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.
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.
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.
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.
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.
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.
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
neither age-related osteoporosis nor the increasing incidence of falls with age sufficiently explains the exponential increase in the incidence of hip fracture with aging.
