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Intertrochanteric Fractures

Incidence

  • elderly woman ( 3:1 female to male )
  • hip #-s -> 30% of all hospitalization in USA
  • mortality 15-20% (2x of mortality of NOF #-s)
    • patients slightly older
    • more severe trauma
    • greater blood loss - up to 2U

Classification

Boyd & Griffin

Type I

  • line from lesser to greater trochanter
  • simple

Type II

  • comminuted #-s with multiple fracture lines
  • more difficult to reduce

Type III

  • subtrochanteric
  • just at or distal to LT

Type IV

  • #-s of trochanteric region & proximal shaft

Evans’ classification

Type I

  • # line extends upward & outward from LT
  • more stable if postero-medial cortex intact or reducible
    • undisplaced
    • displaced - stable
    • displaced - unstable
    • comminuted - unstable

Type II

  • reversed obliquity of #-line
  • tendency to medial displacement of femoral shaft - unstable

Clinical findings

  • history of fall
  • pain in the hip
  • leg shorter, externally rotated, cannot lift it

X - Ray

  • AP & lateral pelvis/hip
  • undisplaced / displaced #

Treatment

Non operative methods

  • traction for 4-6/52
    • skin traction not possible - frail skin -> skeletal traction
  • good union rate (extracapsular)
  • high mortality (pneumonia, DVT etc.)
  • stiff knees

Operative treatment

Aim

  • rigid fixation in best possible position
  • early mobilisation
  • usually closed reduction (traction, abduction & ER)
  • if not possible -> open reduction or osteotomy
    • medial displacement - Dimon & Hughston, Sarmiento
  • important to reduce medial & posterior cortex
    • calcar -> strongest part of prox.femur
  • traction table useful

Fixation devices

sliding compression hip screw (RSP, DHS)

    • optimum position of lag screw -> central or slightly inferior & posterior
    • PMMA if very osteoporotic (like pathological #-s)

Medullary fixation

Ender’s nails

    • less stable fixation -> ER, migration of nails
    • minimally invasive
      • anaesthetic risk, skin break down over #

Russel-Taylor reconstruction nail

Gamma nail

    • complications (# below nail, broken nail)

prosthetic hemiarthroplasty (rather in NOF #-s)

  • prophylactic AB & anticoagulation

Complications

  • << than in NOF # (AVN, non-union)
  • extracapsular # -> << non-union & AVN
  • infection rate << 1%

Aftertreatment

  • sit in a chair D1
  • PWB from D2 until significant callus formation