Intratrochanteric Fracture

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Intratrochanteric Fracture

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Intretrochanteric Fracture:

Intretrochanteric Fracture Dr. saroj suwal

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The proximal femur consists femoral head , femoral neck and trochanteric region.

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enlarg (center- collum diaphysis angle, ie , angle subtended between the femoral neck and shaft axes ). In most cases an implant with a CCD angle of 130º angle will be appropriate.

Anatomy:

Anatomy made of dense trabecular bone Capsule inserts on IT line anteriorly, but at mid-cervical level posteriorly Muscle attachments determine deformity calcar femorale – vertical wall of dense bone that extends from posteromedial aspect of femoral shaft to posterior portion of femoral neck helps determine stable versus unstable fracture patterns

GT:

GT Lateral surface Insertion of the tendon of the gluteus medius . Medial surface the trochanteric fossa (digital fossa), for the insertion of the tendon of the obturator externus , and above and in front of this an impression for the insertion of the obturator internus and superior and inferior gemellus muscles . Superior Border insertion of the piriformis . Inferior Border gives origin to the upper part of the vastus lateralis . Posterior Border  trochanteric fossa.

Inter-trochanteric #:

Inter-trochanteric # Extracapsular fractures of the proximal femur between the greater and lesser trochanters 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. Extracapsular fracture unite quite easily and seldom cause AVN as compared to Intracapsular # ( Neck and Head of Femur #) Comman in elderly , osteoporotic people and most of the patients are women in 8 th decade seen in elderly patients 10 – 12 years older than intracapsular # neck of femur Sex  f:m = 2.8 : 1

MOI:

MOI Fall and hit directly to Greater Trochanter or indirect twisting injury  The crackup runs up between lesser and greater Trochanter proximal fragment tends to displace varus

Etiology:

Etiology increased bone fragility of the intertrochanteric area of the femur . decreased muscle tone of the muscles in the area secondary to the aging process. The increasing bone fragility results from osteoporosis and osteomalacia secondary to a lack of adequate ambulation or antigravity activities, as well as decreased hormone levels, increased levels of demineralizing hormones, decreased intake of calcium and/or vitamin D, and other aging processes. Benign and malignant tumors, along with metastases such as multiple myeloma and other malignancies, can also lead to weakened bony structure

Anatomical Classification:

Anatomical Classification Stability of fracture pattern is arguably the most reliable method of classification stable # - intact posteromedial cortex clinical significance -will resist medial compressive loads once reduced

Unstable Fractures :

Unstable Fractures comminution of the posteromedial cortex clinical significance - fracture will collapse into varus and retroversion There will be displaced fragment from the weight bearing area ( the Calcar or the inferomedial part of the femoral neck Fracture pattern is such that forces of weight bearing continually displace the fragment fracture as those in reverse oblique pattern or with subtrochanteric extenison Oseoporosis leading to poor quality grip by fixation implants

Unstable Fractures:examples:

Unstable Fractures:examples four part fracture . (GT,LT, Proximal and distal femoral fragemnt ) reverse oblique fracture .( subtrochanteric extension) calcar fracture. shattered postero -medial cortex. displaced large posteriomedial fragment including the lesser trochanter .

Classifications:

Classifications Kyles classification-1994 Boyd and griffin classification-1949 Evan’s classificaton Raindier Classification Decoulx and Lavarde's classification (1969 ) Ender's classification Trochanteric eversion fractures AO classification

Classification –Kyles -1994:

Classification – Kyles -1994 Type I  Undisplaced and Uncommuniated Type II  Displace , minimal comminuted LT #, Varus Type III  Displaced GT#, comminuted, Varus Type IV  Severely comminuted, subtrochanter extension, also reverse oblique

Boyd and Griffin Classification:

Boyd and Griffin Classification Type I – fractures extend along intertrochanteric line Type II- comminuted # with main fracture line along intyertrochanteric line but with multiple second aray fracture linese ( may seen coronal line in lateral view Type III- extend to or are distal to lesser trochanter Type IV- fractures of trochanteric region and proximal shaft with fracture in ast least two plane

PowerPoint Presentation:

Evans' classification Type I: Undisplaced 2-fragment fracture Type II: Displaced 2-fragment fracture Type III: 3-fragment fracture without posterolateral support, owing to displacement of greater trochanter fragment Type IV: 3-fragment fracture without medial support, owing to displaced lesser trochanter or femoral arch fragment Type V: 4-fragment fracture without posterolateral and medial support (combination of Type III and Type IV) R: Reversed obliquity fracture

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Figure 2 Ramadier's classification a: Cervico -trochanteric fractures b: Simple pertrochanteric fractures c: Complex pertrochanteric fractures d: Pertrochanteric fractures with valgus displacement e: Pertrochanteric fractures with an intertrochanteric fracture line f: Trochantero-diaphyseal fractures g: Subtrochanteric fractures Decoulx and Lavarde's classification (1969) Cervico -trochanteric fractures (a) Pertrochanteric fractures ( b,c,d ) Subtrochanteric fractures (e) Subtrochantero-diaphyseal fractures (f)

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Figure 4 Ender's classification Trochanteric eversion fractures -1 Simple fractures -2 Fractures with a posterior fragment -3 Fractures with lateral and proximal displacement Trochanteric inversion fractures -4 With a pointed proximal fragment spike -5 With a rounded proximal fragment beak -6 Intertrochanteric fractures Subtrochanteric fractures -7 and 7a Transverse or reversed obliquity fractures -8 and 8a Spiral fractures

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AO classification A1: Simple (2-fragment) pertrochanteric area fractures A1.1 Fractures along the intertrochanteric line A1.2 Fractures through the greater trochanter A1.3 Fractures below the lesser trochanter A2: Multifragmentary pertrochanteric fractures A2.1 With one intermediate fragment (lesser trochanter detachment) A2.2 With 2 intermediate fragments A2.3 With more than 2 intermediate fragments A3: Intertrochanteric fractures A3.1 Simple, oblique A3.2 Simple, transverse A3.3 With a medial fragment

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AO / OTA 31 Stable Unstable

Clinical features:

Clinical features Usually old and unable to stand Leg is shorter and more externally rotated than transcerival # Patient cannot lift leg

Radiographs:

Radiographs X ray AP pelvis, AP of hip, cross table lateral, full length femur radiographs, CT or MRI useful if radiographs are negative but physical exam consistent with fracture Undisplaced and Stable A think crack along the intertrochanteric line, ? Doubt about # Dx conformed by MRI Displaced and Unstable GT and LT can be found as separate fragment

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Stable Unstable Uncontrolled factor: Fracture geometry

Treatment:

Treatment Early internal fixation why? Not because they fail to unite with conservative tx (they unite early –extra capsular) rather to obtain the best possible position To get the patient up and walking soon as possible And reduce further complication

Non-operative Treatment:

Non-operative Treatment Traction in bed till sufficient reduction in pain –physical therapy Non weight bearing with early out of bed to chair indications Non-ambulatory patients patients at high risk for perioperative mortality Possible complications: high rates of pneumonia, urinary tract infections, decubiti, and DVT

Conservative Tx Methods::

Conservative Tx Methods : Simple support with pillows Buck’s traction Plaster spica Skeletal traction through distal femur or tibia for 10 – 12 weeks

Buck’s traction:

Buck’s traction Hip Spica

Traction using Bohler Braun frame:

Traction using Bohler Braun frame

Operative Tx:

Operative Tx internal fixation sliding nail or screw. fixed angle 95° or 135° L-plate. DHS and side plate. intramedullary device and hip screw

sliding hip compression screw or screw slide plate /CHS :

sliding hip compression screw or screw slide plate /CHS indications stable intertrochanteric fractures (non displaced) outcomes equal outcomes when compared to intramedullary hip screws for stable fracture patterns

Compression Hip Screw(CHS):

Compression Hip Screw(CHS)

intramedullary hip screw (cephalomedullary nail):

intramedullary hip screw ( cephalomedullary nail ) indications stable fracture patterns & unstable fracture patterns reverse obliquity fractures 9 56 % failure when treated with sliding hip screw) subtrochanteric extension lack of integrity of femoral wall associated with increased displacement and collapse when treated with sliding hip screw outcomes equivalent outcomes to sliding hip screw for stable fracture patterns use has significant increased in last decade

Cephalo medullary Hip Screw:

Cephalo medullary Hip Screw

arthroplasty:

arthroplasty indications severely comminuted fractures preexisting symptomatic degenerative arthritis osteoporotic bone that is unlikely to hold internal fixation salvage for failed internal fixation

Techniques:

Techniques OT Reduction Slight traction and internal rotation  X-ray Sliding hip compression screw (A1 Snd A2 good ) must obtain correct neck-shaft relationship lag screw with tip-apex distance <25 mm is associated with decreased failure rates 4 hole plates show no benefit clinically or biomechanically over 2 hole plates pros – allows dynamic interfragmentary compression,low cost cons – open technique, increased blood loss, not advisable in unstable fracture patterns coz may result in collapse,l limb shortening, medialization of shaft can cause anterior spike malreduction in left-sided,

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longitudinal Traction and internal rotation ( scissior position Traction) a Lateral approach to proximal femur Or anterolateral approach( watson -john)

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a Trochanteric two-fragment fracture (31-A1 ). b The fracture can be fixed with a dynamic hip screw. The additional insertion of a cancellous bone screw provides increased rotational stability. The guide wire for the hip screw must be placed centrally in the head on both the AP and lateral x-rays. superior quadrant may lead to failure by cutout, particularly in osteoporotic bone

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a Multifragmentary trochanteric fracture (31-A2.3). b Unstable fracture treated with the PFNA. The shaft of the nail prevents lateral displacement of the fragments. Distal locking should be static.

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a Reverse oblique intertrochanteric fracture (31-A3.3). b This fracture is preferably fixed with an intramedullary device (PFNA, TFN, etc ). c Alternatively, the DHS with an additional trochanter stabilizing plate and a tension band wire can be used. d–e The fracture can also be fixed with the dynamic condylar screw or a condylar blade plate. The dynamic condylar screw or the blade is placed high in the proximal fragment. The plates have to be put under tension. Patients cannot fully bear weight immediately after surgery.

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Screw position is important to prevent from cutting out the osteroporotic bone Pass up the femoral neck to end within the center of femoral head wit h diff. of 5mm from subchondral bone plate TAD to identify a sweet-spot for positioning sliding screw If within 25 mm there is lower lisk of screw cutting out the femoral head Side plate should be long enough to accommodate Atleast 4 screw below fracture line If lesser trochanteric fragemt apply with additional crews

TAD (tip apex distance)Calulation:

TAD (tip apex distance) Calulation

Intramedullary hip screw technique :

Intramedullary hip screw technique A3 and some A2 Fractures short implants with optional distal locking standard obliquity fractures long implants standard obliquity fractures reverse obliquity fractures subtrochanteric extension pros percutaneous approach, minimal blood loss, may be used in unstable fracture patterns cons increased incidence of screw cutout,periprosthetic fracture, higher cost than sliding hip screw

For reversed oblique :

For reversed oblique There is tendency to shift distal fragment shift medially under proximal fragment so , 95 degere skew plate device or intrameduallary with hip screw give more stable fixation If close reduction fails ORIF and manipulation of fragments needed. Large posterio medical fragment including LT may need additional fixation Addition of bone graft hasten union of medial cortex. For no proper anatomical reduction possibility v algus osteotomy done to allow the proximal fragment to abut securely against femoral shaft.

Arthroplasty technique :

Arthroplasty technique calcar -replacing prosthesis often needed must attempt fixation of greater trochanter to shaft pros possible earlier return for full weight bearing cons increased blood loss may require prosthesis that some surgeons are unfamiliar with

Post operatively :

Post operatively Exercise to be started on Day after operation Partial weight bearing started as soon as possible.

Complications:

Complications Failed Fixation – improper screw position, delayed union, osteoporotic bone, (Re reduction and fixation may need to do )

Implant failure and cutout incidence :

Implant failure and cutout incidence most common complication usually occurs within first 3 months cause tip-apex distance >45 mm associated with 60% failure rate treatment young corrective osteotomy and/or revision open reduction and internal fixation elderly total hip arthroplasty

PowerPoint Presentation:

Anterior perforation of the distal femur incidence can occur following intramedullary screw fixation Due to mismatch of the radius of curvature of the femur (shorter) and implant (longer) Nonunion incidence < 2% Rx revision ORIF with bone grafting( if healing delayed(beyond 6 mths )re fixation as far as anatomical reductionFixation more securely with bone graft around the fracture) proximal femoral replacement Malunion incidence Coxa vara and external rotational deformities are common Rx-corrective osteotomies Traumatic Osteoarthritis

Pathological Fractures:

Pathological Fractures IC # due to metastatic disease or Myeloma # Fixation is is essential for aceptable quality of life (if not terminally ill) Internal fixation with Methylmethacrylate cement packed in defect to improve stability If Femoral neck involvement  Cemented Prothesis preferable

Sub-Trochanter Fracture:

Sub-Trochanter Fracture By definition these fractures involve an area between the lesser trochanter and the isthmus of the diaphysis of the femoral shaft Sub-trochanteric typically defined as area from lesser trochanter to 5cm distal 10-34% of all hip fractures

Sub trochanteric Fracture:

Sub trochanteric Fracture fractures associated with intertrochanteric component may be called intertrochanteric fracture with subtrochanteric   extension or peritrochanteric fracture   Reason for weaking of bone in this areas is by ostoporoisis , osteomalacia , paget’s disease or seconcary deposit

anatomy:

anatomy primarily of cortical bone Well vascularized muscle groups cover the subtrochanteric region and femoral shaft Must split vastus medialis or reflect to gain exposure of subtrochantreric area The femoral artery  Profunda femoris artery gives rise to perforating muscular branches so , Risk of bleeding from perforators nerves Anteriorly, the Femoral nerve Posteriorly, the Sciatic nerve Rarely involved in closed injuries

Musculatures:

Musculatures Hip muscles act to displace into subtrochanteric fragments The gluteus medius and minimus tendons attach to the greater trochanter and abduct the proximal fragment. The psoas and iliacus attach to the lesser trochanter and flex the proximal fragment. The adductors pull the distal fragment medially.

MOI :

MOI 1. Younger patients: More commonly high energy trauma (i.e. MVA, fall from heights, penetrating injuries); trauma workup 2. Older patients: Low energy such as simple falls; concern about pathologic or periprosthetic fractures bisphosphonate use, particularly alendronate, can be risk factor 3. Gunshot wounds cause approximately 10% of high-energy subtrochanteric femur fractures.

PowerPoint Presentation:

deforming forces on the proximal fragment are      abduction gluteus medius   and gluteus minimus   flexion iliopsoas   external rotation short external rotators  deforming forces on distal fragment adduction & shortening adductors 

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weight bearing   net  compressive forces on medial cortex  tensile forces on lateral cortex Low energy Minimal comminution Spiral pattern more common Osteoporotic bone High energy High comminution involving much of the proximal femur Significant soft tissue damage

Most subtrochanteric fractures are caused by :

Most subtrochanteric fractures are caused by Direct lateral trauma Axial loading (with failure in subtrochanteric region)

Features about subtrochanteric fracture:

Features about subtrochanteric fracture Blood Loss greater than with femoral neck or trochanteric #( region contain anastomosing branching of the medial and lateral circumflex femoral arteries which come from profounda femoris ) There may be subtle extension into intertrochanteric region which may influence the manner in which interal fixation can be performed Proximal part is abducted and externally rotated by the gluteal meuscles and flexion by psoas. So, Shaft of femur has to be brought into position to match the proximal part or else malunion is created by internal fixation

Russel-Taylor Classification:

Russel -Taylor Classification Type I No extension into piriformis fossa Type IA Type IB Fracture lines and comminution are below lesser trochanter Fracture lines and comminution involve the lesser trochanter Type II Extension into greater trochanter with involvement of piriformis fossa  •  look on lateral xray to identify piriformis fossa extension Type IIA -Begin in subtrochanteric region and extend distally. Involve piriformis fossa, but lesser trochanter intact. Type IIB -Involve subtrochanteric region, piriformis fossa, and lesser trochanter.

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AO/OTA Classification 32-A3.1 Simple (A), Transverse (3), Subtrochanteric fracture (0.1) 32-B3.1 Wedge (B), Fragmented (3), Subtrochanteric fracture (0.1) 32-C1.1 Complex (C), Spiral (1), Subtrochanteric fracture (0.1)   Facture Location   • Femur (3) , Diaphysis (2), Subtrochanteric region (0.1) Fracture Pattern  •  Simple (A), Wedge (B), Complex (C)  

Presentation:

Presentation hip and thigh excruciating pain, inability to bear weight & pain with motion typically associated with obvious deformity (shortening and varus alignment) flexion of proximal fragment may threaten overlying skin Legs lies neutral or external rotation

Imaging :

Imaging AP and lateral of the hip, AP pelvis full length femur films including the knee additional views ?traction views may assist with defining fragments in comminuted patterns but is not required

Xray # pattern:

Xray # pattern # Patterns may be transverse, oblique and spiral and frequently communiated Upper fragment flexed and shaft adducted and displaced proximally Three important features should be looked into Unusal long # line extending proximally toward the GT and Piriform fossa Large displaced fragment which includes lesser Trochanter Lytic lesion in the femur

Treatment-Nonoperative :

Treatment - Nonoperative Traction may help to reduce blood loss and pain observation with pain management non-ambulatory patients with medical co-morbidities limited role due to strong muscular forces displacing fracture and inability to mobilize patients without surgical intervention

Operative Treatments(ORIF):

Operative Treatments(ORIF) ORIF is Treatment of choice Generaly Two types of implants are used for # fixation intramedullary nailing  (usually cephalomedullary )  with proximal interlocking screw Can tolerate stresss for longe if healing is slow, For communiated and unstable , pathological #( but may be tumor deposit in disatal part of femur Anatomial reduction provide greatest sufrace area of caonact betweenen fragmentss and Reduce stress on implant . It should be maintained before reaming As little soft tissue dissection as possible

PowerPoint Presentation:

Integrity of medial cortex (around lesser trochanter be established if hip screw and plate used Proximal interlocking screws with intrameduallary nail should be used if # pattern extend above lesser trochanter If fracture enters priform fossa intrameduallary nail design to be insterted at the tip of GT is better or alternatively 95degreee hip screww and plate device can be used

PowerPoint Presentation:

b. fixed angle plate  (95 degress hip screw and plate device) indications surgeon preference associated femoral neck fracture narrow medullary canal pre-existing femoral shaft deformity

PowerPoint Presentation:

Patient position -lateral positioning  advantages  allows for easier reduction of the distal fragment to the flexed proximal fragment  allows for easier access to entry portal, especially for piriformis nail Position -supine positioning advantages protective to the injured spine address other injuries in polytrauma patients easier to assess rotation

PowerPoint Presentation:

IM nailing techniques 1st generation nail (rarely used) 2nd generation reconstruction nail cephalomedullary nail  (IM Nail) trochanteric or piriformis entry portal  piriformis nail may mitigate risk of iatrogenic malreduction from proximal valgus bend of trochanteric entry nail  

PowerPoint Presentation:

pros preserves vascularity load-sharing implant stronger construct in unstable fracture patterns cons reduction technically difficult  nail can not be used to aid reduction  fracture must be reduced prior to and during passage of nail may require percutaneous reduction aids or open clamp placement to achieve and maintain reduction   mismatch of the radius of curvature nails with a larger radius of curvature (straighter) can lead to perforation of the anterior cortex of the distal femur  complications - varus malreduction

Fixed angle plate :

Fixed angle plate  approach - lateral approach to proximal femur  may split or elevate vastus lateralis off later intermuscular septum dangers include perforating branches of profunda femoris technique 95 degree blade plate or condylar screw sliding hip screw is contraindicated due to high rate of malunion and failure blade plate may function as a tension band construct  as femur eccentrically loaded with tensile force on the lateral cortex converted to compressive force on medial cortex cons compromise vascularity of fragments inferior strength in unstable fracture patterns

Complications:

Complications Varus / procurvatum   malunion   the most frequent intraoperative complication with  antegrade nailing of a subtrochanteric femur fracture is varus and procurvatum (or flexion) malreduction

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Thank you ..

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