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