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Intertrochanteric Femur Fracture
Synonyms: IT fracture, intertroch fracture, hip fracture
Intertrochanteric Femur Fx ICD-9
Intertrochanteric Femur Fx Etiology / Epidemiology / Natural History
- 5% initial hopstial mortality, 25% within first year
- Mortality Risk Factors: age >85, lack of independent ADL's prior to fracture, poor nutrition, pre-op ASA class 3 or 4.
- Elderly hip fractures are associated with low-energy falls and osteroporsis. Hip fractures in young patients are associated with high-energy trauma (MVA, fall from height).
- Non-op treatment/delayed surgical treatment = decubiti, UTI, joint contractures, pneumonia, DVT/PE, high mortality rate.
Intertrochanteric Femur Fx Anatomy
- IT fractures occur between the greater and lesser trochanters.
Intertrochanteric Femur Fx Clinical Evaluation
- Lower extremity is shortened and externally rotated with displaced fractures.
- Tender eccymotic hip.
- Pain with any hip ROM.
- Document lower extremity NV exam.
- Document any pre-existing sacral or heel decubitus ulcer.
Intertrochanteric Femur Fx Xray
Intertrochanteric Femur Fx Classification / Treatment
- Stable fracture (posteromedial cortex intact/minimal comminution): 2-hole DHS. Tip-apex distance shoulde be equal to or less than 25mm (tip apex distance = the sum of the distance from the tip of the lag screw to the apex of the femoral head on the AP and lateral Xrays) (Baumgaertner MR, JBJS 1995; 77:1058).
- Unstable fracture (posteromedial cortex comminuted, lateral cortex disruption): IMHS. Generally with long unlocked nail, unless there is subtrochanteric extention. Distal locking indicated for fractures with subtroch extention. Increased failure/complications rate.
- Reverse oblique IT Fxs (5% of all IT/subtrochanteric fxs): Sliding hip screw is associated with many complications and failures. 95 degree fixed-angle device or intramedullary hip screw with distal locking are indicated. (Haidukewych JBJS 2001;83A:643)
- Nonambulatory with minimal pain / medically unstable: Nonoperative treatment (early mobilization is key. Will have varus shortened malunion / nonunion)
- Patholigc fracture: long intramedullary nail.
- Elderly pts with fragility fractures should be evaluated for osteoporosis.
- Orthofix pertrochanteric Fixator (Moroni A, JBJS-AM 2005;87:753-9).
- Gotfried PCCP www.orthofix.com, percutaneous plating system.
- AO Classification (AO Classification)
- IMHS Technique
- DHS Technique
Intertrochanteric Femur Fx Associated Injuries / Differential Diagnosis
Intertrochanteric Femur Fx Complications
- Screw cut-out: associated with tip-apex distance >25mm, increasing age of the patient, an unstable fracture, a poor reduction, & use of a high-angle (150deg) side-plate
- Loss of fixation
- Nonunion
- Malunion (malrotation)
- Osteonecrosis of the femoral head
- Femoral shaft fracture (IMHS)
- Painful hardware
Intertrochanteric Femur Fx Follow-up
- After hip fracture the vast majority of patients require assistance in performing ADLs. Only 20% to 35% of patients who were independent in ADLs before fracture will regain their prefracture ADL independence. Factors predictive of recovery of function in ADL are younger age, absence of dementia or delirium in nondemented patients, and a strong social network. (Koval KJ, JAAOS 1994;2:141)
- Elderly pts with fragility fractures should be evaluated for osteoporosis.
Intertrochanteric Femur Fx References
- Rockwood and Greens
- Kellam JF, Fischer TJ, Tornetta P III, Bosse MJ, Harris MB(eds): OKU Trauma 2. Rosemont, IL, AAOS, 2000, pp 125-131.
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