Rashik ismail

1. DR. RASHIK ISMAIL

2. TOPICS
 INTERTROCHANTERIC FRACTURES
 GREATER TROCHANTER #
 LESSER TROCHANTER #

3. INTERTROCHANTERIC FRACTURES

4. INTRODUCTION
 Extracapsular
 Pertrochanteric fractures involve those occurring in
the region extending from the extracapsular basilar
neck region to the region along the lesser trochanter
proximal to the development of the medullary canal.
 Intertrochanteric and peritrochanteric are generic
terms for pertrochanteric fractures.

5. EPIDEMIOLOGY
 Varies from country to country.
 2-8:1 women:men
 India - Rising because of increasing number of senior
citizens with osteoporosis. By 2040 the incidence is
estimated to be doubled. In India the figures may be
much more.

6. FACTORS CONTRIBUTORY TO THE
DEVELOPMENT OF AN IT FRACTURE
 Advancing age
 Increased number of comorbidities
 Increased dependency in activities of daily living
 History of other osteoporosis-related (fragility)
fractures

7. 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

8. ANATOMY
 Deforming muscle forces will usually produce
shortening, external rotation & varus position at the
fracture.

9. Abductors displace
Greater Trochanter
laterally and proximally
Iliopsoas displaces Lesser
Trochanter medially and
proximally
Hip flexors,
extensors and
adductors pull distal
fragment proximally
ANATOMY
 Abductors tend to
displace GT laterally &
proximally
 Hip flexors, extensors &
adductors pull distal
fragment proximally
 Iliopsoas displaces LT medially
& proximally.

10. MECHANISMS OF INJURY
 YOUNGER INDIVIDUALS – High energy (relatively
rare) - injury such as a motor vehicle accident or fall
from height
 More common in men less than 40 years of age
 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

11. ASSOCIATED INJURIES/DISEASE
STATES
 Low energy falls – distal radius, proximal humerus
fractures and minor head injuries
 High energy hip fractures – ipsilateral extremity
trauma, head injury and pelvic fractures
 Syncopal episodes – gives an idea of the CVS and
neurological status
 Primary neoplastic and metastatic disease – preceding
hip discomfort and subsequent fall

12. CLINICAL EVALUATION
 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

13.  Auscultation Lippmann test – sensitive for detection
of occult fractures of the proximal femur or pelvis
 Bell of the stethoscope on symphysis pubis and
tapping on the patella of both extremities – variation
in sound conduction determines discontinuity
 Decreased tone or pitch – s/o fracture

14. WORKUP
 Pre-surgery workup – CBC, HIV, HBsAG, HCV, RFT,
RBS, Blood grouping & cross matching, Chest XRAY,
ECG
 For Low energy fractures – Serum calcium, phosphate,
alkaline phosphatase, Vitamin D, TSH, PTH, Serum
Protein Electrophoresis

15. WHAT ELSE TO LOOK FOR WHILE
DOING A WORKUP?
 Previous DVT/PE
 Anticoagulant medications
 Immune deficiency disorders
 Malabsorption disease
 Angina
 CVAs
 Active infection – pulmonary or genitourinary (risk of sepsis)
 Protein-calorie malnutrition and Vitamin D deficiency
 Protein–calorie malnutrition & vitamin D deficiency
are now recognized as serious risk factors for increased
mortality and slower recovery.

16. IMAGING STUDIES - XRAYS
 Pelvis with both hips – AP, X ray 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

17. 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.
 Bone scans or CT – reserved for those who have
contradictions to MRI.

18. DIAGNOSIS AND CLASSIFICATION
 Increased surgical complexity and recovery are
associated with UNSTABLE FRACTURE PATTERNS:
- Posteromedial large separate fragmentation
- Basicervical patterns
- Reverse obliquity patterns
- Displaced greater trochanteric (lateral wall fractures)

19. CLASSIFICATION SYSTEMS

20. 1.BOYD AND GRIFFIN
Type 1, stable (two-part);
Type 2, unstable comminuted with posteromedial
comminution
Type 3, unstable reverse obliquity;
Type 4, intertrochanteric–subtrochanteric with
two planes of fracture.

21. 2.EVAN’S CLASSIFICATION
 Evans (Birmingham) in 1949 reported on a post-
treatment classification with 5 types described.
 He compared non-operative treatment with fixed angle
device surgical treatment and found that in 72% fractures
could be fixed in a stable configuration, 28% unstable
(14% as a result of fracture communition and 14% in
which he felt that reduction was never achieved)

22. Type 1, Stable: Either undisplaced or displaced but anatomically reduced (intact medial
cortex).

23. Type 2, unstable: Implies displaced and fixed in an unreduced position,
comminuted with destruction of the anteromedial cortex, or reverse obliquity.

24. 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 comminution.
- 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

25. 3. OTA/AO CLASSIFICATION

26. OTA/AO CLASSIFICATION

27. UNUSUAL FRACTURE PATTERNS
 BASICERVICAL FRACTURE
 REVERSE OBLIQUITY FRACTURES

28. BASICERVICAL FRACTURES
 Located proximal to or along intertrochantericline.
 Although anatomically femoral neck fractures they are
usually extracapsular and behave like intertrochanteric
fractures.
 At greater risk for osteonecrosis when compared to
more distal intertrochanteric fractures
 Lack the cancellous interdigitation seen with fractures
in the intertrochanteric region and are more likely to
sustain rotation of the femoral head

30. REVERSE OBLIQUITY
 Oblique fracture line extending from the medial cortex
proximally to the lateral cortex distally
 Tendency to medial displacement due to the pull of
the adductor muscles
 Should be treated as subtrochanteric fractures

32. TREATMENT
• NON OPERATIVE
• OPERATIVE

33. TREATMENT OPTIONS – NON-
OPERATIVE
 Prolonged bed rest in traction until fracture healing
occurred (usually 10 to 12 weeks), followed by a
lengthy program of ambulation training.
 Can be done for:
1. An elderly person whose medical condition
carries an excessively high risk of mortality
from anaesthesia and surgery.
2. Non ambulatory patient who has minimal
discomfort following fracture.

34. TREATMENT OPTIONS – NON
OPERATIVE
 Buck’s traction or extension
 Russell skeletal traction
 Balanced traction in Thomas splint
 Plaster spica immobilization
 Derotation boot

35. COMPLICATIONS OF NON-
OPERATIVE TREATMENT
 Decubiti, UTI, joint contractures, pneumonia, and
thromboembolic complications, resulting in a high
mortality rate.
 In addition, fracture healing is generally accompanied
by varus deformity and shortening because of the
inability of traction to effectively counteract the
deforming muscular forces.

36. 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

37. OPERATIVE TREATMENT – FACTORS THAT
DETERMINE THE STRENGTH OF THE FRACTURE
FRAGMENT-IMPLANT ASSEMBLY
 Bone quality
 Fracture pattern
 Fracture reduction
 Implant design
 Implant placement

38. REDUCTION – OPEN REDUCTION
 Failed closed reduction
 Large spike on proximal fragment with lesser
trochanter intact
 Reverse oblique fracture
 If a gap exists medially or posteriorly

39. OPEN REDUCTION TECHNIQUES
 Anatomical Stable Reduction
if not severely comminuted
applying a bone holding forceps across the
fracture in an AP plane while adjusting the
traction and rotation
Once achieved – Compression hip screw or other
device can be used to secure the reduction
 Non-anatomical stable reduction -
severely comminuted fracture where anatomical
reduction is difficult.

40. NON ANATOMICAL STABLE
REDUCTION TECHNIQUES
 Medial displacement osteotomy/Dimon Hughston
 Valgus osteotomy/Sarmiento osteotomy
 Lateral displacement osteotomy

41. OPERATIVE METHODS
 Plate Constructs
 Cephalomedullary nailing
 External Fixation
 Arthroplasty

42. 1.PLATE CONSTRUCTS
 Impacted nail-type plate devices. eg. Blade plate and
fixed angle nail plate devices
 Dynamic compression class . eg. Sliding hip screws
 Linear compression class
 Hybrid Locking Class. eg. Proximal Femoral Locking
Plates

43. PLATE CONSTRUCTS – FIXED ANGLE
PLATING
 More commonly used for
corrective osteotomies
nowadays rather than as a
primary treatment of hip
fractures
 Eg. Jewett Nail.
 Consist of a triflanged nail
fixed to a plate at an angle
of 130 to 150 degrees.

44. PLATE CONSTRUCTS – DYNAMIC
COMPRESSION PLATING
SLIDING HIP SCREWS

45. 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)

46. 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

47. PLATE CONSTRUCTS – LINEAR
COMPRESSION CLASS
 a/k/a Rotationally Stable
Plating – adds enhanced
rotational stability with
multiple screw fixation in
the femoral head
 Examples – Gotfried PCCP
and InterTAN CHS

48. PLATE CONSTRUCTS- HYBRID LOCKING PLATE

49. 2.CEPHALOMEDULLARY DEVICES
Russell classified cephalomedullary nails into 4
classes:
 Impaction/Y nail class
 Dynamic compression or Gamma Class
 Reconstruction class
 InterTAN class

50. CEPHALOMEDULLARY DEVICES
IMPACTION CLASS GAMMA NAIL

51. RECON CLASS Inter TAN

52. CEPHALOMEDULLARY NAILS -
ADVANTAGES
 Provides more efficient load transfer.
 decrease tensile strain on the implant, thereby
decreasing the risk of implant failure.
 controlled fracture impaction is maintained.
 Shorter operative time and less soft-tissue dissection.

53. PROXIMAL FEMORAL NAIL
 Have 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.
 acts as a buttress in preventing the medialisation of the
shaft.
 limits the surgical insult to the tendinous hip abductor.

54. 3.EXTERNAL FIXATION
 In elderly osteoporotics- high risk
 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

56. 4.ARTHROPLASTY
 unsuitable for IF.
 -Pathologic fractures,
-severe osteoporotic disease,
- renal dialysis patients,
- pre-existing arthritis under consideration for hip
replacement before the fracture occured.
 Hemiarthroplasty (cemented) reported to have a lower
dislocation rate when compared to total hip arthroplasty

57. SPECIAL CONSIDERATIONS
 When SHS used, GT displacement should be fixed
utilizing tension band techniques or a trochanteric
stabilizing plate and screw construct.
 Basicervical fractures treated with an SHS or IM nail
may require a supplemental antirotation screw or pin
during implant insertion.

58. SPECIAL CONSIDERATIONS
 Reverse obliquity fractures are best treated as
subtrochanteric fractures with either a 95 degree fixed
angle implant or an intramedullary device.
 Ipsilateral fracture of the femoral shaft, although more
common in association with femoral neck fractures,
should be ruled out in cases of high energy trauma.

59. POST-OPERATIVE CARE
 Good pain control
 Early mobilisation WBAT ambulation.
 Protein and caloric nutrition, osteoporotic therapy
 Proper balance and gait training

60. COMPLICATIONS
 Loss of fixation- eccentric placement of lag screw(MC)
 Nonunion
 Malrotation deformity
 Osteonecrosis
 Z-effect

62. 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

63. GREATER TROCHANTERIC
FRACTURES
 ORIF with tension band wiring of the displaced
fragment and the attached abductor muscles.
 Plate and screw fixation with a “hook plate” are the
preferred techniques

65. 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.

66. THANK YOU!