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Intertrochanteric fractures


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Intertrochanteric fractures

  1. 1. By; Sridevi Rajeeve Intern 2008 Batch sridevirajeeve_orthopaedics_july2014 8/28/2014 1
  2. 2. sridevirajeeve_orthopaedics_july2014 8/28/2014 2
  3. 3. Completely Extracapsular fracture with variable comminution Common in elderly osteoporotic patient Usually woman in eighth decade More common than I/C #NoF Unite easily and rarely cause avascular necrosis Some of the factors found to be associated with a patient sustaining an intertrochanteric rather than a femoral neck fracture include advancing age increased number of comorbidities increased dependency in activities of daily living history of other osteoporosis related fractures. sridevirajeeve_orthopaedics_july2014 8/28/2014 3
  4. 4. 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 sridevirajeeve_orthopaedics_july2014 8/28/2014 4
  5. 5. 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 labile blood pressure decreased reflexes vascular disease sridevirajeeve_orthopaedics_july2014 8/28/2014 5
  6. 6. (a) Fall must be oriented so the person lands on or near the hip (b) protective reflexes must be inadequate to reduce the energy of the fall below a certain critical threshold (c) local shock absorbers (muscle and fat around the hip) must be inadequate. (d) bone strength at the hip must be insufficient. sridevirajeeve_orthopaedics_july2014 8/28/2014 6
  7. 7. 50 years 100 years Bone mass Trochcanteric area Neck of the femur Age sridevirajeeve_orthopaedics_july2014 8/28/2014 7
  8. 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 sridevirajeeve_orthopaedics_july2014 8/28/2014 8
  9. 9. Older individuals who sustain an intertrochanteric fracture as a result of a low-energy fall occasionally have an associated osteoporosis related fracture, such as a distal radius or proximal humerus fracture. Intertrochanteric fractures in younger individuals are usually the result of a high-energy injury, such as a motor vehicle accident or fall from a height. In these instances, assessment must be made of possible associated head, neck, chest, and abdominal injuries. sridevirajeeve_orthopaedics_july2014 8/28/2014 9
  10. 10. 1.(AP) view of the pelvis . 2.AP and a cross-table lateral view of the involved proximal femur sridevirajeeve_orthopaedics_july2014 8/28/2014 10
  11. 11. When a hip fracture is suspected but not apparent on standard x-rays, a technetium bone scan or a magnetic resonance imaging (MRI) scan should be obtained. MRI has been shown to be at least as accurate as bone scanning in identification of occult fractures of the hip, and it will reveal a fracture within 24 hours of injury. sridevirajeeve_orthopaedics_july2014 8/28/2014 11
  12. 12. 1. Linear IT line # 2. Linear IT line # with comminution 3. Subtrochanteric # 4. Inter-/Subtrochanteric # with extension into proximal femoral shaft sridevirajeeve_orthopaedics_july2014 8/28/2014 12
  13. 13. sridevirajeeve_orthopaedics_july2014 8/28/2014 13
  14. 14. Type 1 : Two-part Undisplaced. Type 2 : Two-part Displaced. Type 3 : Three-fragment fracture without posterolateral support (displaced GT Fragment) Type 4 : Three fragment fracture without medial support (displaced LT Fragment) Type 5 : Four fragment fracture without posterolateral and posteromedial support Type 6 : Reverse oblique fracture. sridevirajeeve_orthopaedics_july2014 8/28/2014 14
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  16. 16. Group 1 fractures are simple (two-part) fractures, with the typical oblique fracture line extending from the greater trochanter to the medial cortex; the lateral cortex of the greater trochanter remains intact. Group 2 fractures are comminuted with a postero-medial fragment; the lateral cortex of the greater trochanter, however, remains intact. Fractures in this group are generally unstable, depending on the size of the medial fragment. Group 3 fractures are those in which the fracture line extends across both the medial and lateral cortices; this group also includes the reverse obliquity pattern. sridevirajeeve_orthopaedics_july2014 8/28/2014 16
  17. 17. 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 sridevirajeeve_orthopaedics_july2014 8/28/2014 17
  18. 18. In elderly patients, this approach was associated with high complication rates; typical problems included Decubiti Urinary tract infection Joint contractures Hypostatic Pneumonia Thromboembolic complications Fracture healing was generally accompanied by varus deformity and shortening because of the inability of traction to effectively counteract the deforming muscular forces = MALUNION! sridevirajeeve_orthopaedics_july2014 8/28/2014 18
  19. 19. 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 Fixed-angle nail-plate devices The first successful implants While these devices provided stabilization of the femoral head and neck fragment to the femoral shaft, they did not allow fracture impaction Sliding nail-plate devices The experience with fixed-angle nail-plate devices indicated the need for a device that would allow controlled fracture impaction. This gave rise to sliding nail-plate devices e.g., Massie nail, Ken-Pugh nail sridevirajeeve_orthopaedics_july2014 8/28/2014 19
  20. 20. sridevirajeeve_orthopaedics_july2014 8/28/2014 20
  21. 21. The sliding hip screw is the most widely used implant for stabilization of both stable and unstable intertrochanteric fractures. Sliding hip screw side plate angles are available in 5 degree increments from 130 to 150 degrees. The 135 degree plate is most commonly utilized; this angle is easier to insert in the desired central position of the femoral head and neck than higher angle devices and creates less of stress sridevirajeeve_orthopaedics_july2014 8/28/2014 21
  22. 22. The trochanteric stabilizing plate and the lateral buttress plate are modular components that buttress the greater trochanter These plates are placed over a four-hole sideplate and are used to prevent excessive slide (and resulting deformity) in unstable fracture patterns These devices prevent telescoping of the lag screw within the plate barrel when the proximal head and neck fragment abuts the lateral buttress plate sridevirajeeve_orthopaedics_july2014 8/28/2014 22
  23. 23. The PFN nail has been shown to prevent the fractures of the femoral shaft by having a smaller distal shaft diameter which reduces stress concentration at the tip. Acts as a buttress in preventing the medialisation of the shaft The main principle of this type of fixation is based on a sliding screw in the femoral neck-head fragment, attached to an intramedullary nail In comminuted unstable trochanteric #, PFN preferred as it resists the deforming muscle forces (thus superior to DHS) sridevirajeeve_orthopaedics_july2014 8/28/2014 23
  24. 24. General Features Standard length – 24cm Distal part has dynamic and static locking holes Entry point – Pyriformis Fossa Central indication – excessively curved Femur Advantages Can be inserted quickly Less blood loss Early ambulation Sliding and limb shortening is less More successful in Reverse Oblique fractures sridevirajeeve_orthopaedics_july2014 8/28/2014 24
  25. 25. sridevirajeeve_orthopaedics_july2014 8/28/2014 25
  26. 26. EARLY Early complications are the same as with femoral neck fractures, reflecting the fact that most of these patients are in poor health. LATE Failed fixation Screws may cut out of the osteoporotic bone if reduction is poor or if the fixation device is incorrectly positioned. If union is delayed, the implantitself may break. In either event, reduction and fixation may have to be re-done. Malunion Coxa Vara and external rotation deformities are common Seldom severe and rarely interfere with function Non-union (uncommon, unlike #NoF) Traumatic Osteoarthritis Avascular Necrosis (quite rare) sridevirajeeve_orthopaedics_july2014 8/28/2014 26
  27. 27. sridevirajeeve_orthopaedics_july2014 8/28/2014 27