Intertrochanteric Fractures

Question 1

Intertrochanteric Fractures

Answer 1

Extracapsular fractures of the proximal femur between the greater and lesser trochanter

Question 2

incidence

Answer 2

roughly the same as femoral neck fractures

Question 3

demographics

Answer 3

• female:male ratio between 2:1 and 8:1
• typically older age than patients with femoral neck fractures

Question 4

risk factors

Answer 4

proximal humerus fractures increase risk of hip fracture for 1 year

Question 5

mechanism

Answer 5

• elderly
  
  • low energy falls in osteoporotic patients
• young
  
  • high energy trauma

Question 6

Prognosis

Answer 6

• 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

Question 7

Osteology

Answer 7

• 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

Question 8

Classification

Answer 8

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

Question 9

Nonoperative

Answer 9

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

Question 10

Operative

Answer 10

1. sliding hip compression screw
2. intramedullary hip screw (cephalomedullary nail)
3. arthroplasty

Question 11

sliding hip compression screw

Answer 11

• indications
  
  • stable intertrochanteric fractures
• outcomes
  
  • equal outcomes when compared to intramedullary hip screws for stable fracture patterns

lag screw with tip-apex distance >25 mm is associated with increased failure rates

• pros
  
  • allows dynamic interfragmentary compression
  • low cost
  • no violation of hip abductors
• 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

Question 12

intramedullary hip screw (cephalomedullary nail)

Answer 12

• 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
• pros
  
  • percutaneous approach
  • minimal blood loss
  • may be used in unstable fracture patterns
• cons
  
  • periprosthetic fracture
  • higher cost than sliding hip screw
  • requires violation of hip abductors for insertion

Question 13

arthroplasty

Answer 13

indications

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

Question 14

Complications

Answer 14

1. Implant failure and cutout
2. Anterior perforation of the distal femur
3. Nonunion
4. Malunion

Question 15

Implant failure and cutout

Answer 15

• 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

Question 16

Anterior perforation of the distal femur

Answer 16

• incidence
  
  • can occur following intramedullary screw fixation
• cause
  
  • mismatch of the radius of curvature of the femur (shorter) and implant (longer)
  • posterior starting point on the greater trochanter

Question 17

Nonunion

Answer 17

• incidence
  
  • <2%
• treatment
  
  • revision ORIF with bone grafting
  • proximal femoral replacement

Question 18

Malunion

Answer 18

• incidence
  
  • varus and rotational deformities are common
• treatment
  
  • corrective osteotomies