile strain on the implant, thereby decreasing the risk of implant failure.

Because the intramedullary fixation device incorporates a sliding hip screw, the advantage of controlled fracture impaction is maintained

Shorter operative time and less soft-tissue dissection than a sliding hip screw.

PROXIMAL FEMORAL 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.

Due to its position close to the weight-bearing axis the stress generated on the intramedullary implants is negligible.

PROXIMAL FEMORAL NAIL PFN implant also acts as a buttress

in preventing the medialisation of the shaft. The entry portal of the PFN through the trochanter limits the surgical insult to the tendinous hip abductor musculature only , unlike those nails which require entry through the piriformis fossa.

EXTERNAL FIXATION

As reported by Moroni et. al. May be indicated in osteoporotic hip fractures in elderly patients who may be deemed at high risk for conventional open reduction and internal fixation

Also for those who cannot receive blood transfusions because of personal conviction or religion (eg. Jehovah’s witnesses)

EXTERNAL FIXATION

Use was unsuccessful because of high rate of pin-tract infection, subsequent pin loosing, varus collapse, instability and failure

Latest – new fixation designs and the addition of hydroxyapatite coated pin technology

ARTHROPLASTY

Neoplastic fractures, severe osteoporotic disease, renal dialysis patients and pre-existing arthritis under consideration for hip replacement before the fracture occured

Hemiarthroplasty reported to have a lower dislocation rate when compared to total hip arthroplasty

ARTHROPLASTY

Better salvage operation for failed internal fixation rather than a first-line choice in geriatric patient.

No level-one evidence to show any difference between compression hip screw and arthroplasty except for a higher blood transfusion rate with arthroplasty

ARTHROPLASTY-DISADVANTAGES Morbidity associated with a more

extensive operative procedure

Internal fixation problems with greater trochanteric reattachment

Risk of postoperative prosthetic dislocation

POST-OPERATIVE CARE

AP and lateral radiographs while the patient is still in the surgical area

Patient mobilized to chair upright position the day after the operative procedure

Ambulation – under supervision with weight bearing as tolerated with a walker or crutches – emphasis on heel-strike and upright balance exercises

POST – OPERATIVE CARE Multiple trauma/co-morbidities – difficulty in

early ambulation but must be done as soon as possible to minimize secondary complications

Weight bearing – for optimal recovery and to reduce the fear of falling/lack of independence

Good pain control

POST-OPERATIVE CARE Protein and caloric nutrition, osteoporotic

therapy including Vitamin D supplementation

Hip abductor exercises bilaterally in conjunction with proper balance and gait training

Patient to be counseled to report any swelling or respiratory distress – risk of thromboembolic disease

POST – OPERATIVE CARE

ON DISCHARGE – fall prevention education and safe home checks to be explained to the family or social support group

Re-evaluation of the patient in the OPD with X-Rays at 2 weeks and then monthly thereafter until fracture healing is documented OR patient has maximum ambulation (usually 6 months after injury)

COMPLICATIONS

Loss of fixation

Nonunion

Malrotation deformity

Osteonecrosis

Medical, psychosocial, thromboembolic

COMPLICATIONS – LOSS OF FIXATION Commonly characterized by varus

collapse of the proximal fragment with cut-out of the lag screw from the femoral head

Occurs within 3 months of surgery due to eccentric placement of lag screw within femoral head, improper reaming, unstable reduction, excessive fracture collapse which exceeds the sliding capacity of the device

COMPLICATIONS – LOSS OF FIXATION Inadequate screw-barrel

engagement which prevents sliding and severe osteopenia

Management – acceptance of the deformity, revision ORIF with PMMA or conversion to prosthetic replacement

COMPLICATIONS – NON-UNION Uncommon. May follow internal

fixation more often than closed treatment

Should be suspected with patients with persistent hip pain that have radiographs revealing a persistent radiolucency at the fracture site 4-7 months after fracture fixation

COMPLICATIONS NON-UNION Managed by open reduction,

renailing and bone grafting

COMPLICATIONS – MALROTATION DEFORMITY Internal rotation of the distal

fragment at surgery

Unstable fracture patterns – the proximal and distal fragments may move independently – such cases the distal fragment should be placed in neutral/slight external rotation during plate fixation

COMPLICATIONS – MALROTATION DEFORMITY Severe malrotation which interferes

with ambulation – revision surgery with plate removal and rotational osteotomy of the femoral shaft should be considered.

Z-Effect – seen most commonly with dual screw CM nails – most proximal screw penetrates the hip joint and distal screw backs out of the femoral head

COMPLICATIONS – OSTEONECROSIS OF THE FEMORAL HEAD Rare

Lag screw-side plate dissociation

Occurs due to traumatic laceration of the superficial femoral artery by a displaced lesser trochanter fragment

COMPLICATIONS - MEDICAL Cardiopulmonary complications most

frequent

Other complications – GI bleeding, venous thromboembolism, transient ischemic attacks or stroke.

Renal complications rare.

COMPLICATIONS - MEDICAL Infection – seen in 1-2%

postoperative patients – can be minimized by preoperative antibiotics – cephalosporins

Vigilance with a high index of suspicion for any signs of wound inflammation or drainage

Oral antibiotics for 7-10 days if the infection is superficial

GREATER TROCHANTERIC FRACTURES Rare – typically occur in older

patients as a result of an eccentric muscle contraction or less commonly a direct blow

Treatment – usually non-operative. Operative considered in younger, active patients with a widely displaced greater trochanter

GREATER TROCHANTERIC FRACTURES ORIF with tension band wiring of the

displaced fragment and the attached abductor muscles or plate and screw fixation with a “hook plate” are the preferred techniques

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LESSER TROCHANTERIC FRACTURES Most common in adolescence, typically

secondary to forceful iliopsoas contracture

In elderly, isolated lesser trochanter fractures have been recognised as pathognomonic for pathologic lesions of the proximal femur

Treatment – identifying the pathologic lesion and treating accordingly. If no evidence of pathologic lesion – symptomatic treatment to gain ROM and ambulation.

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