PERTROCHANTERIC FRACTURE AND ITS MANAGEMENT

1. TROCHANTERIC FRACTURE AND
ITS MANAGEMENT
DR.VIGNESHWAR A

2. TROCHANTERIC FRACTURES :
• Extra-capsular
• occur in the region between Greater
trochanter and lesser trochanter of femur
often extending to the sub-trochanteric
region .
• part of pertrochanteric fracture.

3. • PERTROCHANTERIC FRACTURE
↓
1. Intertrochanteric fracture
2.Peritrochanteric fracture
• Extending from extracapsilar basilar neck
to LT (proximal to development of
medullary canal) .

4. HISTORY :
• Before 1930, treatment - conservative by traction until
healing ( ↑ morbidity )
• In 1930, jewett nail was introduced - immediate
stability of fracture fragments and early mobilization of
the patient .
• In 1950, Earnest roll - sliding screw and pugh &
badgley - sliding screw with Trephine tip.
• In 1962, Massie modified sliding screw to allow
collapse and impaction of fragments. Richard
manufacturing co. of USA produced Dynamic hip
screw

5. • In 1966, Kuntscher and later in 1970 Enders
introduced Condylocephalic intramedullary
devices.
• In 1984, Russel Taylor reconstructed im nail for
pertrochanteric and subtrochanteric fractures.
• In1992, Halder and williams introduced Gamma
nail.

6. ANATOMY OF PROXIMAL FEMUR :
• Proximal end of femur includes the Head, the
neck , Greater Trochanter, Lesser Trochanter
and intertrochanteric line and intertrochanteric
crest .
• Normal neck shaft angle : 120 to 130 ⁰
• Angle of anteversion : 10 to 30 ⁰
• Intertrochanteric region : Area between GT and
LT represents the zone of transition from the
femur neck to femoral shaft , characterized
primarily by Dense trabecular bone .

7. AP PA

9. BLOOD SUPPLY :
Crock described the blood supply to
proximal end of femur , into 3 main groups
1.Extracapsular arterial ring at the base of
femoral neck
2.Ascending cervical branches of the arterial ring
on the surface of femoral neck ( retinacular
vessels)
3.Arteries of the ligamentum teres.

13. TRABECULAR SYSTEM OF PROXIMAL
FEMUR
• Described by WARD in 1838 .
• In accordance with Wolffs law, trabeculations
arise along the Lines of force to which the bone
is exposed.
• It forms the transition of shaft cortex into
metaphyseal cancellous bone .
• WARD’s triangle .
• non homologous pattern of bone density and
stiffness particularly apparent in osteoporotic
patient

16. CALCAR FEMORALE :
• Dense vertical
plate of bone .
• posterio-medial
part of femoral
shaft .

17. DEFORMING MUSCLE FORCES :

18. MECHANISM OF INJURY :
• 90% IT femur fractures in elderly occurs due to a
trivial fall .
• Fall from standing height .
• most fractures result from a Direct impact to the
greater trochanter area.
• YOUNGER INDIVIDUALS - High energy trauma (
MVA OR FALL FROM HEIGHT )
• ↑ fracture incidence with ↑ Age .
• Hip fractures also results from Cyclic mechanical
stresses like fatigue/pathological fractures
secondary to osteoporosis,osteomalacia, etc.,

19. CUMMING’s FACTORS :
• The Patient must be oriented to fall or "impact" near
the hip .
• Local Shock absorbers (inadequate soft tissue -
muscle/fat coverage) to prevent fracture .
• Protective responses must be inadequate to reduce
the energy of the fall beyond a certain critical
threshold .
• Residual energy of the fall applied to the proximal
femur must exceed its strength (i.e. Bone strength at
the hip must be insufficient .

20. ASSOCIATED INJURIES :
• Distal radius / proximal humerus fracture
( most common )
• High energy trauma - ipsilateral lower limb
fractures , pelvic fractures ,.
• Head injury
• Primary neoplastic / metastatic disease -
preceding hip discomfort and subsequent fall .

21. CLINICAL FEATURES :
• Pain and swelling at the hip
• inability to ambulate after a fall
• limb shortened with External rotation
deformity.
• ecchymosis over the GT .
• undisplaced/ impacted fracture - pt may be
ambulatory .

23. • Auscultation Lippmann test - sensitive for
detection of occult fractures of the proximal
femur or pelvis .
• Bell of the stethoscope on symphysis pubis and
tapping on the patella of both extremities -
variation in sound conduction determines
discontinuity
• Decreased tone or pitch - Fracture .

24. RADIOGRAPHIC IMAGING :
• Anteroposterior view - to know fracture
obliquity , quality of the bone .
• cross table lateral view - to assess size,
location and comminution of posterior fracture
fragment and helps to determine the fracture
stability .
• CT and MRI
• Technetium bone scan - suspected hip fracture
but not apparent to standard radiographs , it
requires 2-3 days to become positive .

28. CLASSIFICATION :
• In 1822, Astley cooper described the first Pre-
radiographic classification of hip fractures ,
- Intra-capsular ( main complication - Non union )
- Extra-capsular ( main complication -Coxa vara )

29. BOYD AND GRIFFIN CLASSIFICATION :
• TYPE 1 Stable (Two part) Fracture
• TYPE 2 Unstable with posteromedial communition
• TYPE 3 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)
• TYPE 4 Subtrochanteric with intertrochanteric
extension with the fracture lying in atleast two
planes.

31. EVANS CLASSIFICATION :

32. Distinguished stable from unstable fractures and also
defined the characteristics of a stable reduction.
• Stable fracture patterns - posteromedial cortex
remains intact OR minimal communition
• Unstable fracture patterns - Disrupted
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 .

33. OTA/AO CLASSIFICATION : 31 A

34. DORR’S INDEX :

35. CANAL-CALCAR RATIO :

36. DORR’S INDEX :
• Selection of cemented or Non cemented femoral
arthroplasty components .
• Used for implant selection for Hip fracture patients .
• Type A - young patient,narrow metaphysis,Thick
cortex and high constricting isthmus .
↓
Excessive bone removal required for intramedullary
devices either a plate type construct or smaller
diameter reconstruction nail are bone conserving .
Type C - most problematic in geriatric populations
with hip fractures , Wide metephysis , wide medullary
canal and loss of isthmus constriction .

37. TREATMENT :
NON-OPERATIVE :
• Prolonged bedrest in traction until fracture healing
occurs (usually 10 to 12 weeks), followed by a
lengthy program of ambulation training .
Can be done for :
1. An elderly person with high risk of
mortality from anaesthesia and surgery.
2. Nonambulatory patient who has minimal
discomfort following fracture .
3. Undisplaced/Minimal displaced fracture .

38. METHODS OF NON-OPERATIVE TREATMENT
• Buck's traction or extension
• Russell skeletal traction
• Balanced traction in Thomas splint
• Plaster spica immobilization
• De-rotation boot

39. skin traction :
Skeletal traction :

40. COMPLICATIONS :
• Varus Deformity with Limb shortening .
• Pin-tract infection in skeletal traction
• Decubitus ulcers
• Urinary tract infection
• Pneumonia
• Thromboembolic complications .

41. OPERATIVE TREATMENT :
• Pertrochanteric fractures are best treated
with Surgical Repair .
• Goal : Strong and stable fixation of fracture
segments .
• OUTLINE :
Position
Approaches
Implant of choice
complications

42. POSITION :

43. LATERAL SURGICAL APPROACH :

44. WATSON-JONES APPROACH :

46. SLIDING HIP SCREW SHS :

47. DYNAMIC HIP SCREW :
• PRINCIPLE : Controlled collapse
• Dynamic action reduces the incidence of screw
cut out and penetration of screw into hip joint .
• Used for Stable per-trochanteric fracture .
• Lateral cortical wall of the proximal femur should
be intact ( pre-requisite).
• If not intact , DHS + TSP ( trochanteric
stabilisation plate ) should be used .

48. SHS :

49. TIP APEX DISTANCE : TAD
• 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 .
• TAD > 25 mm , the surgeon should reassess
the fracture reduction and position of Guide
Pin.

50. TIP APEX DISTANCE :

51. PROXIMAL FEMORAL NAIL :

52. • Better fixation and stability compared to SHS.
• Has two screws- load bearing lag screw and
proximal thinner antirotation screw to counter
rotational tendency.
• Distal locking screws to control rotation and to
increase construct stiffness.
PROXIMAL FEMORAL NAIL :

53. • The lag screw withstands the bending moment which is
transferred to the intramedullary nail and
counterbalanced by its locking mechanism with the
femoral cortex in the medullary canal.
• Entire load is transferred to the nail and a negligible
portion to the medial femoral cortex.
• PFN acts as an BUTTRESS in preventing medialisation of
the shaft . The entry portal of the PFN through the
trochanter limits the surgical insult to the tendinous hip
abductor muscle only, unlike those nails which require
entry through piriformis fossa .

54. SKIN INCISION :

55. ENTRY POINT :

57. ADVANTAGES OF PFN :
• Superior biomechanics
- Shorter lever arm
- ↓ Tensile strain on the implant
- Controlled shaft medialisation and
collapse
- Less soft tissue dissection
- Early weight bearing

58. EXTRAMEDULLARY :
Anatomical reconstruction
• Very stable reconstruction
• Weak implant
• Open procedure
• No weight bearing
INTRAMEDULLARY :
Near anatomical
reconstruction
• Stable reconstruction
• Strong implant
• Semi-closed procedure
• Direct full weight bearing

59. • Lateral migration of the lag screw and the
concomitant medial migration of the
antirotation screw.
• Both the screws come under cyclic loading.
• The proximal thinner screw bends easily, jams,
fails to slide and cuts off the head.
• The distal thicker screw is minimally affected
retaining its sliding properties, permits
impaction of metaphyseal fracture area.
Z EFFECT :

61. POST-OPERATIVE RADIOGRAPHIC ANALYSIS
• 1. Neck shaft angle
• 2. Neck length
• 3. Horizontal offset
• 4. Cal TAD
• 5. Position of hip screw - Parker's ratio
• 6. Greater trochanter orthogonal line (GTOL)
• 7. Chang's reduction quality criteria(CRQC)

62. PARKER’S RATIO :
• The Parker's ratio on AP view
is represented by the
percentage AB/ACx100
indicating the distance of the
screw from the inferior border
of the femoral neck (the
superior border is considered
as 100%)
• Cut- out is the most common
mechanical complication of the
osteosynthesis of the
pertrochanteric fracture .

63. GREATER TROCHANTERIC
ORTHROGONAL LINE :
A) Passing through 1st quadrant - varus NSA
B) Passing through 2nd quadrant - valgus/normal NSA
C) Normal hip GTOL through 2nd quadrant

64. CHANG’S REDUCTION QUALITY CRITERIA

65. POSITIVE MEDIAL
CORTEX SUPPORT
NEGATIVE MEDIAL
CORTEX SUPPORT

66. OTHER IMPLANTS :
Jewett Nail :
SP Nail with
Mclaughlin’s plate :

67. MEDOFF SLIDING PLATE :

68. PROXIMAL FEMUR
LOCKING PLATE : ANGLE BLADE
PLATE :

69. EXTERNAL FIXATION :
• Pin 1 and 2 -
cancellous bone pin .
• Pin 3 and 4 - cortical
bone pin .

70. TROCHANTERIC FIXATION NAIL TFN :

71. GAMMA NAIL :

72. RECON NAIL :

73. InterTAN :

74. RECENT ADVANCES :
PFNA 2
• Medio-lateral angle - 5
degrees .
• optimal stress distribution
• lateral flattened cross section
• rotational and angular
stability achieved with one
single element .
• No Z-effect
• Higher cutout resistance .

75. POSTOPERATIVE CARE :
• Ambulation - under supervision with weight
bearing as tolerated with a walker or crutches .
• Regular strengthening exercises .
• complete weight bearing - Radiographic healing
should be there .
• Radiographic follow up : 6 weeks , 3 months,
6 months, 1 year and 2 year .
• D V T prophylaxis for 6 weeks postoperatively .
• vitamin D3 supplementation

76. SUBTROCHANTERIC FRACTURE :
• Definition - Fracture occuring within 5 cm of the distal
extent of the Lesser trochanter and represents an
unstable injury .

77. RUSSELL-TAYLOR CLASSIFICATION :

78. AO/OTA CLASSIFICATION :

79. FIELDING AND MAGLIATO’S :
• Type 1 Fracture at the
level of LT
• Type 2 Fracture
2.5cm - 5 cm below
the level of LT
• Type 3 Fracture > 5
cm below the lesser
trochanter .

80. SEINSHEIMER’S CLASSIFICATION :
• Type 1 Non-displaced / less than 2 mm displacement .
• Type 2 Two part fracture
A.Transverse fracture > 2mm displ.
B.Spiral configuration with LT attached to
proximal fragment
C.Spiral configuration with LT attached to distal
fragment .
• Type 3 Three part fracture
A.Spiral configuration with LT a part of Third
fragment
B.Spiral configuration with third part a butterfly
fragment .
• Type 4 Comminuted fracture with four or more
fragments
• Type 5 Subtrochanteric with intertrochanteric

81. TREATMENT :
• Non-operative
• Operative
AO 95 angled blade plate
Proximal femur LCP plating
Trochanteric Femoral Nail
Gamma nail
Russell-taylor nail
PFN A and PFN A2
Syrus nail
Zimmer natural nail

83. COMPLICATIONS :
• Delayed union
• Non-union ( rare in IT fractures )
• Malunion
• Infection
• Implant failure
• Infections

84. HIP FRACTURES IN CHILDREN :

85. HIP FRACTURES IN CHILDREN :
• classification proposed by Delbet and
popularized by Colonna .

86. HIP FRACTURES IN CHILDREN :

87. COMPLICAGTIONS OF HIP FRACTURES IN
CHILDREN :
• Avascular Necrosis
• Coxa Vara
• Non-Union
• Premature epiphyseal closure

88. MANAGEMENT :
• Rapid union (within 6 to 8 weeks) child’s osteogenic
potential ↑↑
• Initially , skeletal traction for 2-3 weeks to
obtain reduction
↓
Abduction spica cast for 6-12 weeks
If not reduced with TRACTION
↓
closed manipulation + abduction spica cast
Rarely, internal fixation required ( depends on the age
of child ) .

89. SUBTROCHANTERIC FRACTURES IN
CHILDREN
• WADDELL’S TRIAD :
Fractured femoral shaft
Intra-thoracic/intra-abdominal injury
Contralateral Head injury

90. MANAGEMENT :
• Infants 0-6 months : pavlik harness
• children 6 months to 5 years : Hip spica cast if
fracture unstable Internal fixation necessary
• children 5-11 years : Flexible IM nails,open plating
or submuscular plating
• children > 11 years : Rigid IM nails using lateral
trochanteric entry .

91. THANK YOU