Intertrochantric fractures and intracapsular fracture neck of femur

1. Presented by:-
Dr. Rakesh Goyal
(MBBS, MS ortho, DNB ortho)

3.  Arteries are:-
1) Medial circumflex
2) Lateral Circumflex
3) Foveal artery

5.  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

6.  Completely extra-articular fracture with
variable comminution
 Common in elderly osteoporotic patient
 More common than I/C #NoF
 Unite easily and rarely cause avascular necrosis

7.  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

8.  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

9.  .(AP) view of the pelvis .
 2.AP and a cross-table lateral view of the involved
proximal femur

11.  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

12.  Intertrochanteric fractures are almost always
treated
 by early internal fixation – not because they fail
to unite with conservative treatment (they
unite quite readily), but
(a) Obtain the best possible position
(b) Early ambulation to reduce the complications
associated with prolonged recumbency

13.  Options:
-Dynamic Hip Screw
- Proximal femoral Nailing

14.  Clinical Features:
1. H/o trauma
2. Pain in groin region
3. Restriction of movements
 Examination points
1. Tenderness over anterior joint line
2. External rotaion attitude
3. Minimal shortening

15.  The capsule of the hip joint is attached to the
distal fragment
 This capsule prevents extreme rotation and
displacement of the distal fragment

16.  Garden’s
 Pauwel’s
 Anatomical

19. 1. Subcapital
2. Transcervical
3. Basicervical

20.  Options
1. Multiple cannulated screws
2. DHS
3. Replacement
-Hemiarthroplasty
-total hip arthroplasty

21.  Maneuvers in extension
1. Whitman
2. Deyerle
3. Swiontkowsi
 Maneuvers in Flexion
1. Leadbetter
2. Flynn
3. Smith Peterson method

22.  Garden’s alignment
index
 Lowell’s S curves

27.  CAUSES:-
1. Morphologic features- high # angle ( Pauwel’s 3)
2. Displaced fractures- Garden III/ IV
3. # Comminution
4. Injury to vascularity- direct tamponade effect
5. Absence of cambium layer of periosteum
6. Chondrogenic factors in synovial fluid inhibit callus
formation and consolidation

28. #NOF #IT
Age After 50 yrs After 60 years
Gender F>M M>F
Ability to walk May walk in impacted # Not possible
Pain Mild Severe
Swelling mild Severe
Tenderness In scarpa’s triangle Over GT
Ext. rotation < 45 degree > 45 degree
Shortening <1 inch > 1 inch
Treatment Internal fixation always Conservative/operative
Complication AVN /Non-union malunion