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


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The lecture has been given on Apr. 13th, 2011 by Dr. Ali A.Nabi.

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

  1. 1. Intertrochanteric fractures
  2. 2. Intertrochanteric fractures <ul><li>Extracapsular fracture. </li></ul><ul><li>Common in elderly osteoporotic patient. </li></ul><ul><li>Usually woman in eighth decade. </li></ul><ul><li>Unite easily and rarely cause avascular necrosis. </li></ul>
  3. 3. Intertrochanteric fractures <ul><li>The site </li></ul><ul><li>The proximal femur consists of the femoral head, femoral neck, and the trochanteric region. 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. </li></ul>
  4. 6. Intertrochanteric fractures <ul><li>Mechanism </li></ul><ul><li>fall directly onto greater trochanter. </li></ul><ul><li>indirect twisting injury. </li></ul>
  5. 7. Intertrochanteric fractures <ul><li>Etiology </li></ul><ul><li>The etiology of intertrochanteric fractures is the combination of </li></ul><ul><li>increased bone fragility of the intertrochanteric area of the femur. </li></ul>
  6. 8. Intertrochanteric fractures <ul><li>decreased muscle tone of the muscles in the area secondary to the aging process. The increasing bone fragility results from osteoporosis and osteomalacia secondary to a lack of adequate ambulation or antigravity activities, as well as decreased hormone levels, increased levels of demineralizing hormones, decreased intake of calcium and/or vitamin D, and other aging processes. </li></ul>
  7. 9. Intertrochanteric fractures <ul><li>Benign and malignant tumors, along with metastases such as multiple myeloma and other malignancies, can also lead to weakened bony structure. </li></ul>
  8. 10. Intertrochanteric fractures <ul><li>Types </li></ul><ul><li>stable fracture. </li></ul>
  9. 12. Intertrochanteric fractures <ul><li>unstable fracture in which there is poor contact between fracture fragments. There will be displaced fragment from the weight bearing area ( the Calcar or the inferomedial part of the femoral neck). </li></ul>
  10. 14. Intertrochanteric fractures <ul><li>Unstable factors: </li></ul><ul><ul><li>four part fracture. </li></ul></ul><ul><ul><li>reverse oblique fracture. </li></ul></ul><ul><ul><li>calcar fracture. </li></ul></ul><ul><ul><li>shattered postero-medial cortex. </li></ul></ul><ul><ul><li>displaced large fragment including the lesser trochanter. </li></ul></ul>
  11. 15. Intertrochanteric fractures <ul><li>Clinical features </li></ul><ul><li>usually old unfit female. </li></ul><ul><li>H/O fall or just twisting. </li></ul><ul><li>unable to stand or walk. </li></ul><ul><li>the leg is short and externally rotated. </li></ul><ul><li>the patient cannot left her leg. </li></ul>
  12. 16. Intertrochanteric fractures <ul><li>X-Ray </li></ul><ul><li>undisplaced stable fracture only show crack line along with the interrochanteric line. </li></ul><ul><li>displaced with comminution or displaced lesser trochanter are usually obvious. </li></ul>
  13. 19. Intertrochanteric fractures <ul><li>Treatment </li></ul><ul><li>The current treatment of intertrochanteric fractures is surgical intervention. Despite an acceptable healing rate with nonsurgical methods, surgical intervention for intertrochanteric fractures has replaced previous nonsurgical methods of </li></ul>
  14. 20. Intertrochanteric fractures <ul><li>Prolonged bed rest. </li></ul><ul><li>Prolonged traction in bed. </li></ul><ul><li>Prolonged immobilization in a full-body (spica) cast. </li></ul>
  15. 21. Intertrochanteric fractures <ul><li>Though healing rates for previous nonsurgical methods may have been acceptable, they were accompanied by unacceptable morbidity and mortality rates because of frequent nonorthopedic complications associated with prolonged immobilization or inactivity. Complications included the following: </li></ul>
  16. 22. Intertrochanteric fractures <ul><li>Pulmonary complications of pneumonia resulting from inactivity. </li></ul><ul><li>Pulmonary emboli from deep vein thrombosis (DVT) caused by immobilization of an extremity. </li></ul><ul><li>Bedsores from prolonged bed rest. </li></ul>
  17. 23. Intertrochanteric fractures <ul><li>Loss of motion of the lower extremity joints and muscle atrophy due to prolonged immobilization. </li></ul><ul><li>Union of the fracture in an unacceptable position resulting in a deformity. (Known as a malunion, the fracture heals with unacceptable shortening, rotation, and/or angulation of the extremity, resulting in decreased mobility and subsequent handicap, impairment, and disability.) </li></ul>
  18. 24. Intertrochanteric fractures <ul><li>Surgical options </li></ul><ul><li>close reduction and internal fixation. </li></ul><ul><li>Open reduction and internal fixation. </li></ul>
  19. 25. Intertrochanteric fractures <ul><li>Types of internal fixation </li></ul><ul><li>sliding nail or screw. </li></ul><ul><li>fixed angle 95° or 135° L-plate. </li></ul><ul><li>DHS and side plate. </li></ul><ul><li>intramedullary device and hip screw </li></ul>
  20. 27. Intertrochanteric fractures <ul><li>Complications </li></ul><ul><li>Early </li></ul><ul><li>the same of the femoral neck fractures. </li></ul>
  21. 28. Intertrochanteric fractures <ul><li>Late </li></ul><ul><li>failed fixation either the screw cut out the osteoporotic bone or the screw itself breaks because of nonunion. </li></ul><ul><li>malunion which is usually follow conservative treatment. </li></ul><ul><li>non-union which is rare complication. </li></ul>
  22. 29. Subtrochanteric fractures
  23. 30. Subtrochanteric fractures <ul><li>The subtrochanteric region of the femur, arbitrarily designated as the region between the lesser trochanter and a point 5 cm distal, consists predominantly of cortical bone. Healing in this region is predominantly through a primary cortical healing. Thus, the fracture is quite slow to consolidate. During normal activities of daily living, up to 6 times the body weight is transmitted across the subtrochanteric region of the femur. </li></ul>
  24. 33. Subtrochanteric fractures <ul><li>Mechanism </li></ul><ul><li>In elderly patients, minor slips or falls that lead to direct lateral hip trauma are the most frequent mechanism of injury. This age group is also susceptible to </li></ul><ul><ul><li>metastatic disease that can lead to pathologic fractures. </li></ul></ul><ul><ul><li>Osteoporosis and osteomalacia </li></ul></ul><ul><ul><li>Paget’s disease. </li></ul></ul>
  25. 34. Subtrochanteric fractures <ul><li>In younger patients, the mechanism of injury is almost always high-energy trauma, either from direct lateral trauma (eg, motor vehicle accident [MVA]) or from axial loading (eg, a fall from height). </li></ul>
  26. 35. Subtrochanteric fractures <ul><li>Gunshot wounds cause approximately 10% of high-energy subtrochanteric femur fractures. </li></ul>
  27. 37. Subtrochanteric fractures <ul><li>Clinical features </li></ul><ul><li>Physical findings at the time of injury often include </li></ul><ul><li>a shortened extremity on the fractured side. </li></ul><ul><li>Significant swelling is frequently present, with tenderness to palpation in the proximal thigh region. </li></ul>
  28. 38. Subtrochanteric fractures <ul><li>The leg may lie in internal or external rotation. </li></ul><ul><li>The patient cannot flex the hip or abduct the leg. </li></ul><ul><li>Hemorrhage into the injured thigh may be substantial, and the patient should be monitored for systemic shock and compartment syndrome. </li></ul>
  29. 39. Subtrochanteric fractures <ul><li>In high-energy fractures, a complete system examination must be performed. Associated injuries to the cranium, thorax, and abdomen must be recognized. Pelvic, spine, and long bone injuries are also common, especially on the ipsilateral side, and these should be identified early to optimize treatment and outcomes. </li></ul>
  30. 40. Subtrochanteric fractures <ul><li>X-Ray </li></ul><ul><li>Fracture through or below the lesser trochanter can be seen, the fracture could be transverse, oblique or spiral. </li></ul><ul><li>the upper fragment is flexed and appear short. </li></ul><ul><li>the shaft adducted and displaced proximally. </li></ul>
  31. 41. Subtrochanteric fractures <ul><li>Treatment </li></ul><ul><li>The goals of treatment includes </li></ul><ul><li>anatomic alignment. </li></ul><ul><li>early mobilization. </li></ul><ul><li>effective rehabilitation. </li></ul>
  32. 42. Subtrochanteric fractures <ul><li>With the improvements in surgical techniques and implants, most of these goals can be achieved with surgical treatment. </li></ul>
  33. 43. Subtrochanteric fractures <ul><li>indications </li></ul><ul><li>Current indications for surgical treatment include </li></ul><ul><li>displaced. </li></ul><ul><li>nondisplaced fractures in adults. </li></ul>
  34. 44. Subtrochanteric fractures <ul><li>fractures in patients with multiple traumatic injuries. </li></ul><ul><li>open fractures, severe ipsilateral extremity injuries. </li></ul><ul><li>pathologic fractures. </li></ul>
  35. 45. Subtrochanteric fractures <ul><li>Open reduction and internal fixation is the treatment of choice. </li></ul>
  36. 46. Subtrochanteric fractures <ul><li>Types </li></ul><ul><li>For fractures at the level of lesser trochanter, DHS and plate is satisfactory. </li></ul><ul><li>for fractures below the level of the lesser trochanter, interlocking nail is suitable. </li></ul>
  37. 47. Subtrochanteric fractures <ul><li>for fractures extended to piriformis fossa, 95° angled L-plate is safer. </li></ul><ul><li>if there is comminution or cortical defect, bone graft added to the above procedures. </li></ul>
  38. 48. Subtrochanteric fractures <ul><li>Complications </li></ul><ul><li>malunion. </li></ul><ul><li>non-union. </li></ul>