InterTrochanteric Fractures

Definition, Mech of Injury, Classification, Imaging and both Conservative and Operative Treatment Methods.

1. Intertrochanteric fracture Dr. Kevin Joseph Ambadan

2. definition An InterTrochanteric fracture occurs between the greater trochanter, where the Gluteus M edius and Minimus muscles (hip extensors and abductors) attach, and the lesser trochanter, where the I liopsoas muscle (hip flexor) attaches.

3. General features Completely ExtraCapsular fracture with variable comminution Common in elderly osteoporotic patient, usually women in their 80’s More common than IntraCapsular # - Neck of Femur Unites easily Rarely causes avascular necrosis

4. Mechanism of Injury 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).

5. Signs and Symptoms Pain Marked shortening of lower limb Patient cannot lift their leg Complete External Rotation Deformity Swelling, ecchymosis and tenderness over the Greater Trochanter Displaced fractures are clearly symptomatic, such patients usually cannot stand, much less ambulate Non-displaced 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

6. Associated Injuries 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.

7. Diagnostic imaging X-ray is the standard diagnostic tool. When a hip fracture is suspected but not apparent on standard x-rays, a technetium bone scan or a 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.

8. Boyd & griffin’s classification Linear IT line # Linear IT line # with comminution Subtrochanteric # Inter-/ Subtrochanteric # with extension into proximal femoral shaft

9. Classification of kyle

10. Evan’s classification

11. TREATMENT Nonoperative Treatment Indications 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. Bucks Traction

13. Hip spica

14. 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 !

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

16. Sliding hip compression screw I ndications stable intertrochanteric fractures O utcomes equal outcomes when compared to intramedullary hip screws for stable fracture patterns

17. 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

18. Trochanteric stabilizing plates The trochanteric stabilizing plate and the lateral buttress plate are modular components that reinforces 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

19. Intramedullary hip screw Also known as the Proximal Femoral Nail (PFN). Indications stable fracture patterns unstable fracture patterns reverse obliquity fractures ( 56% failure when treated with sliding hip screw) subtrochanteric extension lack of integrity of femoral wall Outcome equivalent to sliding hip screw for stable fracture patterns use has significantly increased in last decade

20. complications EARLY T he 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 implant itself may break. In either event, reduction and fixation may have to be re-done. Malunion Coxa Vara and external rotation deformities are common Non-union (uncommon, unlike # NoF ) Traumatic Osteoarthritis Avascular Necrosis (rare)

21. Pathological fracture Due to metastatic disease or myeloma. Unless patients are terminally ill, fracture fixation is essential in order to ensure an acceptable quality of life for their remaining years. In addition to internal fixation, methylmethacrylate cement may be packed in the defect to improve stability.

22. Thank you