Intertrochanteric Fractures Flashcards
risk factors
proximal humerus fractures increase risk of hip fracture for 1 year
osteoporosis
advancing age
increased number of comorbidities
increased dependency with ADLs
associated conditions
osteoporosis
recurrent falls
dementia
parkinsons
unsteady gait
visual impairment
medications
what is the normal neck shaft angle
130 +/- 7 degrees
what is normal anteversion
10 +/- 7 degrees
intertrochanteric area exists between ____
greater and lesser trochanters
vertical wall of dense bone that extends from posteromedial aspect of femoral shaft to posterior portion of femoral neck
calcar femorale
what is the calcar femorale?
vertical wall of dense bone that extends from posteromedial aspect of femoral shaft to posterior portion of femoral neck
level of involvement helps determine stable versus unstable fracture patterns
calcar
what is the radius of curvature of the femur?
average 114-120 cm
factors that decrease radius of curvature
elderly
asian
short stature
what are the deforming forces on the proximal segment?
flexion, abduction, ER
deforming flexion forces
iliopsoas
sartorius
rectus femoris
pectineus
deforming abduction forces
gluteus maximus
gluteus medius
gluteus minimus
tensor fascia lata
deforming external rotation forces
piriformis
superior gemellus
obturator internus
inferior gemellus
quadratus femoris
deforming forces on distal segment
adduction and shortening
adductor longus
adductor brevis
adductor magnus
gracilis
rich collateral circulation reduces risk of _____
nonunion
trochanteric anastomosis:
ascending branch of medial circumflex femoral artery (MFCA)
ascending branch of lateral circumflex femoral artery (LFCA)
deep branch of superior gluteal artery
inferior gluteal artery
area of lowest BMD in femoral neck bordered by 3 main compressive/tensile trabeculae
ward’s triangle
what is ward’s triangle
area of lowest BMD in femoral neck bordered by 3 main compressive/tensile trabeculae
extends from medial femoral head along calcar and excellent support to proximal femur
primary compressive trabeculae
what is the primary compressive trabeculae
extends from medial femoral head along calcar and excellent support to proximal femur
vertically oriented with a triangular configuration
primary compressive trabeculae
forms an arc through the superior cortex of the femoral head and neck
principle tensile trabeculae
what is the principle tensile trabedculae
forms an arc through the superior cortex of the femoral head and neck
extends from greater trochanter to inferior aspect of femoral head below fovea
principle tensile trabeculae
fan-like configuration crossing from greater trochanter to lesser and also comprises calcar
secondary compressive trabeculae
what is the secondary compressive trabeculae?
fan-like configuration crossing from greater trochanter to lesser and also comprises calcar
what is the definition of a stable IT fracture?
intact posteromedial cortex
clinical significance of stable IT fractures
will resist medial compressive loads once reduced
definition of an unstable IT fracture
fracture will collapse into varus or shaft will displace medially
fracture will collapse into varus or shaft will displace medially
unstable IT fracture
factors that make an IT fracture unstable:
reverse obliquity
subtrochanteric extension
large or comminuted posteromedial cortex
fracture line extending from medial cortex out through lateral cortex
reverse obliquity
what is reverse obliquity
fracture line extending from medial cortex out through lateral cortex
measured from 3 cm distal from innominate tubercle at 135 degrees to the fracture site
lateral wall thickness
lateral wall thickness measured from:
measured from 3 cm distal from innominate tubercle at 135 degrees to the fracture site
lateral wall thickness <_____ mm suggest risk of postoperative lateral wall fracture
20.5
<20.5 mm suggest risk of postoperative lateral wall fracture
which should be treated with
cephalomedullary nail
key role in stabilizing proximal femur by providing lateral buttress
lateral wall thickness
predictor of postoperative functional status
pre-injury functional status
physical exam inspection will reveal
shortened, externally rotated lower extremity
physical exam palpation will reveal
tenderness over greater trochanter
physical exam:
pain with log roll and axial load
unable to perform active straight leg raise
TTP over greater trochanter
radiographic views to obtain
AP pelvis
AP hip
cross table lateral
full length femur
improve accuracy of fracture classification with direct impact on surgical planning
traction internal rotation view
compare this view to contralateral hip and assess neck shaft angle
AP pelvis
defines fracture pattern
AP hip
helps assess for posterior cortex comminution
cross table lateral
how does an AP hip view help you
defines fracture pattern
how does a cross table lateral help you
helps assess for posterior cortex comminution
full length femur films show what
assess subtrochanteric extension
possibility of pathological fracture
estimate length of intramedullary nail
assess femoral bowing
assess canal diameter
assess subtrochanteric extension
possibility of pathological fracture
estimate length of intramedullary nail
assess femoral bowing
assess canal diameter
full length femur films
second line imaging to evaluate for occult fracture
no access or contraindication to MRI
CT
CT indications
second line imaging to evaluate for occult fracture
no access or contraindication to MRI
MRI indications
occult hip fracture
isolated greater trochanteric fracture to evaluate for intertrochanteric extension
occult hip fracture
isolated greater trochanteric fracture to evaluate for intertrochanteric extension
MRI
bone marrow edema STIR or fat-suppressed T2
line of decreased intensity on T1 coronal view corresponding with signal on T2 and STIR
MRI findigns
MRI findings
bone marrow edema STIR or fat-suppressed T2
line of decreased intensity on T1 coronal view corresponding with signal on T2 and STIR
nonambulatory patients
high risk for perioperative mortality
skin breakdown at surgical site
incomplete fractures
non op
non op indications
nonambulatory patients
high risk for perioperative mortality
skin breakdown at surgical site
incomplete fractures
non op modalities
non-weight bearing with early mobilization from bed to chair
non op outcomes
high mortality rate
84.4% at 1-year
higher rates of pneumonia, UTI, decubitus ulcers, and DVT
low risk of displacement with occult fracture
mortality rate if non op
84.4% at 1 year
operative techniques
cephalomedullary nail
ORIF
arthroplasty
cephalomedullary nail indications
stable fracture patterns
unstable fracture patterns
reverse obliquity fractures
subtrochanteric extension
lack of integrity of femoral wall
stable fracture patterns
unstable fracture patterns
reverse obliquity fractures
subtrochanteric extension
lack of integrity of femoral wall
cephalomedullary nail indications
ORIF indications
stable fracture pattern
sliding hip compression (SHS) screw (most common)
proximal femur locking plate
95 degree blade plate (rarely used)
ORIF techniques
ORIF techniques
sliding hip compression (SHS) screw (most common)
proximal femur locking plate
95 degree blade plate (rarely used)
salvage for failed internal fixation
severely comminuted fractures
preexisting severe degenerative hip arthritis
severely osteoporotic bone that is unlikely to hold internal fixation
arthroplasty indications
arthroplasty indications
salvage for failed internal fixation
severely comminuted fractures
preexisting severe degenerative hip arthritis
severely osteoporotic bone that is unlikely to hold internal fixation
biologically friendly with potentially closed technique
less estimated blood loss (EBL)
can be used in unstable fracture patterns
decreased bending strain on implant
cephalomedullary nail
cephalomedullary nail pros
biologically friendly with potentially closed technique
less estimated blood loss (EBL)
can be used in unstable fracture patterns
decreased bending strain on implant
periprosthetic fracture
higher implant cost than sliding hip screw
violation of hip abductors for insertion
cephalomedullary nail
cephalomedullary nail cons
periprosthetic fracture
higher implant cost than sliding hip screw
violation of hip abductors for insertion
advantages of a short nail
ease of use
decreased OR time
decreased EBL
lower implant cost
disadvantages of long nail
increased OR time
increased EBL
increased radiation exposure
possible mismatch of implant bow and femur
advantages of long nail
theoretical benefit of protecting entire femur
short nail can tolerate up to ____ cm of subtrochanteric extension
3-4
proven track record
femoral head rotation during insertion
lag screw
theoretical benefit of compacting cancellous bone around blade during insertion
avoids removal of bone with reamer
biomechanical studies showing higher cutout resistance
helical blade
helical blade benefits
theoretical benefit of compacting cancellous bone around blade during insertion
avoids removal of bone with reamer
biomechanical studies showing higher cutout resistance
lag screw or helical blade cutout
anterior perforation of femur
perimplant fracture
cephalomedullary nail
complications of cephalomedullary nail
lag screw or helical blade cutout
anterior perforation of femur
perimplant fracture
lag screw with tip-apex distance should be less than ____ mm
25
lag screw with tip-apex distance <____ mm is associated with reduced failure rates
25
4 hole plates show no benefit clinically or biomechanically over ___ hole plates
2
sliding hip screw pros
allows dynamic interfragmentary compression
lower implant cost
no violation of hip abductors
allows dynamic interfragmentary compression
lower implant cost
no violation of hip abductors
sliding hip screw
sliding hip screw cons
open technique
increased blood loss
not advisable in unstable fracture patterns
excessive fracture collapse
limb shortening
medialization of shaft
anterior spike malreduction in left-sided, unstable fractures due to screw torque
open technique
increased blood loss
not advisable in unstable fracture patterns
excessive fracture collapse
limb shortening
medialization of shaft
anterior spike malreduction in left-sided, unstable fractures due to screw torque
sliding hip screws
proximal femoral locking plate indication
infrequently used
consider in young patient with unstable fracture
allow for intraoperative fracture compression
avoid excessive postoperative fracture compression
maintain limb length
avoid shaft medicalization
proximal femoral locking plate
proximal femoral locking plate pros
allow for intraoperative fracture compression
avoid excessive postoperative fracture compression
maintain limb length
avoid shaft medicalization
cons of proximal femoral locking plate
limited evidence
highly dependent on surgeon experience
must obtain anatomic reduction
arthroplasty technique
long stem with calcar-replacing prosthesis often needed
must attempt fixation of greater trochanter to shaft
arthroplasty pros
possible early return to unrestricted weight bearing
not reliant on internal fixation in osteoporotic bone
arthroplasty cons
increased blood loss and OR time
increased cost
may require prosthesis that some surgeons are less familiar with
complications:
Implant failure and cutout
nonunion and malunion
peri-implant fracture
Anterior perforation of the distal femur
Postoperative anemia and transfusions
implant failure risk factors
older age
osteoporosis
fracture type
quality of reduction
tip-apex distance (TAD)
older age
osteoporosis
fracture type
quality of reduction
tip-apex distance (TAD)
risk factors for implant failure
tip apex distance
sum of distances from tip of lag screw to apex of femoral head on AP and latera
sum of distances from tip of lag screw to apex of femoral head on AP and latera
tip apex distance
goal tip apex distance
<25 mm
TAD >45 mm associated with _____% failure rate
60
treatment of implant failure and cutout in a young patient
corrective osteotomy and/or revision open reduction and internal fixation
treatment of implant failure and cutout in an elderly patient
total hip arthroplasty
nonunion incidence
<2%
____ can occur with excessively lateral starting point (>3mm)
varus malreduction
varus malreduction can occur with excessively ____ starting point (>3mm)
lateral
hip pain with persistent radiolucent defect at fracture site 4-7 months after surgery
nonunion/malunion
diagnosis of nonunion/malunion
hip pain with persistent radiolucent defect at fracture site 4-7 months after surgery
rule out infection
nonunion/malunion treatment options
valgus intertrochanteric osteotomy + bone grafting
arthroplasty
____ CMN typically fracture just distal to tip of nail
short
short CMN typically fracture where
just distal to tip of nail
____ CMN typically fracture more around the rod
long
long CMN typically fracture where
around the rod
distal interlocking screw protective against ____
fracture
treatment of short CMN peri implant fracture
distally inserted lateral femoral plate with cables
revise to long CMN
treatment of long CMN peri implant fracture
closed reduction and insertion of distal locking screw
distal femoral plating (fracture distal to tip)
risk factors for anterior perforation of the distal femur
mismatch of the radius of curvature of the femur (shorter) and implant (longer)
posterior starting point on the greater trochanter
mismatch of the radius of curvature of the femur (shorter) and implant (longer)
posterior starting point on the greater trochanter
anterior perforation of the distal femur risk factors
post op transfusion rate
> 30%
what medication is recommended to use to decrease EBL and post op transfusions
TXA
Mortality risk in the first year following fracture
15-30%
mortality at 1 year with non op
84.4%
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)
increase mortality
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)
factors that decrease mortality
Surgery within 48 hours decreases 1 year mortality
early medical optimization and co-management with medical hospitalists or geriatricians
surgery within ____ decreases 1 year mortality
48 hours
what is the one third general rule?
1/3 regain function
1/3 lose one level of independence
1/3 mortality rate
_____% maintain pre-injury ambulatory status
41
_____% become more dependent on assistive devices
40
_____% became household ambulators
12
_____% became nonfunctional ambulators
8
