trochanteric #

TROCHANTERIC FRACTURES

Proximal Femur Anatomically covers

• Intracapsular Femoral Neck Fractures.

• Extra capsular Trochanteric Fractures.

• Subtrochanteric Fractures.

STRUCTURAL ANATOMY• Neck shaft angle - 130 degree +/- 7

degree• Anteverion – 10 degree +/- 7 degree• Average femoral head size – 40 to

60mm• Joint capsular attachment• Intracapsular portion of neck has no

periosteum • Fractures must heal by endosteal

union• Trabecular network

Bone density

Intertrochanteric fracture.• Occurs in the transitional zone between

Cancellous and cortical bone. • Role of calcare femorale in stability.

• AVN and NONUNION are rare.

• Malunion.

Intertrochanteric Fractures

Stable Unstable

Stability is based on• Reconstructable posteromedial cortical

buttress• Subtrochanteric Extension• Reverse Obliquity

Classification

• Stable - Standard oblique IT fracture pattern without communition.

• Unstable – reverse oblique fracture pattern with communition of posteromedial cortex extension into subtrochanteric region

EVANS - Stable vs. unstable.

Treatment Options

• Surgery is the main stay – allows early mobilization

• Closed (more acceptable) / Open Reduction Internal Fixation

• Implants 1) Sliding Hip Screw Fixation2) Med off Plate3) Intramedullary Hip Screw Device.4) Recon IM nail.

Sliding Hip Screw• Placement of screw• Angle of Barrel Plate• Plate Length• Use of synthetic calcium sulfate bone cement in

osteoporotic bones• No need for medial displacement osteotomy• Tip apex distance < 20 - 25mm• Loss of fixation (4-12%)• Impacted reduction better• 10mm minimum slide required.

INTERTROCHANTERIC FRACTURE FEMUR

BOYD AND GRIFFIN TYPE -4 DYNAMIC HIP SCREW

Two hole side plate advantageous in sliding hip screw fixation of stable and unstable trochanteric fractures.

Bolhofner et al., J. Orthop, Trauma, 1999 13: 5 – 8

Intramedullary Devices

Ideal Indications • Communited intertrochanteric with

subtrochanteric extension• Reverse oblique fractures• High subtrochanteric fractures

Intramedullary device.

ANGLED BLADE PLATE FIXATION

Medoff Side Plate with CHS

• CHS – allows compression along neck femur• M Plate – allows compression parallel to long

axis of femur• Comparative study: no difference in stable

fracture patterns• Lower failure rate with Medoff plate in

unstable fractures.

DHS Vs Medoff sliding plate for I / T fractures

• Stable fractures: United well in both groups • Unstable fractures: overall failure rate – 9.6%

DHS – 14%MSP – 03% - increased surgical time & blood loss

Watson et al; Clin. Orthop, 1998 348: 79 – 86.

Norian SRS cement augmentation in trochanteric fracture fixation useful.

Goodman et al; C. Orthop. 1998 348: 42 - 50

No difference between CHS and IMHS

• Surgical time• Duration of hospital stay• Infection rate• Wound complications• Implant failure• Transfusion requirements• Screw cutout / screw sliding• Increased risk of thigh pain• Increased risk for femoral shaft fractures IMHS• Less limb shortening

Comparison of IMHS Vs SHS in treatment of I/T fractures less screw sliding and less shortening in IMHS group and better mobility in early post op.No differences in mortality, complications, functional outcome and ambulatory ability

Hardy et al; JBJS, A 1998 80: 618 - 631

Prosthetic Replacement in Trochanteric Fractures

Limitations• More extensive surgical procedure• Increased dislocationsIndications• In grossly communited fractures• When internal fixation fails• osteoporosis

To Conclude

• Trochanteric fractures gives the best outcome when anatomically reduced and internally fixed using the appropriate implant.