Lecture on Intertrochanteric fracture at GMC Bhopal

1. Intertrochanteric Fractures
Dr Abhishek Pathak
Associate Prof.
Orthopaedics
Gandhi Medical College Bhopal

2. 2
Introduction

3. 3
Intracapsular fractures
Treatment mechanically based
Result biologically determined
Extracapsular fractures
Treatment mechanically based
Result mechanically determined
Introduction

4. 4
Anatomy

5. 5
Anteversion

6. 6
Etiology
In the elderly
In young people

7. 7
Intertrochanteric fractures
Risk factors in the elderly:
• Less soft-tissue cover
• Muscle weakness
• Poor protective response
• Impaired cognition/vision
• Comorbidity/drugs

8. 8
Impact
• 17% will die within 6 months
• 25% reduction in life expectancy
• 50% new permanent deficits in activities of daily living
• $ 81,300.- lifetime costs ($ 8,900 initially)
• $ ????? savings due to fracture deaths

9. 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 the coronal 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
I II
III IV

10. Clinical feature
INTRA-CAPSULAR
FRACTURE
EXTRA-CAPSULAR
FRACTURE
AGE > 50 YEARS > 60 YEARS
SEX > IN FEMALE > IN MALE
SWELLING LIMITED TO ANTERIOR REGION EXTENSIVE
ECCHYMOSIS NOT EVIDENT EXTENSIVE
WT. BEARING POSSIBLE IN IMPACTED
FRACTURE
NOT POSSIBLE
ATTITUDE INCOMPLETE EXT. ROTN. ALMOST FULL
MOVEMENT POSSIBLE IN IMPACTED # N/F ALL RESTRICTED
LIMB SHORTENING 1-2 CM 2-5 CM
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11. TREATMENT
GOALS
 TO ACHIEVE UNION WITHOUT DEFORMITY
 FRACTURE REDUCTION, STABILIZATION
 EARLY MOBILIZATION, LESS COMPLICATIONS
USUALLY OPERATIVE

12. 12
What does the patient want?
Treatment that enables them to return to
normal as soon as possible

13. Primary Treatment
• Analgesics
• Splintage
• Skin Traction
All these treatment
options are aimed at
alleviating the pain
Bucks Traction
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14. 14
Treatment options
Nonoperative:
• ± 14 weeks bed rest
• Virtually impossible
• Secondary
displacement obligatory
• Old fragile patient with poor
surgical risk (almost
Abandoned)

15. OPERATIVE TREATMENT
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16. 16
Fracture—implant assembly
• Bone quality
• Fragment geometry
• Reduction
• Implant
• Implant placement

17. 17
Bone—quality
• Transition at IV / III
• Patient-determined
• Considerable variations

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Fracture—geometry
Medial and posterior:
- Portion are of importance
Trauma-determined
Need for classification

19. 19
31-A1

20. 20

21. 21
31-A2

22. 22

23. 23
31-A3

24. 24

25. 25
Reduction
• Of uttermost
importance
• To some degree
surgeon’s choice

26. 26
Implant
... or intramedullaryExtramedullary...

27. 27
Implant placement
• Ideal position depends on
the type of implant
• Surgeon’s skills

28. 28
Fracture—implant assembly
• Bone quality
• Fragment geometry
• Reduction
• Implant
• Implant placement
!

29. 29
Implants available

30. EXTERNAL FIXATION
ADVANTAGES
 HIGH SURGICAL RISK
 LESS VASCULAR DAMAGE
PROVIDES
 STABLE, NOT RIGID FIXN.
 EARLY MOBILIZATION & WT.
BEARING not possible
COMPLICATIONS
 COXA VARA
 SHORTENING
 PIN TRACT INFECTION
 MIGRATION OF PINS

31. INTRA MEDULLARY DEVICE
 CLOSER TO MECHANICAL AXIS OF FEMUR
 SUBJECTED TO SMALLER BENDING MOMENTS THAN PLATE
SCREW DEVICES
BIOMECHANICAL ADVANTAGE

32. 32
Choice of implant
There is evidence that a rigid
extramedullary fixation bears too
high a risk for:
- early failure (cut out)
- more postoperative hip pain
- reduced postoperative mobility

33. 33
Implants available

34. 34
Choice of implant
Read the fracture
“stable”
after reduction
“unstable”

35. 35
How to choose?
In a “stable” fracture (31-A1) any
(dynamic) device extramedullary
or
intramedullary will serve well

36. 36
How to choose in an unstable fracture?
Varus deformation medialization shaft

37. 37
Extramedullary implant
DHS with TSP DCS Angled Blade Plate

38. 38
Extramedullary implant
DHS
DHS + trochantor stabilizing plate

39. 39
Intramedullary implant
Gamma-nailPFN

40. 40
Conclusion
31-A1 (“stable”) fractures might be treated with any
sliding device
31-A2 (“unstable“) fractures can be treated either with
an intramedullary device which permits immediate full
weight bearing or a sliding hip screw

41. Dynamic Hip Screw
• Gold standard
• Still used commonly
for stable trochanteric
fracture
• Comes in angle of
125ᵒ to 145ᵒ
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42. Dynamic Hip Screw
3 parts
• Barrel plate
• Lag screw or richards
Screw
• Compression bolt
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43. Proximal Femoral nail
• Choice of implant for
unstable fracture
• High surgical skills
• Unforgiving
43

44. Tip Apex Distance
• The sum total of
distance from the
apex of the hip to tip
of implant in AP and
Lat View should be
less than 25mm so as
to prevent the cut out
of the implant.
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45. Classify fracture
45

46. Treatment
46

47. Subtrochanteric Fractures
• Fractures occurring in the area between the
lesser trochanter and the isthmus of the femoral
canal are considered subtrochanteric fractures
• occurring within the first 5 cm distal to the lesser
trochanter.
• Challanging to treat so many modalities
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48. High Deforming Forces
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49. Russel Taylor Classification
• Type I: Fractures do not extend into the
piriformis fossa.
• IA: Lesser trochanter is intact.
• IB: Lesser trochanter is not intact.
• Type II: Fractures extend into the piriformis
fossa.
• IIA: Lesser trochanter is intact.
• IIB: Lesser trochanter is not intact
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50. Russel Taylor Classification
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51. Treatment
Intramedullary nailing esp Proximal femoral nail
is the standard treatment
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52. Complication
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53. Thank you
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