Trochanteric fractures occur in the region between the greater and lesser trochanters of the femur. They were traditionally treated conservatively but surgical fixation using devices like the sliding hip screw and proximal femoral nail are now preferred. Key factors in operative treatment include implant choice, surgical approach, and postoperative analysis of fixation parameters like tip-apex distance to minimize complications like screw cutout.

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