You are in: eMedicine Specialties > Orthopedic Surgery > HIP Intertrochanteric Hip FracturesArticle Last Updated: Jul 6, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Richard S Goodman, MD, JD, FAAOS, Chair, Department of Surgery, SABA University Medical School; Consulting Staff, Department of Orthopedics, Long Island Jewish/North Shore University Hospital Richard S Goodman is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Bar Association, American College of Legal Medicine, American College of Surgeons, Arthritis Foundation, Eastern Orthopaedic Association, International College of Surgeons, Medical Society of the State of New York, and Pan American Medical Association Editors: James F Kellam, MD, Vice-Chair, Department of Orthopedic Surgery, Director of Orthopedic Trauma and Education, Carolinas Medical Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; James J McCarthy, MD, FAAOS, FAAP, Associate Professor, Consulting Orthopedic Surgeon, Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health;; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; William L Jaffe, MD, Clinical Professor of Orthopedic Surgery, New York University School of Medicine; Vice Chairman, Department of Orthopedic Surgery, Hospital for Joint Diseases Author and Editor Disclosure Synonyms and related keywords: hip fractures, broken hip, femoral neck fractures hip fracture, fracture of the hip, femoral head fractures, trochanteric fractures, subtrochanteric fractures, hip joint, iliofemoral ligament, ischiofemoral ligament, avascular necrosis, intracapsular fracture, extracapsular fracture, anterior dislocation, posterior dislocation, single fragment fracture, comminuted fracture, stress fracture, incomplete fracture, impacted fracture, partially displaced fracture, completely displaced fracture, single fracture lines, multiple fracture lines, nondisplaced fracture INTRODUCTIONSection 2 of 12
  Intertrochanteric fractures are considered 1 of 3 types of hip fractures. The anatomic site of this type of hip fracture is the proximal, upper part of the femur or thigh bone. The proximal femur consists of the femoral head, femoral neck, and the trochanteric region. An intertrochanteric hip fracture occurs between the greater trochanter, where the gluteus medius and minimus muscles (hip extensors and abductors) attach, and the lesser trochanter, where the iliopsoas muscle (hip flexor) attaches (Netter, 1987). Fractures of the femoral neck are proximal or cephalad to intertrochanteric fractures, and subtrochanteric fractures are distal or below (sub) to the trochanters. These fracture types are discussed in other eMedicine articles. Though all of these fractures are often referred to simply as hip fractures, the above distinctions between femoral neck fractures, intertrochanteric factors, and subtrochanteric fractures are important because the anatomy, prognosis, and management are different for these fracture types. Femoral neck fractures are frequently treated using a prosthesis or replacement device to substitute for the proximal femoral fragment, including the residual neck fragment with the devitalized femoral head. Intertrochanteric fractures are treated using an engineered metallic fixation device (internal splintage device) designed to maintain the nondisplaced, minimally displaced, or postreduction fracture fragments in their anatomic, near-anatomic, or acceptable postreduction position. This stability assists in the healing of the fracture. In addition, postoperative care and rates of complications, including mortality and morbidity, vary for different fractures and different subcategories of intertrochanteric fractures. The current treatment of intertrochanteric fractures is surgical intervention. Despite an acceptable healing rate with nonsurgical methods, surgical intervention for intertrochanteric fractures has replaced previous nonsurgical methods of prolonged bed rest, prolonged traction in bed, or prolonged immobilization in a full-body (spica) cast (Rang, 2000). Though healing rates for previous nonsurgical methods may have been acceptable, they were accompanied by unacceptable morbidity and mortality rates because of frequent nonorthopedic complications associated with prolonged immobilization or inactivity. Complications included the following:
Currently, with a few exceptions, surgical intervention is used to treat essentially all intertrochanteric fractures and is described as open reduction and internal fixation (ORIF). Various surgical fixation devices are now available for the treatment of essentially all intertrochanteric fractures. Each device requires a careful match between the appropriate internal fixation device and the specific type of fracture. The correct surgical technique described by the developer of the device should also be used. Therefore, the optimal device is chosen after a precise diagnosis of the type of intertrochanteric fracture. The indications and contraindications of the technique must also be matched with the patient's activity level, degree of osteoporosis, and realistic expected outcome. To accomplish this match between technique and patient, at a minimum, technically adequate preoperative radiographs of the hip are necessary, including anteroposterior (AP) view of the pelvis and involved hip and true lateral view (cross-table technique). In some cases, a frog lateral view, a computerized axial tomography (CAT) scan, or even a reconstituted CAT scan may be necessary to define the fracture in sufficient detail to accurately plan the surgery. Gentle traction applied during the radiograph will help define the fracture, particularly if significant shortening has occurred. History of the ProcedureAn intertrochanteric fracture was described by Cooper in his treatise of 1851 as follows: ...fracture of the femur through the trochanter major, passes obliquely upwards and outwards from the lower portion of the neck but instead of traversing the neck completely, it penetrates the base of the trochanter major; the line of fracture being such as to separate the femur into two fragments, one of which is composed of the head, neck and trochanter major, and the other of the shaft with the remaining portions of the femur. (Bick, 1976) Cooper's recommended treatment was "moderate extension and steady support of the limb in its natural position" (Bick, 1976). Cooper also contributed to the knowledge of intertrochanteric fractures in his book of 1822, in which he was the first to distinguish between fractures of the neck of the proximal femur (intracapsular) and those outside of the joint capsule (extracapsular) through the trochanteric level. He recognized that fractures external to the capsule united, whereas fractures internal to the capsule did not unite. His treatment consisted of bed rest, followed by the use of crutches and a cane, and then an elevated shoe, all in an attempt to save the patient's life if not the limb. The diagnosis and care of intertrochanteric fractures were then studied and written about by Dupuytren, Malgaigne, Velpeau, and Whitman, among others (Rang, 2000). In 1902, Royal Whitman first reported on the reduction of fractures with abduction, internal rotation, and traction under anesthesia with immobilization in a spica cast from the nipple line to the toes (Rang, 2000). Ledbetter reported on the heel and palm test for adequate reduction, saying that "after the leg has been brought down in the measured degree of abduction and internal rotation, the heel of the injured leg is allowed to rest on the outstretched palm. If the reduction is complete, the leg will not exert itself. Should there be no interlocking of the fragments, however, the leg will slowly rotate externally" (Bick, 1976). As opposed to closed treatment following the reduction of the fracture, Langenbeck attempted internal fixation of the reduced fracture in 1850 using an intramedullary nail. Other physicians followed with different nails but faced problems with the procedure. Blind reduction and fixation of the fracture and blind nailing or percutaneous insertion of a nail or other internal fixation device without visualization of the tract of the nail meant that malposition of the fracture, the device, or both was frequent. Moreover, technology was unavailable to produce fixation devices with adequate tensile strength or devices that caused only a minimal or inconsequential reaction from body tissues. In addition, the lack of antibiotics meant that postoperative infections received only minimal treatment and resulted in significant complications. Portable radiographic machines and the subsequent development of portable fluoroscopy machines with image intensification screens and low radiation technology resulted in control and confirmation of the fracture reduction in the operating room. Cannulated fixation devices (eg, nails, hip screws, side plates) that are placed over temporary guide wires allow the surgeon to more easily plan and confirm the position of the fixation device and add to the surgeon's armamentarium. Today, the procedure uses radiographs on an image intensifier screen to project and record a satisfactory stable reduction of the fracture. Operating room fracture tables with traction devices hold the reduced position of the fractured femur while guide wires are properly inserted to guide the eventual position of the planned fixation device. The planned device is then inserted with a lag screw or screws to hold the proximal fragment, a side plate to hold the lag screw to the distal femur, and screws to attach the plate to the distal femur. A compression screw draws the lag screw into the side plate barrel and compresses the proximal and distal fragments to each other. ProblemThe literature, as noted from the early 1800s, revealed that intertrochanteric hip fractures routinely healed but were malunited in varus, leading to deformity and decreased function secondary to a limp and hip abductor weakness. However, nonoperative care of intertrochanteric fractures had significant, unacceptable morbidity and mortality rates because of concurrent medical problems and prolonged incumbency that prevented union from occurring. Because of these significant problems, conservative treatment was deemed unacceptable regardless of the mortality rate. Therefore, progress in the care of intertrochanteric fractures has involved decreasing the mortality from nonorthopedic coexisting or concurrent medical problems and decreasing the degree of malunion and possible nonunion of these fractures. FrequencyApproximately 252,000 hip fractures occur each year in the United States. Despite the relatively small incidence, hip fractures are responsible for approximately 3.5 million hospital days in the United States; hip fractures account for more hospital days than tibial fractures, vertebral fractures, and pelvic fractures combined. In addition, hip fractures account for more than half of the total hospital admissions of all fractures and more than half of the ambulance calls for fractures. EtiologyThe etiology of intertrochanteric fractures is the combination of increased bone fragility of the intertrochanteric area of the femur associated with decreased agility and decreased muscle tone of the muscles in the area secondary to the aging process. The increasing bone fragility results from osteoporosis and osteomalacia secondary to a lack of adequate ambulation or antigravity activities, as well as decreased hormone levels, increased levels of demineralizing hormones, decreased intake of calcium and/or vitamin D, and other aging processes. Benign and malignant tumors, along with metastases such as multiple myeloma and other malignancies, can also lead to weakened bony structure. The combination of increased fragility of bone and a traumatic event such as a motor vehicle accident or fall may result in either a direct impact or generation of a torsional force transmitted through the leg to the intertrochanteric area. When such forces are greater than the strength of the bone in the intertrochanteric area, a fracture occurs. ClinicalElderly patients frequently have other significant coexisting or preexisting pathologic conditions that result in decreased resistance to the stresses of anesthesia, trauma, and surgery and an increased need for extensive postoperative rehabilitation. Coexisting or preexisting conditions that were present but unknown, undiagnosed, or simply tolerable before the fracture include pulmonary insufficiency, cardiac insufficiency, mitral valve insufficiency, aortic valve insufficiency, cardiovascular insufficiency, hypertension, dehydration, malnutrition, and any of a number of metabolic diseases or endocrine diseases, including diabetes and hypothyroidism. In addition, metabolic changes are consistent with the postoperative stresses from the postoperative analgesics and the postoperative rehabilitation program. As a result of these comorbidities, a 2-stage treatment program is recommended. Stage 1 Identify the fracture on the basis of the history and the findings from physical examination and radiographs. The patient typically presents with a history of slipping on, falling on, or twisting of the lower extremity that is followed by severe pain in the affected hip area. Patients may be unable to stand or move their body or the affected extremity without pain. Local physical examination typically reveals the affected lower extremity in a position of hip extension with the leg externally rotated, with the patient experiencing pain on any active or passive motion of the hip or any part of the extremity. The diagnosis of an intertrochanteric fracture is confirmed by the review of appropriate radiologic images, including an AP pelvic view and either a cross-table lateral view of the hip or a frog lateral view of the hip and a traction AP hip radiograph. A full-length radiograph of the involved femur is necessary to rule out any pathologic process or deformity that may exist distal to the fracture. These images also define the inherent stability or instability of the fracture, the need for a reduction of the fracture, and whether further manipulation is indicated to produce a reduction sufficiently stable to heal before the implant fixation is lost. The stability of the fracture is defined by the amount of contact between the proximal and distal main fragments. Two-part intertrochanteric fractures are very stable, as there are only 2 fragments, which, once reduced, are impacted on each other and provide inherent stability for the implant. The fracture stability is inversely proportional to the size of the lesser trochanteric fragment (3-part fracture). Instability occurs when more than 50% of the calcar is affected, allowing the proximal fragment to collapse into varus position and shorten. Therefore, a fracture is considered unstable if there is a large lesser trochanteric fragment or if the greater and the lesser trochanter are separate fracture fragments (4-part fracture). The more unstable the fracture, the more difficult it is to reduce the fracture and the more likely it is that an implant, such as a cephalomedullary nail, will be needed to stabilize the fracture and prevent collapse. Stable fractures can be treated with a sliding hip screw–plate device (2- to 4-hole plate). Stage 2 Stabilize the patient's medical condition before surgical intervention. This phase almost always requires consultation with an internist, a primary care physician, or a hospitalist and frequently requires secondary consultations with members of various medical subspecialties. This phase also includes the identification of any known preexisting medical conditions as well as any medical condition discovered at the time of hospital admission. If any medical conditions are discovered, appropriate preoperative care is provided to eliminate potential postoperative problems that may arise from such conditions. These medical conditions are determined by a complete physical examination; cardiac, laboratory, and pulmonary studies; and any other studies that may be indicated. Preoperative tests frequently include a complete blood cell (CBC) count, a urinalysis, an SMA-12 (sequential multiple analysis–12-channel biochemical profile), a chest radiograph, and an electrocardiogram. Additional tests may be required, depending on the patient's clinical findings, past and current medical history, and results of the screening laboratory studies and images. Any medical abnormalities are treated promptly and appropriately before surgical intervention, without allowing complications to occur because of any unnecessary delay in initiating surgery. During this period, appropriate measures are instituted to decrease the possibility of a DVT and secondary pulmonary embolism (usually considered a preoperative protocol). The surgical procedure follows with the reduction and internal fixation of the fracture, followed by the postoperative rehabilitation phase. INDICATIONSSection 3 of 12
Open reduction and internal fixation (ORIF) is indicated for all intertrochanteric fractures, unless the patient's medical condition is such that any anesthesia, general or spinal, is contraindicated; if the patient is unable to tolerate any surgical procedure because of an uncontrollable or uncorrectable bleeding disorder or other noncorrectable metabolic disorder with an unacceptable mortality rate; or if the patient has a stable, nondisplaced intertrochanteric fracture, can physically and mentally tolerate nonsurgical care, and declines surgery for personal reasons. RELEVANT ANATOMYSection 4 of 12
The intertrochanteric area of the femur is distal to the femoral neck and proximal to the femoral shaft. It is the area of the femoral trochanters, the lesser and the greater trochanters. The intertrochanteric area can also be seen as the area where the femur changes from an essentially vertical bone to a bone angling at a 45° angle from the near-vertical to the acetabulum or pelvis. The femoral artery and nerve are anterior; the sciatic nerve is posterior. The attachments of the iliopsoas and gluteus medius can cause certain displacements, depending on the fracture patterns. These factors may make reduction difficult. The attachment of the gluteus maximus to the femoral shaft is a guide to the level of the lesser trochanter and helpful when placing a guidewire for the compression screw. The vastus lateralis overlies the lateral cortex of the proximal femur and must be elevated to apply a side plate. CONTRAINDICATIONSSection 5 of 12
Contraindications to surgery include those listed in Indications and consist of medical conditions that preclude anesthesia or surgery and stable fractures in patients who can tolerate nonoperative care. WORKUPSection 6 of 12
Lab Studies
Imaging Studies
TREATMENTSection 7 of 12
Surgical therapyThe patient with an intertrochanteric fracture is ready to proceed with surgery after the medical evaluation is completed and medical pathology is decreased or medical conditions stabilized without undue delay. Preoperative detailsThe patient is taken to the operating room after appropriate surgical consent has been obtained. Correct side identification and patient identification are completed. According to the judgment of the anesthesiologist, the patient is given either general anesthesia or spinal anesthesia. When adequate anesthesia has been administered, the patient is transferred to an orthopedic or fracture table. Intraoperative detailsThe patient and the affected extremity are positioned on the table, where closed reduction of the fracture is performed. The sequence for reduction commences with longitudinal traction in a well-relaxed patient. The fracture is fully extended when the top of the greater trochanter is at the center of the femoral head; at this point, the normal neck shaft angle is restored. The leg is then internally rotated to align the neck with the shaft in the lateral view and to ensure proper anteversion. Appropriate images are obtained with 1 or 2 fluoroscopic imaging (C-arm) machines. If the reduction is not satisfactory, then adjustments are made by changing the rotation, abduction, or the amount of traction of the affected extremity. Surgery proceeds when an adequate, stable, or near-anatomic reduction is obtained, with correction of any problems with rotation, leg length, lateral angulation, and AP angulation. Certain fracture patterns cannot be reduced in a closed manner; in such cases, open reduction is required. The lateral hip and femur are then prepared and draped. A side plate is indicated to provide a more stable attachment of the device (pin, sliding nail, or screw) in the neck of the femur with the distal femoral shaft. The plate is applied to the outside or lateral side of the femur with screws going through the plate into one or both cortices of the femur. The upper end of the plate attaches to the device, which is placed in the femoral neck by using a nut or compression screw. A lateral incision is made in the skin directly over the greater trochanter and continued down through the overlying fascia and muscles to the femur. The lateral femur is exposed and a guidewire is drilled from the lateral femur to the femoral head, so that the guidewire is centered in the femoral neck in both the lateral view and the AP view, as shown on the fluoroscopic images. The angle between the wire and the femoral shaft must equal the angle of the proposed fixation device, usually an angle of 135°. The tip of the guidewire must lie in the center of the femoral head and 1 cm from the subchondral line on both the AP and lateral views. This is the tip apex distance (TAD), as described by Baumgaertner. The TAD must be less than 2.5 cm for a minimal screw cutout. If the guidewire is placed appropriately, the drilled hole is enlarged with the cannulated drills supplied with the fixation device over the already placed guidewire. The lag screw is inserted into the femoral head. The side plate and barrel are placed over the screw, and the guidewire is removed. The side plate is then attached to the femoral shaft with the appropriate screws. Fluoroscopic images are taken throughout the repair to ensure the maintenance of the reduced fracture position and the proper positioning of the fixation device. Intramedullary nailing Intramedullary nailing has been used as a treatment alternative for intertrochanteric fractures. Multiple thin-diameter solid nails (Enders nails) inserted from the knee in a retrograde fashion were popular in the 1970s and 1980s. This technique, however, led to excessive external rotation and knee pain and has been abandoned. The use of antegrade nails inserted through the greater trochanter, with a compression hip screw inserted through the proximal portion of the nail into the femoral head, is now being used, especially for unstable fracture patterns. The cephalomedullary nails may help with reduction of unstable fractures and prevent excessive shortening from collapse, because the nail acts as a calcar replacement and supports the femoral neck. This technique provides for a percutaneous insertion technique and has the potential for less blood loss, earlier full weightbearing, and better reductions. However, it is technically demanding and has had a high rate of femoral shaft fractures below the nailtip; modifications of nail design have reduced this complication. Percutaneous hip screw and plate insertion is now possible with the introduction of a new implant that has been designed to allow this surgical technique. After the appropriate fixation device has been placed, the muscles, fascia, and skin are closed. The patient is then transferred to a recovery room. Postoperative detailsThe patient's nonorthopedic conditions continue to be treated following an intertrochanteric fracture repair. Preventive DVT protocol is followed with an appropriate combination or selection of antiembolism stockings and anticoagulants. The anticoagulants include, but are not limited to, aspirin, heparin or a heparin derivative, and warfarin (Coumadin) or a warfarin derivative. Anticoagulants require appropriate monitoring to ensure adequate dosage and to prevent overmedication and bleeding. With each medication or protocol, the dosage of medication is different, length of treatment is different, and combination of medications and use of anticoagulant socks vary. Follow the manufacturer's protocol. Physical therapy is instituted to allow the patient to ambulate with the aid of physical therapists or other nursing personnel. Equipment includes walkers, crutches, 4-post canes, and other canes as recommended by the physical therapist and surgeon. The physical therapist guides therapy and the use of assisted ambulatory supports on the basis of proper instructions from the surgeon. The surgeon indicates the differences between nonweightbearing, toe touching, partial weightbearing, and full weightbearing therapies and the proper techniques for use of various ambulatory devices. In patients of advanced age, it may be difficult to institute therapy beyond full weightbearing. COMPLICATIONSSection 8 of 12
Intertrochanteric hip fractures have significant complication rates: 20-30% in the first year, including a 5% nonunion rate, a 5% infection rate, and an 11% rate of device failure. Important approaches to prevention of complications are to follow a careful preoperative sterilization technique, to do a careful preoperative study of radiographs, to perform meticulous insertion of devices, and to do careful postoperative monitoring with radiographs and a clinical examination to ensure healing of the fracture. Medical complications of intertrochanteric hip fractures are secondary to any preexisting medical conditions that have or have not been recognized, diagnosed, or properly treated, depending on the limitations of time and facilities and the current level of medical care. Medical complications include cardiac, pulmonary, renal, hepatic, and vascular conditions. Systemic complications can occur because of anesthesia (general or spinal) used in the procedure, stress from the surgical procedure, or even stress in general. Local orthopedic complications can occur if an adequate stable reduction of the fracture is not obtained and maintained or if the correct position is lost before healing because of movement associated with daily activities and personal hygiene. Loss of position before healing can also occur from a failure of the fixation device because of improper insertion or from a failure of the fracture to heal before the end of the mechanical life of the device. OUTCOME AND PROGNOSISSection 9 of 12
A stable and acceptably fixed intertrochanteric fracture is expected to heal. The activity level of elderly patients usually drops 1 level after recovery from this injury. The mortality rate is 20-30% during the first year after fracture for these patients. FUTURE AND CONTROVERSIESSection 10 of 12
The future of intertrochanteric fracture repair focuses, in part, on the prevention of the fracture from antiosteoporosis treatments, including medications and health programs. Another focus includes fixation devices that require smaller incisions and are more forgiving, with retention of the fixation, regardless of whether the fracture is ideally reduced or has an element of instability. Finally, the goal is to eliminate or substantially decrease the mortality and morbidity of postoperative DVT and pulmonary emboli by developing a better understanding of the clotting mechanism and the genetic, metabolic, serologic, and hormonal factors that affect the likelihood of developing pulmonary emboli. The current controversy regarding pulmonary emboli prevention is over the antiembolism treatments available, with a conflict between anticoagulants (eg, aspirin, heparin, warfarin) and mechanical protocols (eg, antiembolism stockings) to prevent emboli. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Intertrochanteric Hip Fractures excerpt Article Last Updated: Jul 6, 2006 | |||||||||||||||||||||||||||||||||||||||||||||||
