Intertrochanteric Fractures of Femur

An Introduction, History, Diagnosis, Current Guidelines on Treatment of trochanteric fractures of femur. Presentation also contain an introduction of Dynamic Hip Screw and Surgical Techniques.

1. Intertrochanteric Fractures of the Femur By Dr. W. G. P. Kanchana Registrar in Surgery Teaching Hospital Peradeniya

2. Introduction The trochanteric area of the femur is the region of the femoral metaphysis between the base of the femoral neck and the most distal level of the lesser trochanter.

3. Definition Radiographically, trochanteric fractures are distinguished from fractures of the femoral neck in having a center of the fracture line that is distal to the base of the femoral neck . Involving the area between the lesser and the greater trochanters. Passing through the lateral cortex of the femur, with separation from the remainder of the femur of the greater or lesser trochanter, or both, as discrete fragments.

4. Demographics 281,000 hospital admissions for hip fracture in the Unites States in 2007.( Incidence expected to double in 2040 ) Trochanteric fractures represent more than half of these hip fractures. 90% of patients >65 years. 75% of these fractures occur in women.

5. Mechanism Low ­energy injuries. Fragility hip fractures. Mostly due to Direct impact on trochanteric region. Simple falls from an upright position are common in elderly individuals. Patients with Multiple medical comorbidities. Increased tendency to fall because of impaired vision, diminished reflexes, and muscle weakness.

6. Cummings and Nevitt Hypothesis The faller must be oriented to impact near the hip. Protective responses must fail. Local soft tissues must absorb less energy than necessary to prevent fracture. The residual energy of the fall applied to the proximal femur must exceed its strength.

7. Mechanism Falls with a rotational component are more common with extracapsular hip fractures.

8. Mechanism The strong plate of bone posteriorly is named the calcar femorale . This is the region most affected with posteromedial fracture comminution leaving only the anteromedial cortex potentially stable for repair. Soft tissue attachment is also important for stable reduction .

9. Deforming forces Abductors pull on the greater trochanter laterally and proximally. Iliopsoas pulls on the lessor trochanter medially and proximally. Adductors, flexors and extensors displace the distal segment proximally. (shortening) Leads to a Varus deformity and external rotation of the extremity.

10. Diagnosis Clinical – Suggestive history, Shortened and external rotated extremity. Pain with axial load on the hip has a high correlation with occult fracture X-ray – For Diagnosis and pre-op planning. Pre-op Intra-op CT MRI

11. X-Ray AP pelvis, AP and cross-table lateral of the affected hip. AP and Lateral X-ray of full length of femur, Assess Sub trochanteric extension Possibility of pathological fracture Implant length selection Assess femoral bowing Assess medullary cannel diameter

12. Classification and History Pre-radiological classification by Astley cooper in 1822 Intracapsular – lead to non-union and AVN Extracapsular – Malunion and Coxa- vara As early as 1850 Langenbek has attempted internal fixation.

13. Classification and History Royal Whiteman (1902) – Reduction of fracture with abduction, internal rotation and traction under anaesthesia with immobilization in a spica cast from nipple line to toes. Jewette (1930) – Introduced Jewette nail and to immediately stabilize fracture fragments and early mobilization. The real modern era of internal fixation of hip fractures began with Smith-Petersen in 1925 and his invention of the triflange nail for hip fractures.

14. Smith-Peterson Nail

15. Classification and History In 1949, Boyd and Griffin described the first treatment recommendation classification. predictive of the difficulty of achieving, securing, and maintaining the reduction in four fracture types.

16. Boyd and Griffin Classification Type I – Stable two part Type II – Unstable Comminuted Type III - Unstable Reverse Oblique Type IV – Intertrochanteric – sub trochanteric with two planes of fracture

17. Evan’s Classification 1949, Evans reported on a posttreatment classification with five types described. He compared nonoperative treatment and fixed-angle device surgical treatment .

18. Classification and History 1950 – Earnest Roll was first to use a Sliding Screw. 1962 – Massie – Modified the sliding devices to collapse and impaction of fragments. Richard Manufacturing Co. USA produced the Dynamic Hip Screw.

19. Kyle Classification

20. AO/OTA classification A1 – Simple two part #. Lateral cortex remains intact. A2 – Comminuted with postero -medial fragment. Lateral cortex remains intact. A3 – # line extend across both medial and lateral cortices. Include reverse oblique #s.

21. Patient Assessment ATLS guidelines Mechanism of Injury Hip pain before the injury. Fall after # / Fall and #, ? Pathological # Pre-injury level of activity of the patient Medical / Drug History

22. Initial Management Elderly patients with trochanteric fractures can have additional medical problems needing attention. Multidisciplinary Team Effort - combined care by an orthopaedic surgeon and a geriatrician practicing internal medicine or family medicine is strongly recommended. Up to 2 days (no longer) may be spent optimizing the patient 's condition. Rehydration, general medical care, and preoperative evaluation by the anesthesia team are necessary for patients undergoing surgery

23. Initial Management All patients with trochanteric fractures need prophylaxis for deep vein thrombosis (DVT) . Initial mechanical prophylaxis with compression devices, followed by chemical prophylaxis beginning with low molecular­ weight heparin. Social services and physical therapy departments should be involved from the beginning. To Allow patient to return to pre-injury status as soon as possible. Shown to significantly reduce 1 year mortality .

24. Initial Management Skin and even skeletal traction have in the past been used to minimize discomfort and maintain skeletal alignment in patients with trochanteric fractures. Recent studies have failed to show any benefit of preoperative traction , and have suggested that this practice be discontinued. If surgery has to be delayed or if there is marked deformity, transtibial skeletal traction can be applied.

25. Conservative Mx This is now only rarely practiced, because an unfixed hip fracture causes continuing pain, loss of weight-bearing and very high levels of dependency. Non-union is common and length of stay high. Studies have indicated much improved outcomes for those treated operatively.

26. Conservative Mx Conservative treatment may thus be appropriate only in a few specific situations: 1. Where the patient‘s life expectancy is very short and the risks of surgery outweigh the benefits. However, even in those with a short life expectancy, surgery provides excellent pain relief and makes nursing care easier. 2. For those patients who present late with a fracture that shows signs of healing. 3. For the totally immobile patient. However, surgery does assist pain relief and makes nursing care easier, particularly if the patient uses the limb for standing during transfers. 4. For those who refuse surgery.

27. Surgical Management The aims of surgery are to control pain and promote early mobilization; delay from admission to surgery causes distress to the patient and is associated with greater morbidity and mortality. All patients with hip fracture who are medically fit should have surgery within 48 hours of admission, and during normal working hours. British Orthopedic Association Care of patients with Fragility fractures

28. Goals of Surgical Treatment Stable fixation of the fracture Restoration of a near ­normal femoral neck­ shaft angle Early mobilization of the patient Avoidance of complications Younger patients require more stringent fracture reduction to allow better long ­term results.

29. Methods of Fixation Extra Medullary DHS DCS (Dynamic Condylar Screw) 95° fixed­ angle condylar screw and side plate Angled blade plate

30. Methods of Fixation Intra Medullary Devices A) K-nail B) Ender’s nails C) Centromedullary nails D) Cephalomedullary nails E) Third generation Gamma nails F) Proximal femoral nails

31. Methods of Fixation Arthroplasty Hemiarthroplasty (unipolar or polar) is indicated in older patients in whom primary fixation has failed or who have significant osteoporosis and unstable fractures. In this procedure, repair of the greater trochanter can be achieved with a tension band or by other suitable means, and calcar replacement or a modular ­stem revision prosthesis can be used if the lesser trochanter is broken. Total hip arthroplasty should be considered for otherwise physically fit patients with an acetabulum that has been severely damaged by preexisting degenerative joint disease or penetrating hardware.

32. DHS DHS will provide excellent fixation for all stable trochanteric fractures (those having an intact lateral cortex with minimal comminution of the posteromedial cortex) (AO/OTA types 31A1 and 31A2.1) A DHS is less expensive than a cephalomedullary nail. Contraindications: Reverse Oblique Fractures, Large Postero -medial Comminution, physically fit patients with preexisting arthritis ipsilateral to the trochanteric fracture.

33. Positioning and # Reduction Positioned on the traction table with the contralateral leg abducted, flexed, and externally rotated (if no hip contracture is present) or extended in a slightly lower position than the leg to be treated. (also called the heel ­to­ toe position).

34. # Reduction Traction, slight abduction, and internal rotation usually reduce the fracture. Occasionally, it is necessary to increase the external rotation of the fractured limb (to " unlock" the fracture ) and to then pull it distally and rotate it internally . ( Leadbetter Maneuver) Posterior sagging of the fracture can be corrected by pushing from the back.

35. # Reduction The aim is to achieve the same femoral neck ­shaft angle as in the contralateral hip, or 5° more of valgus than in the contralateral hip.

36. Surgical Approach The proximal level of the incision for insertion of a DHS is determined by using the C­-arm and starting at the lower level of the projection of the lesser trochanter.

37. Surgical Approach

38. Sliding Screw Technique

39. Sliding Screw Technique The barrel of the side plate of the DHS assembly has to be long enough to prevent disengagement of the lag screw. The lag screw must be able to slide so as to allow at least 5 mm of impaction Side plate must be parallel to and be seated fully on the shaft of the femur, to which it is fixed with from two to four bicortical screws.

40. Sliding Screw Technique

41. Extramedullary Vs Intramedullary Intramedullary devices may provide stronger fixation. Require shorter surgical times. Cause less blood loss than blade plate, screw­ and ­side ­plate. Many prospective randomized comparative trials of the intramedullary versus extramedullary fixation of trochanteric fractures found significant differences in outcome for unstable but not for stable fractures.

42. Extramedullary Vs Intramedullary Intramedullary nails stronger than extramedullary devices for the fixation of trochanteric fractures with subtrochanteric extension. Use of extramedullary devices such as dynamic condylar screws, blade plates, or locking plates should be reserved for unstable fractures in young patients, with the primary goal of restoring the anatomy of the hip.

43. Complications Wound Complications Loss of Proximal Fixation varus collapse lag­screw cutout Malunion

44. References Update on the Management of Trochanteric Fractures of the Hip Orthopaedic Knowledge Online Journal 2012 10(12) : http://orthoportal.aaos.org/oko/article.aspx? article=OKO_TRA036 Blue Book on fragility fracture care – British Orthopedic Association Rockwood and Green's Fractures in Adults - 8E

45. Thank You!