intertrochentric femur fracture by dr.naveen rathor
TRANSCRIPT
INTERTROCHANTERIC FRACTURES OF THE FEMUR
Presented by- DR.NAVEEN RATHOR RESIDENT DOCTOR DEPT. OF ORTHOPAEDICS RNT MEDICAL COLLEGE,UDAIPR
General features 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.
03/05/2023 sridevirajeeve_orthopaedics_july2014 3
definition
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
FEMUR
Upper end consists of head, neck, greater and lesser trochanters.
Head forms roughly 2/3 of sphere.
Shaft of femur is slightly twisted and curved with convexity forward.
Neck extends inferolaterally from head to meet shaft of femur at angle of about 125 degrees
(<120 : Coxa vara, >135 : Coxa vulga)
Angle varies with age, stature and width of pelvis.
(less in adults, in persons with short limbs, and in women)
ANATOMY
Occur in the region between the greater and lesser trochanters of the proximal femur, occasionally extending into the subtrochanteric region
Since they occur in cancellous bone with abundant blood supply – no problems of non-union and osteonecrosis
Abductors displace Greater Trochanterlaterally and proximally
Iliopsoas displaces Lesser Trochanter medially and proximally
Hip flexors, extensors and adductors pull distal fragment proximally
ANATOMY
ANATOMY
Deforming muscle forces will usually produce shortening, external rotation and varus position at the fracture
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). 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
MECHANISMS OF INJURY
Most fractures result from a direct impact to the greater trochanter area
Low energy falls from a standing height – approximately 90% of community hip fractures in patients more than 50 years of age with a higher proportion of women
HISTORY AND PHYSICAL EXAMINATION History of pain and inability to ambulate
after a fall or other injury Pain is localized to the proximal thigh;
exacerbated by passive attempts at hip flexion or rotation
Drug use – contributing factor Nursing home and institutionalized patients
– potential neglect and abuse – previous fractures, injuries in different states of repair and decubiti (bedsores/skin peels)
Signs and Symptoms 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
EXAMINATION
Shortening of the extremity and deformity of rotation in resting position compared with the other extremity
Pain with motion/Crepitance testing – NOT elicited unless there are no obvious physical signs of deformity and radiographic studies are negative for an obvious fracture.
Pain with axial load on the hip – high correlation with occult fracture
IMAGING STUDIES - XRAYS Pelvis with both hips – AP, xray of the
affected hip – AP and cross-table lateral
Traction films (with internal rotation) – helpful in communited and high-energy fractures and in determining implant selection
Subtrochanteric extension – Femur AP and lateral
OTHER IMAGING STUDIES Magnetic Resonance Imaging (MRI) –
currently the imaging study of choice in delineating non-displaced or occult fractures that may not be apparent on plain radiographs – Preferred over CT due to higher sensitivity and specificity for a more rapid decision process
OTHER IMAGING STUDIES
Bone scans or CT – reserved for those who have contradictions to MRI. Technetium bone scans
Technetium bone scan – when a hip fracture is suspected but not apparent to standard radiographs – requires 2-3 days to become positive
BOYD AND GRIFFIN CLASSIFICATION
i. Stable (Two part)ii. Unstable with posteromedial
communition iii. 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)
iv. Subtrochanteric with intertrochanteric extension with the fracture lying in atleast two planes
Boyd & griffin’s classification
1. Linear IT line #2. Linear IT line # with comminution3. Subtrochanteric #4. Inter-/Subtrochanteric # with extension
into proximal femoral shaft
BOYD AND GRIFFIN CLASSIFICATION Type iii and iv are the most difficult
types to manage
Account for one third of the trochanteric fractures
Evan’s classification
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.
WHY WAS EVAN’S CLASSIFICATION IMPORTANT? Because it distinguished stable from unstable
fractures and helped define the characteristics of a stable reduction.- Stable fracture patterns – posteromedial cortex remains intact OR has minimal communition- Unstable fracture patterns – characterised by disruption or impaction of the 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
OTA/AO CLASSIFICATION
The most quoted in recent scientific articles – a derivative of the Muller classification
Has been very useful in evaluating the results of treatment of intertrochanteric fracture and allowing comparisons among reports in literature
OTA/AO CLASSIFICATION
Group 1 fractures (31A1) – Pertrochanteric 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.
A1.1 – Along intertrochanteric lineA 1.2 – Through greater trochanterA 1.3 – Below lesser trochanter
OTA/AO CLASSIFICATION
Group 2 fractures (31A2) – Pertrochanteric multifragmentary - 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.
A2.1 – With one intermediate fragmentA2.2 – With several intermediate fragmentsA2.3 – Extending more than 1cm below lesser trochanter.
OTA/AO CLASSIFICATION
Group 3 fractures (31A3) – TRUE INTERTROCHANTERIC - are those in which the fracture line extends across both the medial and lateral cortices; this group also includes the reverse obliquity pattern.A3.1 – Simple obliqueA3.2 – Simple transverseA3.3 - Multifragmentary
OTA/AO CLASSIFICATION
OTA/AO CLASSIFICATION
TREATMENT OPTIONS
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
TREATMENT OPTIONS – NON OPERATIVE Buck’s traction or extension Russell skeletal traction Balanced traction in Thomas splint Plaster spica immobilization Derotation boot
Buck’s traction
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!
OPERATIVE TREATMENT
As soon as the general condition of this patient is under control, internal fixation should be carried out.
The goal of surgical treatment is strong, stable fixation of the fractured fragments
OPERATIVE TREATMENT – FACTORS THAT DETERMINE THE STRENGTH OF THE FRACTURE FRAGMENT-IMPLANT ASSEMBLY Bone quality
Fracture geometry
Reduction
Implant design
Implant placement
OPERATIVE METHODS
Plate Constructs Cephalomedullary nailing External Fixation Arthroplasty
PLATE CONSTRUCTS – DYNAMIC COMPRESSION PLATING From the 1980s to 2000 – Sliding compression hip
screws became the gold standard for hip fracture fixation.
Historically the most commonly used device for both stable and unstable fracture patterns. Available in plate angles from 130deg to 150deg.
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 a stress riser in the subtrochanteric region.
SLIDING HIP SCREW
PLATE CONSTRUCTS – DYNAMIC COMPRESSION PLATING
The most important technical aspects of screw insertion are:
1. Placement within 1cm of subchondral bone to provide secure fixation
2. Central position in the femoral head (Tip-apex distance)
TIP-APEX DISTANCE
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
CEPHALOMEDULLARY DEVICES Inserted through the piriformis fossa OR
lateral greater trochanter OR medial greater trochanter
Femoral head component – screw/blade interlocked with nail component
Dissatisfaction with use of a sliding hip screw in unstable fracture patterns led to the development of intramedullary hip screw devices.
CEPHALOMEDULLARY NAILS - ADVANTAGES Because of its location, theoretically provides more
efficient load transfer than does a sliding hip screw.
The shorter lever arm of the intramedullary device can be expected to decrease tensile strain on the implant, thereby decreasing the risk of implant failure.
Because the intramedullary fixation device incorporates a sliding hip screw, the advantage of controlled fracture impaction is maintained
Shorter operative time and less soft-tissue dissection than a sliding hip screw.
PROXIMAL FEMORAL NAIL 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.
Due to its position close to the weight-bearing axis the stress generated on the intramedullary implants is negligible.
PROXIMAL FEMORAL NAIL PFN implant also acts as a buttress
in preventing the medialisation of the shaft. The entry portal of the PFN through the trochanter limits the surgical insult to the tendinous hip abductor musculature only , unlike those nails which require entry through the piriformis fossa.
EXTERNAL FIXATION
As reported by Moroni et. al. May be indicated in osteoporotic hip fractures in elderly patients who may be deemed at high risk for conventional open reduction and internal fixation
Also for those who cannot receive blood transfusions because of personal conviction or religion (eg. Jehovah’s witnesses)
EXTERNAL FIXATION
Use was unsuccessful because of high rate of pin-tract infection, subsequent pin loosing, varus collapse, instability and failure
Latest – new fixation designs and the addition of hydroxyapatite coated pin technology
ARTHROPLASTY
Neoplastic fractures, severe osteoporotic disease, renal dialysis patients and pre-existing arthritis under consideration for hip replacement before the fracture occured
Hemiarthroplasty reported to have a lower dislocation rate when compared to total hip arthroplasty
ARTHROPLASTY
Better salvage operation for failed internal fixation rather than a first-line choice in geriatric patient.
No level-one evidence to show any difference between compression hip screw and arthroplasty except for a higher blood transfusion rate with arthroplasty
ARTHROPLASTY-DISADVANTAGES Morbidity associated with a more
extensive operative procedure
Internal fixation problems with greater trochanteric reattachment
Risk of postoperative prosthetic dislocation
POST-OPERATIVE CARE
AP and lateral radiographs while the patient is still in the surgical area
Patient mobilized to chair upright position the day after the operative procedure
Ambulation – under supervision with weight bearing as tolerated with a walker or crutches – emphasis on heel-strike and upright balance exercises
POST – OPERATIVE CARE Multiple trauma/co-morbidities – difficulty in
early ambulation but must be done as soon as possible to minimize secondary complications
Weight bearing – for optimal recovery and to reduce the fear of falling/lack of independence
Good pain control
POST-OPERATIVE CARE Protein and caloric nutrition, osteoporotic
therapy including Vitamin D supplementation
Hip abductor exercises bilaterally in conjunction with proper balance and gait training
Patient to be counseled to report any swelling or respiratory distress – risk of thromboembolic disease
POST – OPERATIVE CARE
ON DISCHARGE – fall prevention education and safe home checks to be explained to the family or social support group
Re-evaluation of the patient in the OPD with X-Rays at 2 weeks and then monthly thereafter until fracture healing is documented OR patient has maximum ambulation (usually 6 months after injury)
COMPLICATIONS
Loss of fixation
Nonunion
Malrotation deformity
Osteonecrosis
Medical, psychosocial, thromboembolic
COMPLICATIONS – LOSS OF FIXATION Commonly characterized by varus
collapse of the proximal fragment with cut-out of the lag screw from the femoral head
Occurs within 3 months of surgery due to eccentric placement of lag screw within femoral head, improper reaming, unstable reduction, excessive fracture collapse which exceeds the sliding capacity of the device
COMPLICATIONS – LOSS OF FIXATION Inadequate screw-barrel
engagement which prevents sliding and severe osteopenia
Management – acceptance of the deformity, revision ORIF with PMMA or conversion to prosthetic replacement
COMPLICATIONS – NON-UNION Uncommon. May follow internal
fixation more often than closed treatment
Should be suspected with patients with persistent hip pain that have radiographs revealing a persistent radiolucency at the fracture site 4-7 months after fracture fixation
COMPLICATIONS NON-UNION Managed by open reduction,
renailing and bone grafting
COMPLICATIONS – MALROTATION DEFORMITY Internal rotation of the distal
fragment at surgery
Unstable fracture patterns – the proximal and distal fragments may move independently – such cases the distal fragment should be placed in neutral/slight external rotation during plate fixation
COMPLICATIONS – MALROTATION DEFORMITY Severe malrotation which interferes
with ambulation – revision surgery with plate removal and rotational osteotomy of the femoral shaft should be considered.
Z-Effect – seen most commonly with dual screw CM nails – most proximal screw penetrates the hip joint and distal screw backs out of the femoral head
COMPLICATIONS – OSTEONECROSIS OF THE FEMORAL HEAD Rare
Lag screw-side plate dissociation
Occurs due to traumatic laceration of the superficial femoral artery by a displaced lesser trochanter fragment
COMPLICATIONS - MEDICAL Cardiopulmonary complications most
frequent
Other complications – GI bleeding, venous thromboembolism, transient ischemic attacks or stroke.
Renal complications rare.
COMPLICATIONS - MEDICAL Infection – seen in 1-2%
postoperative patients – can be minimized by preoperative antibiotics – cephalosporins
Vigilance with a high index of suspicion for any signs of wound inflammation or drainage
Oral antibiotics for 7-10 days if the infection is superficial
GREATER TROCHANTERIC FRACTURES Rare – typically occur in older
patients as a result of an eccentric muscle contraction or less commonly a direct blow
Treatment – usually non-operative. Operative considered in younger, active patients with a widely displaced greater trochanter
GREATER TROCHANTERIC FRACTURES ORIF with tension band wiring of the
displaced fragment and the attached abductor muscles or plate and screw fixation with a “hook plate” are the preferred techniques
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LESSER TROCHANTERIC FRACTURES Most common in adolescence, typically
secondary to forceful iliopsoas contracture
In elderly, isolated lesser trochanter fractures have been recognised as pathognomonic for pathologic lesions of the proximal femur
Treatment – identifying the pathologic lesion and treating accordingly. If no evidence of pathologic lesion – symptomatic treatment to gain ROM and ambulation.
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