Intertrochanteric Fractures

Topic updated on 07/19/16 3:20pm
  • Extracapsular fractures of the proximal femur between the greater and lesser trochanters
  • Epidemiology
    • incidence
      • roughly the same as femoral neck fractures
    • demographics
      • female:male ratio between 2:1 and 8:1
      • typically older age than patients with femoral neck fractures
    • risk factors
      • proximal humerus fractures increase risk of hip fracture for 1 year
  • Pathophysiology
    • mechanism
      • elderly
        • low energy falls in osteoporotic patients
      • young
        • high energy trauma
  • Prognosis
    • nonunion and malunion rates are low
    • 20-30% mortality risk in the first year following fracture
    • factors that increase mortality
      • male gender (25-30% mortality) vs female (20% mortality)
      • higher in intertrochanteric fracture (vs femoral neck fracture)
      • operative delay of >2 days 
      • age >85 years
      • 2 or more pre-existing medical conditions
      • ASA classification (ASA III and IV increases mortality) 
    • surgery within 48 hours decreases 1 year mortality
    • early medical optimization and co-management with medical hospitalists or geriatricians can improve outcomes 
  • Osteology
    • intertrochanteric area exists between greater and lesser trochanters
    • made of dense trabecular bone
    • 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
  • Stability of fracture pattern is arguably the most reliable method of classification
    • stable
      • definition
        • intact posteromedial cortex
      • clinical significance
        • will resist medial compressive loads once reduced
    • unstable
      • definition
        • comminution of the posteromedial cortex
      • clinical significance
        • fracture will collapse into varus and retroversion when loaded
      • examples
        • fractures with a large posteromedial fragment
          • i.e., lesser trochanter is displaced
        • subtrochanteric extension
        • reverse obliquity
          • oblique fracture line extending from medial cortex both laterally and distally
  • Physical Exam
    • painful, shortened, externally rotated lower extremity
  • Radiographs
    • recommended views
      • 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
  • Nonoperative
    • nonweightbearing with early out of bed to chair
      • indications
        • nonambulatory patients
        • patients at high risk for perioperative mortality
      • outcomes
        • high rates of pneumonia, urinary tract infections, decubiti, and DVT
  • Operative
    • sliding hip compression screw
      • indications
        • stable intertrochanteric fractures
      • outcomes
        • equal outcomes when compared to intramedullary hip screws for stable fracture patterns
    • intramedullary hip screw (cephalomedullary nail)
      • indications
        • stable fracture patterns
        • unstable fracture patterns 
        • reverse obliquity fractures
          • 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 significantly increased in last decade
    • arthroplasty
      • indications
        • severely comminuted fractures
        • preexisting symptomatic degenerative arthritis
        • osteoporotic bone that is unlikely to hold internal fixation
        • salvage for failed internal fixation
  • Sliding hip compression screw
    • technique
      • must obtain correct neck-shaft relationship
      • lag screw with tip-apex distance >25 mm is associated with increased 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 
        • may result in
          • collapse
          • limb shortening
          • medialization of shaft
      • can cause anterior spike malreduction in left-sided, unstable fractures due to screw torque
  • Intramedullary hip screw
    • technique
      • 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
  • 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
  • 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
  • Anterior perforation of the distal femur
    • incidence
      • can occur following intramedullary screw fixation
    • cause
      • mismatch of the radius of curvature of the femur (shorter) and implant (longer)
  • Nonunion
    • incidence
      • <2%
    • treatment
      • revision ORIF with bone grafting
      • proximal femoral replacement
  • Malunion
    • incidence
      • varus and rotational deformities are common
    • treatment
      • corrective osteotomies


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Qbank (17 Questions)

(OBQ11.172) Which of the following methods accurately describes the measurement of tip-apex-distance as it relates to placement of a lag screw in the femoral head? Topic Review Topic

1. Summation of the distance between the end of the screw and the apex of the femoral head on AP and lateral radiographs
2. Distance from the acetabular teardrop to the tip of the screw on an AP radiograph of the hip
3. Multiplication of the distance between the end of the screw and the apex of the femoral head on AP and lateral radiographs
4. Distance from the center of the lesser trochanter to the tip of the screw on an AP hip radiograph
5. Summation of the distance between the tip of the greater trochanter and end of the screw on AP and lateral hip radiographs

(OBQ11.189) Which of the following deformities is most likely to occur with dynamic hip screw fixation of unstable left sided standard obliquity hip fractures? Topic Review Topic

1. Posterior spike displacement of the proximal fragment
2. Anterior spike displacement of the proximal fragment
3. Lateral displacement of the proximal fragment relative to the distal fragment
4. Shortening of the proximal fragment relative to the distal fragment
5. Medial displacement of the proximal fragment in relation to the distal fragment

(OBQ10.17) A 74-year-old female falls from a standing height and sustains the fracture shown in Figure A. The occurrence of this injury most increases her risk of sustaining which of the following fractures? Topic Review Topic
FIGURES: A          

1. Sacral fracture
2. Hip fracture
3. Distal radius fracture
4. Distal fibula fracture
5. Distal humerus fracture

(OBQ09.3) Which of the following factors has been shown to be the strongest predictor of screw cutout of a dynamic compression hip screw used for an intertrochanteric femur fracture? Topic Review Topic

1. Age of the patient
2. Intrinsic stability of the fracture
3. Tip-apex distance
4. Quality of reduction
5. Angle of the sideplate

(OBQ09.222) A patient with an intertrochanteric hip fracture undergoes reduction and dynamic hip screw application. The post-operative radiographs demonstrate that the lag screw is superior in the femoral head with a tip-apex distance of 40 millimeters. This patient is at increased risk of what complication? Topic Review Topic

1. lag screw cutout
2. osteonecrosis
3. osteoarthritis
4. peri-prosthetic fracture
5. lag screw breakage

(OBQ09.233) Which of the following statements is true regarding treatment of intertrochanteric hip fractures with an intramedullary nail versus a sliding hip screw? Topic Review Topic

1. The use of intramedullary nail has increased in the last ten years
2. The use of sliding hip screws has increased in the last ten years
3. Medicare reimbursement is more for a sliding hip screw
4. Intramedullary nails have demonstrated superior outcomes in randomized-controlled studies
5. Sliding hip screw is superior for treatment of reverse obliquity intertrochanteric fractures

(OBQ08.138) An 82-year-old female sustains an intertrochanteric hip fracture and is treated with a sliding hip screw. What is the most appropriate definitive step in treating the failure seen in figure A? Topic Review Topic
FIGURES: A          

1. Non-weight bearing
2. Valgus proximal femoral osteotomy
3. Total hip arthroplasty
4. Revision open reduction and internal fixation
5. Proximal femoral resection

(OBQ07.86) Which of the following is not an appropriate implant for treatment of the fracture seen in Figure A? Topic Review Topic
FIGURES: A          

1. Cephalomedullary nail
2. External fixation
3. Proximal femoral locking plate
4. 95 degree blade plate
5. Sliding hip screw

(OBQ07.153) Anterior perforation of the distal femur from antegrade femoral nailing has been attributed to what factor? Topic Review Topic

1. Non-anatomic reduction
2. Mismatch of the radius of curvature of implant and bone
3. Usage of too large an implant
4. Lateral patient positioning
5. Lateral proximal starting point

(OBQ07.246) A 72-year-old male sustains the injury shown in Figure A as a result of a fall from a ladder. Following internal fixation for this fracture with a sliding hip screw, which of the following factors has been shown to be associated with increased collapse or sliding displacement? Topic Review Topic
FIGURES: A          

1. Use of a long intramedullary device
2. Use of a short intramedullary device
3. Use of external fixation
4. Post operative weight bearing status
5. Intraoperative fracture of the lateral femoral wall

(OBQ06.157) Which of the following is a recognized predictor of mortality after hip fracture? Topic Review Topic

1. American Society of Anesthesiologist (ASA) classification
2. Post-operative weight bearing status
3. Fracture comminution
4. Fixation device used
5. Type of anesthetic used

(OBQ05.161) A 55-year-old male is involved in a motor vehicle accident and sustains the injury seen in Figure A. What is the most appropriate treatment for this type of injury? Topic Review Topic
FIGURES: A          

1. Total hip arthroplasty
2. Bipolar hemi-arthroplasty
3. Sliding hip screw
4. Percutaneous screw fixation
5. Cephalomedullary nail fixation

(OBQ05.210) All of the following implants offer adequate fracture fixation of the injury shown in Figure A EXCEPT: Topic Review Topic
FIGURES: A          

1. Trochanteric entry point cephalomedullary nail
2. Piriformis fossa entry point cephalomedullary nail
3. Dynamic hip screw
4. Fixed angle blade plate
5. 95 degree dynamic condylar screw

(OBQ05.262) When treating a stable 2-part intertrochanteric hip fracture with a sliding hip screw construct, what is the minimum number of screw holes that are needed in the side plate for successful fixation? Topic Review Topic

1. One
2. Two
3. Three
4. Four
5. Five

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