Definition
Fracture which extends between the trochanters of the proximal femur
- lower limit is inferior border of lesser tuberosity
Anatomy
Extra capsular / well vascularized
The key to stability is the posteromedial cortex
Epidemiology
Elderly
- 90% > 65
- peak at 80 years
F:M 2:1
NHx 1st year
- 1/3 die
- 1/3 worse function
- 1/3 same function
Mechanism of injury
Low energy injuries in osteoporotic patient
- direct = blow to GT
- indirect = torque force secondary to fall
Signs
Leg
- shortened
- externally rotated
- groin pain with leg movement
Prevention
Judicious use of medications
- avoid confusing / sedating
Poor vision
- adapt home environment
- avoid slippery rugs etc
Adapt bathrooms for safety / stability
Hip pads
Dx Occult Hip Fractures
Definition
Hip pain
Normal Xray
Investigations
CT scan
- easily obtained in emergency departments
Bone Scan
- 100% sensitive at 72 hours
MRI
- sensitive within 24 hours
- more expensive and difficult to obtain
Results
Lubovsky et al Injury 2005
- compared CT and MRI
- MRI more accurate
- 4/6 CT inaccurate
Evans Classification
Two main types
- Type 1 Intertrochanteric
- Type 2 Reverse Oblique
Stability
- depends on medial cortical reduction
Unstable
- collapse into varus or shaft medialises
- comminuted PM cortex
- reverse oblique
- subtrochanteric extension
Type 1 Intertrochanteric
1. 2 part undisplaced & stable
2. 2 part displaced, but stable on reduction
3. 3 part with posterolateral support (GT fracture)
4. 3 part without posteromedial support (LT fracture)
5. 4 part without posterolateral or medial support (combination 3 and 4)
Type II Reverse Oblique Type
Inherently unstable
- 2° tendency of femoral shaft fragment to shift medially
Modified Boyd Classification
Type I 21%
- nondisplaced & stable
Type II 36%
- stable, but displaced fractures
- stable construct with pin and plate
Type III 28%
- unstable with pin and plate
- large posteromedial comminution
Type IV 15%
- intertrochanteric with subtrochanteric component
Isolated GT Fracture
Management
Non operative
Issues
Little place for non operative treatment
Immobilization = Severe morbidity
- bed sores
- chest infection
- non-union
Indications
Unit for surgery
Incomplete fractures
Alam et al JBJS Br 2005
- 5 partial intertrochanteric fractures treated non operatively, 3 operatively
- no refractures
- similar length of hosptial stay
Operative
Medical Workup
1. Improve any reversible medical disease
Otherwise surgery in first 24 hours
Consider Cause of fall
- exclude medical cause
- TIA / UTI / MI / Arrythmia
Treat
- electrolyte imbalance / anaemia
- pneumonia / UTI
- arrythmias
2. Patient on anticoagulation
- operate if on plavix
- on warfarin, wait or use FFP to reduce INR < 1.6
Timing
Zuckerman et al JBJS Am 1995
- delay > 2 days increases mortality within the first postoperative year
Goal
Obtain stable anatomical reduction and allow early mobilisation
Options
Sliding Hip Screw and Plate
Intramedullary Hip Screw
Calcar Replacing Prosthesis
Post operative
Mobilise +++
DVT prophylaxis
- chemical and mechanical
Nutrition
Foster et al J Orthop Trauma 1990
- higher morbidity if albumin< 3 (70%) than > 3 (17%)
Prevent secondary fractures
- vitamin D + calcium to all patients
- bisphosphonates if tolerated
Sliding hip screw and Plate
Mechanism
Plate is a lateral tension band whilst the sliding screw allows controlled fracture impaction
Contraindications
1. No lateral buttress
2. Reverse oblique fracture
3. Subtrochanteric extension
Technique
Set up
- traction table with anatomic reduction
- traction, adduction, IR
- other leg: hip and knee flexed with hip abducted to allow II
- lateral approach to femur
Guide wire
- centred in femoral head in 2 planes
- tip-apex distance < 25 mm
Tip - apex distance
- from tip of screw to apex femoral head
- accumulative on AP and lateral
- strong predictor of cut out
- < 25 mm, virtually zero
- > 25 mm, increases cut out
Measure angle
- wire in centre of neck / centre of head
- usually 130o prosthesis
- often only 135o available / need to be lower in neck
- being in the centre of the head is most important
Ream to within 5 mm of end of wire
- tap
- insert screw / tip apex distance < 25 mm
- attach plate
Options for improving stability
A. Valgus Osteotomy for unstable Fractures
Theory
- reduces shear force
- increases compression
- stronger construct
Technique
- 135° plate placed in at 120°
- valgises proximal fragment
- medializes shaft
- +/- lateral wedge removed / Sarmiento Valgus Osteotomy
Cochrane Database Sytemic Review 2009
- no evidence for improved outcome
- higher blood loss
B. Trochanteric stabilisation plate
Theory
- buttresses the GT and prevents lateral displacement
Madsen et al J Orthop Trauma 1998
- compared first generation Gamma nail / CHS and DSH/TSP in unstable fractures
- DHS/ TSP had lowest rate of varus malunion / lag screw cutout / excessive lag screw sliding with medialisation
- CHS still had lowest rate of reoperation
Intra-medullary Hip Screw
Mechanical Advantages
- load sharing rather than load bearing
- decreases lever arm
- supports medial cortex
- less distance for collapse
Theoretical Surgical Advantages
- smaller incision / mini invasive
- reduced blood loss
- shorter surgical times
Indications
- reverse oblique
- unstable fracture / loss of lateral buttress / loss posteromedial support
- intertrochanteric extension
- pathological fractures
History
First generation Gamma Nail (Stryker) had 5% distal femoral fracture rate
Reasons for distal fracture
- fit and fill caused increased distal stresses (higher fracture with 16 mm diameter nail)
- no anterior bow
- poor distal locking technique (missed holes caused fractures)
- 2 distal screws
Second Generation intra-medullary hip screws
IMHS / Gamma Nail
- trochanteric entry
- decreased distal diameter
- shorter length (180 mm v 200mm)
- only 4o valgus offset
- 125 - 130o angle
- one distal screw with jig
Results
Second Generation IMN v Sliding hip screws
- several prospective randomised studies
- very similar rates of complications
- similar cut out, blood loss, time of operation
- slight risk femoral fracture IMN
- learning curve for IMN (25 cases)
Cochrance database review 2008
- no evidence of superiority of IMN over sliding hip screw
- increased complications with nail
3. Calcar replacing prosthesis
Indications
- salvage of failure of fixation
- severe comminution
- RA
Problems
- high cost
- higher morbidity / mortality
- high risk of dislocation
Complications
1. Screw Cut Out 6%
Causes
- poor screw position
- 150° screw
- high tip apex distance
Options
- 95o DCS
- THR / calcar replacing prosthesis
THR Issues
A. Cemented femoral component
- cement will come out screw holes
- Option 1: leave screws in laterally, and strip medially to insert small screws
- Option 2: use uncemented stem
B. Length of femoral stem
- should bypass distal screw hole by 2 cortical diameters
C. Calcar
- normal stem usually sufficient if LT healed back on
Barrel Impingement / Excessive Lateral sliding / Shaft medialisation
Cause
1. Long screw
2. Collapse with insufficent lateral buttress
3. Reverse obliquity fracture
Management
1. Fracture united
- remove screw
2. Fracture non union
- revise fixation in young patient
- THR
Lateral Slide Off Proximal Fragment
Femoral medialisation
Due to
- insufficient lateral cortex
- reverse obliquity fracture
Use 95° plate
Non Union
Uncommon / 1%
- exclude infection
Presentation
- continued pain (case 1)
- hardware failure (case 2)
Case 1
Case 2
Options
A. Closing lateral wedge valgising osteotomy + graft
- success 90% / indicated in younger patients
B. 95 degree DCS Plate
C. Revision IMN
D. THR
Infection 2-5%
Malrotation
Cause
- posterior sag of femur in unstable fracture
- get malrotation if use excessive IR to "reduce" fracture on II
Periprosthetic fracture
Usually fracture at tip of plate
- remove distal screws and insert retrograde nail