Intertrochanteric Fractures

Author: Derek Moore

Topic updated on 04/08/13 11:20am

Introduction

Bimodal distribution
- older patients (older than femoral neck fx)
  - low energy in osteoporotic patient
  - ASA classification is predictor of mortality
  - proximal humerus fracture increases the risk of a subsequent hip fracture for 1 year
- younger patients
  - high energy
  - often more comminution

Classification

Stable
- will resist medial compressive loads once reduced
Unstable
- include
  - reverse obliquity pattern
  - large posteromedial fragment (lesser troch fx)
  - subtrochanteric extension
- will collapse into varus or shaft displaces medially despite axial reduction

Presentation

Physical Exam
- painful, shortened, externally rotated lower extremity

Imaging

Radiographs
- recommended view
  - AP pelvis and cross table lateral

Treatment

Operative
- sliding hip compression screw
  - indications
    - in stable intertroch fracture in ambulatory patients
  - contraindications
    - in reverse obliquity fractures
      - 56% failure rate when sliding hip screw used in reverse obliquity fractures
    - lack of integrity of lateral femoral wall
      - associated with increased sliding displacement (collapse)
  - outcomes
    - surgery within 48 hours associated with decreased 1 yr. mortality
    - 4 hole plates show no benefit clinically or biomechanically over 2 hole plates
    - cephalomedullary nails show not benefit over SHS
- cephalomedullary fixation nail
  - indications
    - reverse obliquity fx pattern (unstable fx pattern) in ambulatory patients
    - use has significantly increased recently
  - advantages of cephalomedullary fixation vs. blade plate
    - pros
      - decreased reoperation rate at one year
      - shorter operative time
      - prevents medialization of shaft
      - fewer blood transfusions
      - shorter hospital stay
    - cons
      - creates stress riser in proximal femur (stress fxs at tip of prosthesis have been reported)
- blade plate
  - indications
    - reverse obliquity pattern (unstable)
    - improved outcomes for unstable peritrochanteric fractures as compared to sliding hip screws

Techniques

Sliding hip compression screw
- technique
  - allows dynamic interfragmentary compression
  - obtain correct neck-shaft relationship
  - can cause anterior spike malreduction in left sided unstable fractures due to screw torque
Cephalomedullary nail
- postoperative treatment
  - weight bearing as tolerated (cognitively intact patients will autoprotect)

Complication

Implant failure and cutout
- most common complication
- in young: treat with corrective osteotomy and/or revision open reduction and internal fixation
- in elderly: treat with total hip arthroplasty
Anterior perforation of the distal femur
- can occur after intramedullary nailing
  - due to mismatch of the radius of curvature of the femur (shorter) and implant (longer)

Please Rate Educational Value!

4.0

Average 4.0 of 20 Ratings

Qbank (14 Questions)

TAG

(OBQ11.172) Which of the following methods accurately describes the measurement of tip-apex-distance as it relates to placement of a lag screw in the femoral head? Topic

Review Topic

1. Summation of the distance between the end of the screw and the apex of the femoral head on AP and lateral radiographs
2. Distance from the acetabular teardrop to the tip of the screw on an AP radiograph of the hip
3. Multiplication of the distance between the end of the screw and the apex of the femoral head on AP and lateral radiographs
4. Distance from the center of the lesser trochanter to the tip of the screw on an AP hip radiograph
5. Summation of the distance between the tip of the greater trochanter and end of the screw on AP and lateral hip radiographs

PREFERRED RESPONSE ▶

DISCUSSION: TIp-apex distance (TAD) as it relates to a lag screw in the femoral head is the summation of the distance between the end of the screw and the apex of the femoral head on AP and lateral radiographs. This is shown in Illustration A.

TAD is a useful intraoperative indicator of deep and central placement of the lag screw in the femoral head, regardless of whether a nail or a plate is chosen to fix a fracture. A TAD of <25mm has been shown to minimize the risk of fixation cut-out in stable and unstable intertrochanteric hip fractures.

Baumgaertner et al examined factors leading to the failure of sliding hip screws (SHS) in the treatment of 198 intertrochanteric fractures. They determined that the tip-apex distance (TAD) is a reproducible, standard measurement to predict SHS failure. The average TAD for successful fractures was 24mm while the average TAD for failures was 38mm. No screw with a TAD <25mm failed. Calculation of the TAD is shown in Illustration B.

Kyle et al reviewed 622 intertrochanteric fractures. For unstable patterns, a SHS was superior to a fixed angle nail. Early ambulation and weight bearing contributed to improved results.

Illustrations B and C show a lag screw with an excessive TAD, and subsequent failure of fixation.

Illustrations: A

REFERENCES:

1. Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am. 1995 Jul;77(7):1058-64. PMID:7608228 (Link to Abstract)

2. Kyle RF, Gustilo RB, Premer RF. Analysis of six hundred and twenty-two intertrochanteric hip fractures. J Bone Joint Surg Am. 1979 Mar;61(2):216-21. PMID:422605 (Link to Abstract)

3. Koval KJ, Zuckerman JD. Intertrochanteric fractures. In: Bucholz RW, Heckman JD, eds. Rockwood and Green's Fractures in Adults. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:1635-1663.

Question Authors:

Terrill Julien MD, Ben Taylor MD, Michael Hughes MD,

Please Rate Educational Value!

3.0

Average 3.0 of 18 Ratings

TAG

(OBQ11.189) Which of the following hip fracture patterns is at increased risk of proximal fragment flexion malreduction with dynamic hip screw fixation? Topic

Review Topic

1. Right-sided unstable intertrochanteric fracture
2. Left-sided unstable intertrochanteric fracture
3. Left-sided stable intertrochanteric fracture
4. Right-sided stable intertrochanteric fracture
5. All unstable intertrochanteric fractures

PREFERRED RESPONSE ▶

DISCUSSION: Left-sided unstable intertrochanteric hip fractures are at increased risk of malreduction compared to unstable right-sided fractures fixed with dynamic hip screws. In left-sided fractures the rotational torque imparted to the proximal head and neck fragment can cause loss of reduction leading to potential failures of fixation. With these left sided injuries, the rotational torque can cause an anterior spike, whereas with right-sided injuries the rotational torque causes compression and reduction of the fracture. In addition, if a nail is used for these injuries and the proximal fracture fragment is not being held by the nail itself, this phenomenon can be seen as well.

Mohan et al conducted a study to assess the effect of clockwise rotational torque onto the fracture configuration in unstable and stable intertrochanteric fractures fixed with a dynamic hip screw construct. They found that 11 out of 30 unstable fractures showed an anterior spike (flexion malreduction) in left-sided fixations due to clockwise torque. This malreduction was not present in right-sided or stable fractures.

Illustrations A and B are images from Mohan et al's study showing the rotational affect on the fracture with placement of a dynamic hip screw.

Illustrations: A

REFERENCES:

1. Mohan R, Karthikeyan R, Sonanis SV. Dynamic hip screw: does side make a difference? Effects of clockwise torque on right and left DHS. Injury. 2000 Nov;31(9):697-9. PMID:11084157 (Link to Abstract)

2. Koval KJ. Intertrochanteric fractures. Use of a sliding hip screw. In: Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006;233-248.

Question Authors:

Joshua Blomberg MD, Ben Taylor MD, John Badylak MD,

Please Rate Educational Value!

2.0

Average 2.0 of 24 Ratings

TAG

(OBQ10.17) A 74-year-old female falls from a standing height and sustains the fracture shown in Figure A. The occurrence of this injury increases her risk of sustaining a subsequent hip fracture for what amount of time? Topic

Review Topic

FIGURES: A

1. Only until the humerus fracture is healed
2. 1 year
3. 5 years
4. 10 years
5. Lifelong increase in risk

PREFERRED RESPONSE ▶

DISCUSSION: Clinton et al performed a Level 2 study of 8049 women that demonstrated that proximal humeral fractures independently increased the risk of a subsequent hip fracture. The risk was more than five times in the first year after the humeral fracture but was not associated with a significant increase in the hip fracture risk in subsequent years.

Johnell et al performed a Level 4 review that found that men and women had an increased risk of hip, forearm and spine fractures following a prior spine, hip or shoulder fracture.

Schousboe et al performed a Level 2 investigation of 9516 community-dwelling elderly women and found that 521 hip fractures occurred after 10 years of follow-up. They found that prior non-spine fractures, non-hip fractures, and prevalent moderate to severe radiographic vertebral fractures were modestly associated with incident hip fracture.

REFERENCES:

1. Clinton J, Franta A, Polissar NL, Neradilek B, Mounce D, Fink HA, Schousboe JT, Matsen FA 3rd. Proximal humeral fracture as a risk factor for subsequent hip fractures. J Bone Joint Surg Am. 2009 Mar 1;91(3):503-11. PMID:19255209 (Link to Abstract)

2. Johnell O, Kanis JA, Odén A, Sernbo I, Redlund-Johnell I, Petterson C, De Laet C, Jönsson B. Fracture risk following an osteoporotic fracture. Osteoporos Int. PMID:14691617 (Link to Abstract)

3. Schousboe JT, Fink HA, Lui LY, Taylor BC, Ensrud KE. Association between prior non-spine non-hip fractures or prevalent radiographic vertebral deformities known to be at least 10 years old and incident hip fracture. J Bone Miner Res. 2006 Oct;21(10):1557-64. PMID:16995810 (Link to Abstract)

Question Authors:

Michael Hughes MD, Robert Boykin MD, Dave Marcu MD,

Please Rate Educational Value!

2.0

Average 2.0 of 27 Ratings

TAG

(OBQ09.3) Which of the following factors has been shown to be the strongest predictor of screw cutout of a dynamic compression hip screw used for an intertrochanteric femur fracture? Topic

Review Topic

1. Age of the patient
2. Intrinsic stability of the fracture
3. Tip-apex distance
4. Quality of reduction
5. Angle of the sideplate

PREFERRED RESPONSE ▶

DISCUSSION: Illustration A found below depicts the method to calculate Tip-apex distance (TAD). The tip-apex distance is the sum of the distances from the tip of the lag screw to the apex of the femoral head as seen on the AP and lateral radiographs.

Baumgaertner et al reported that he had no screws cut out if the tip-apex distance was less than 25mm. Tip-apex distance was the strongest predictor of cutout. Increasing age of the patient, poor reduction, use of a high angle sideplate, and unstable fracture were weaker predictors of cutout.

Kyle et al demonstrated that obtaining an anatomic reduction when using a sliding hip screw with intertrochanteric fractures leads to the best radiographic and clinical outcomes.

Illustrations: A

REFERENCES:

1. Baumgaertner MR, Curtin SL, Lindskog DM, et al: The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am 1995;77:1058-1064 PMID:7608228 (Link to Abstract)

2. Kyle RF, Gustilo RB, Premer RF: Analysis of six hundred and twenty-two intertrochanteric hip fractures. J Bone Joint Surg Am 1979;61:216-221 PMID:422605 (Link to Abstract)

3. Koval KJ, Zuckerman JD: Intertrochanteric fractures, in Bucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 1635-1663

Question Authors:

Greg Galano MD, Patrick McCulloch MD, Ben Taylor MD,

Please Rate Educational Value!

4.0

Average 4.0 of 8 Ratings

TAG

(OBQ09.222) A patient with an intertrochanteric hip fracture undergoes reduction and dynamic hip screw application. The post-operative radiographs demonstrate that the lag screw is superior in the femoral head with a tip-apex distance of 40 millimeters. This patient is at increased risk of what complication? Topic

Review Topic

1. lag screw cutout
2. osteonecrosis
3. osteoarthritis
4. peri-prosthetic fracture
5. lag screw breakage

PREFERRED RESPONSE ▶

DISCUSSION: Baumgaertner et al in their classic study in 1995 determined that the position of the lag screw in the femoral head influenced the risk of cutout of a dynamic hip screw construct in treatment of intratrochanteric fractures. They had no cutouts if the tip-apex distance on the combined AP and lateral radiographs was less than 25 millimeters. Subsequent studies demonstrated a decreased cutout rate once people were aware of the tip-apex distance importance.

REFERENCES:

1. Baumgaertner MR, Solberg BD: Awareness of tip-apex distance reduces failure of fixation of trochanteric fractures of the hip. J Bone Joint Surg Br 1997;79:969-971 PMID:9393914 (Link to Abstract)

2. Templeman D, Baumgaertner MR, Leighton RK, et al: Reducing complications in the surgical treatment of intertrochanteric fractures. Instr Course Lect 2005;54:409-415 PMID:15948470 (Link to Abstract)

3. Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am. 1995 Jul;77(7):1058-64. PMID:7608228 (Link to Abstract)

Question Authors:

Greg Galano MD,

Please Rate Educational Value!

4.0

Average 4.0 of 12 Ratings

TAG

(OBQ09.233) Which of the following statements is true regarding treatment of intertrochanteric hip fractures with an intramedullary nail versus a sliding hip screw? Topic

Review Topic

1. The use of intramedullary nail has increased in the last ten years
2. The use of sliding hip screws has increased in the last ten years
3. Medicare reimbursement is more for a sliding hip screw
4. Intramedullary nails have demonstrated superior outcomes in randomized-controlled studies
5. Sliding hip screw is superior for treatment of reverse obliquity intertrochanteric fractures

PREFERRED RESPONSE ▶

DISCUSSION: Anglen et al reviewed the database of orthopaedic surgeons taking Step II of the boards and found that the use of intramedullary nails for intertrochanteric hip fractures dramatically increased from 3% in 1999 to 67% in 2006. The authors call attention to the fact that Medicare reimbursement was higher until 2010 for intramedullary nails despite a lack of definitive evidence demonstrating that they are the superior treatment. Furthermore, they noted that patients managed with intramedullary nailing had more procedure-related complications compared to plate fixatoin. Forte et al found geographic differences in the use of intramedullary nails not explained by patient-related factors. Barton et al conducted a randomized controlled trial and found no difference in outcomes between the gamma nail and sliding hip screw for standard obliquity intertrochanteric hip fractures.

REFERENCES:

1. Anglen JO, Weinstein JN: American Board of Orthopaedic Surgery Research Committee. Nail or plate fixation of intertrochanteric hip fractures: Changing pattern of practice. A review of the American Board of Orthopaedic Surgery Database. J Bone Joint Surg Am 2008;90:700-707 PMID:18381305 (Link to Abstract)

2. Forte ML, Virnig BA, Kane RL, et al: Geographic variation in device use for intertrochanteric hip fractures. J Bone Joint Surg Am 2008;90:691-699 PMID:18381304 (Link to Abstract)

3. Barton TM, Gleeson R, Topliss C, Greenwood R, Harries WJ, Chesser TJ. A comparison of the long gamma nail with the sliding hip screw for the treatment of AO/OTA 31-A2 fractures of the proximal part of the femur: a prospective randomized trial. J Bone Joint Surg Am. 2010 Apr;92(4):792-8. PMID:20360500 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, Patrick McCulloch MD, John Badylak MD,

Please Rate Educational Value!

2.0

Average 2.0 of 10 Ratings

TAG

(OBQ08.138) An 82-year-old female sustains an intertrochanteric hip fracture and is treated with a sliding hip screw. What is the most appropriate definitive step in treating the failure seen in figure A? Topic

Review Topic

FIGURES: A

1. Non-weight bearing
2. Valgus proximal femoral osteotomy
3. Total hip arthroplasty
4. Revision open reduction and internal fixation
5. Proximal femoral resection

PREFERRED RESPONSE ▶

DISCUSSION: Figure A shows superior cutout of the lag screw from the sliding hip screw as well as the superior cannulated screw used for an "antirotation" device.

In the referenced review article by Haidukewych and Berry, salvage of failed treatment of hip fractures in the elderly is limited by bone quality and comorbidities. They recommend total hip arthroplasty in this instance to restore function, decrease pain, and limit periods of immobilization. They mention that the major challenges for arthroplasty are: assessing the need for acetabular resurfacing, selecting the femoral implant, and managing the greater trochanter.

REFERENCES:

1. Haidukewych GJ, Berry DJ. Salvage of failed treatment of hip fractures. J Am Acad Orthop Surg. 2005 Mar-Apr;13(2):101-9. PMID:15850367 (Link to Abstract)

2. Orthopaedic Knowledge Update 3: Hip and Knee, Barrack R, Booth R, Looner J, American Academy of Orthopaedic Surgeon, Rosemont IL, 2006

Question Authors:

Ben Taylor MD, Patrick McCulloch MD, Jan Szatkowski MD,

Please Rate Educational Value!

3.0

Average 3.0 of 12 Ratings

TAG

(OBQ07.86) Which of the following is not an appropriate implant for treatment of the fracture seen in Figure A? Topic

Review Topic

FIGURES: A

1. Cephalomedullary nail
2. External fixation
3. Proximal femoral locking plate
4. 95 degree blade plate
5. Sliding hip screw

PREFERRED RESPONSE ▶

DISCUSSION: The image shows a reverse obliquity intertrochanteric hip fracture.

According to the referenced article by Haidukewych et al, unstable peritrochanteric hip fractures have a worse outcome (failed in 9/16 cases) if treated with a sliding hip screw. Two additional factors that were found to have a strong correlation with postoperative failure (nonunion, loss of reduction) were poor reduction and poor implant placement. In this study, fixed angle devices were superior. Intramedullary fixation has the added advantage of a shorter lever arm and less potential for fracture collapse and limb shortening. The IMN also acts as a medial buttress.

According to Sanders et al, the dynamic condylar screw (DCS) can also be used in subtrochanteric models, but should not be used if extensive comminution is seen, as they reported a high failure rate with DCS in these fractures if highly comminuted. They report a 77% overall union rate with this device.

REFERENCES:

1. Haidukewych GJ, Israel TA, Berry DJ. Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am. 2001 May;83-A(5):643-50. PMID:11379732 (Link to Abstract)

2. Sanders R, Regazzoni P. Treatment of subtrochanteric femur fractures using the dynamic condylar screw. J Orthop Trauma. 1989;3(3):206-13. PMID:2809821 (Link to Abstract)

3. Browner BD, Jupiter JB, Levine AM (eds): Skeletal Trauma, ed 2. Philadelphia PA, WB Saunders, 1998, pp 1833-1881

Question Authors:

Ben Taylor MD, Patrick McCulloch MD, Jan Szatkowski MD,

Please Rate Educational Value!

2.0

Average 2.0 of 18 Ratings

TAG

(OBQ07.153) Anterior perforation of the distal femur from antegrade femoral nailing has been attributed to what factor? Topic

Review Topic

1. Non-anatomic reduction
2. Mismatch of the radius of curvature of implant and bone
3. Usage of too large an implant
4. Lateral patient positioning
5. Lateral proximal starting point

PREFERRED RESPONSE ▶

DISCUSSION: Anterior perforation of the femur has been attributed to a simple mismatch in the radius of curvature of implants and the apex anterior bowed femur.

The radius of curvature is generally smaller (114-120 cm) than many earlier generation femoral nails (up to 300 cm), and the referenced article by Ostrum et al describes a case series of 3 such patients with subtrochanteric fractures. He noted that the difference in femoral anteroposterior bow between the bone and the implant is a contributing factor to distal femoral anterior cortex penetration in intramedullary nailing of subtrochanteric fractures.

Illustration A shows an example of a nail penetrating the anterior femoral cortex.

Illustrations: A

REFERENCES:

1. Ostrum RF, Levy MS. Penetration of the distal femoral anterior cortex during intramedullary nailing for subtrochanteric fractures: a report of three cases. J Orthop Trauma. 2005 Oct;19(9):656-60. PMID:16247312 (Link to Abstract)

Question Authors:

Ben Taylor MD, Patrick McCulloch MD, Michael Hughes MD,

Please Rate Educational Value!

3.0

Average 3.0 of 7 Ratings

TAG

(OBQ07.246) A 72-year-old male sustains the injury shown in Figure A as a result of a fall from a ladder. Following internal fixation for this fracture with a sliding hip screw, which of the following factors has been shown to be associated with increased collapse or sliding displacement? Topic

Review Topic

FIGURES: A

1. Use of a long intramedullary device
2. Use of a short intramedullary device
3. Use of external fixation
4. Post operative weight bearing status
5. Intraoperative fracture of the lateral femoral wall

PREFERRED RESPONSE ▶

DISCUSSION: Intertrochanteric hip fractures with lateral wall fractures should be treated with an intramedullary device as opposed to a sliding hip screw, as the intact lateral wall provides a buttress for the proximal fragment facilitating fracture impaction as well as rotational and varus stability.

Palm et al showed that 22% of patients with a fractured lateral femoral wall underwent reoperation for collapse of fracture compared to 3% with an intact lateral femoral wall. Interestingly, 74% of the lateral proximal femoral wall fractures were iatrogenic during the procedure itself.

Gotfried et al reported on 24 patients with postoperative intertrochanteric hip fracture collapse and noted that this complication followed fracture of the lateral wall in every instance and resulted in protracted period of disability until fracture healing. They recommend care when drilling at the base of the lateral wall intraoperatively.

The referenced article by Lindskog et al reviews the diagnosis, treatment, as well as biomechanical reviews of treatment options for unstable intertrochanteric hip fractures.

Incorrect Answers:
Answer 1, 2, and 3: No difference in collapse has been shown between long or short intramedullary device and a sliding hip screw in stable intertrochanteric hip fractures.
Answer 4: Early postoperative weight bearing is the goal after repair, and no differences have been shown in collapse rates with different weight bearing protocols.

REFERENCES:

1. Palm H, Jacobsen S, Sonne-Holm S, Gebuhr P; Hip Fracture Study Group. Integrity of the lateral femoral wall in intertrochanteric hip fractures: an important predictor of a reoperation. J Bone Joint Surg Am. 2007 Mar;89(3):470-5. PMID:17332094 (Link to Abstract)

2. Gotfried Y. The lateral trochanteric wall: a key element in the reconstruction of unstable pertrochanteric hip fractures. Clin Orthop Relat Res. 2004 Aug;(425):82-6. PMID:15292791 (Link to Abstract)

3. Lindskog DM, Baumgaertner MR. Unstable intertrochanteric hip fractures in the elderly. J Am Acad Orthop Surg. 2004 May-Jun;12(3):179-90. PMID:15161171 (Link to Abstract)

Question Authors:

Ben Taylor MD, Derek Moore, John Badylak MD,

Please Rate Educational Value!

3.0

Average 3.0 of 10 Ratings

TAG

(OBQ06.157) Which of the following is a recognized predictor of mortality after hip fracture? Topic

Review Topic

1. American Society of Anesthesiologist (ASA) classification
2. Post-operative weight bearing status
3. Fracture comminution
4. Fixation device used
5. Hip fracture type

PREFERRED RESPONSE ▶

DISCUSSION: The ASA classification (detailed in Illustration A) was initially developed in 1963 and has been shown to be predictive of post-surgical mortality in hip fracture patients. Basic categories are as follows: 1= normal, healthy; 2= mild systemic disease; 3= severe systemic disease, not incapacitating; 4= severe incapacitating systemic condition, constant threat to life; 5= moribund patient; 6 = brain dead, organs being donated.

The study by Richmond et al looked at 836 patients treated for a hip fracture and found that this injury is not associated with significant excess mortality amongst patients older than age 85. However, in younger patients, those with ASA classifications of 3 or 4 have significant excess mortality following hip fracture that persists up to 2 years after injury.

Illustrations: A

REFERENCES:

1. Richmond J, Aharonoff GB, Zuckerman JD, Koval KJ. Mortality risk after hip fracture. J Orthop Trauma. 2003 Jan;17(1):53-6. PMID:12499968 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, Derek Moore, John Badylak MD,

Please Rate Educational Value!

3.0

Average 3.0 of 8 Ratings

TAG

(OBQ05.161) A 55-year-old male is involved in a motor vehicle accident and sustains the injury seen in Figure A. What is the most appropriate treatment for this type of injury? Topic

Review Topic

FIGURES: A

1. Total hip arthroplasty
2. Bipolar hemi-arthroplasty
3. Sliding hip screw
4. Percutaenous screw fixation
5. Cephalomedullary nail fixation

PREFERRED RESPONSE ▶

DISCUSSION: The radiographs demonstrate a reverse obliquity intertrochanteric femur fracture. Compared to the more stable intertrochanteric femur fracture, a reverse oblique intertrochanteric hip fracture is not optimally treated with a sliding hip screw. Compression along a sliding hip screw is designed to create compression along the plane of the fracture, however in a reverse obliquity fracture pattern as seen here, shear force is created causing medial displacment of the femoral shaft and screw cutout.

Haidukewych et al showed in their retrospective review of 55 consecutively treated reverse oblique intertrochanteric fractures, that patients treated with a sliding hip screw had a nearly a 56% failure rate (9/16). The failure rate of patients treated with a blade plate was only 13%.

Sadowski et al showed in their prospective randomized trial in patients with a reverse oblique or transverse intertrochanteric fracture who were randomized to either a 95 degree screw-plate or cephalomedullary nail a much higher failure rate for the plate screw implant. Implant failure was seen in 7/19 patients treated with the 95 degree screw plate and only 1/30 in the intramedullary nail group. Both articles support the use of a blade plate or cephalomedullary nail for reverse obliquity fractures.

An example of screw cutout and medial displacement is seen in Illustration A.

Illustrations: A

REFERENCES:

1. Haidukewych GJ, Israel TA, Berry DJ. Reverse obliquity fractures of theintertrochanteric region of the femur. J Bone Joint Surg Am. 2001May;83-A(5):643-50. PMID:11379732 (Link to Abstract)

2. Sadowski C, Lübbeke A, Saudan M, Riand N, Stern R, Hoffmeyer P. Treatment of reverse oblique and transverse intertrochanteric fractures with use of anintramedullary nail or a 95 degrees screw-plate: a prospective, randomized study.J Bone Joint Surg Am. 2002 Mar;84-A(3):372-81. PMID:11886906 (Link to Abstract)

Question Authors:

Jan Szatkowski MD, Michael Hughes MD, John Badylak MD,

Please Rate Educational Value!

4.0

Average 4.0 of 11 Ratings

TAG

(OBQ05.210) All of the following implants offer adequate fracture fixation of the injury shown in Figure A EXCEPT: Topic

Review Topic

FIGURES: A

1. trochanteric entry point cephalomedullary nail
2. piriformis fossa entry point cephalomedullary nail
3. dynamic hip screw
4. fixed angle blade plate
5. 95 degree dynamic condylar screw

PREFERRED RESPONSE ▶

DISCUSSION: The Haidukewych et al study quoted demonstrated the superiority of fixed angle devices such as blade-plates or dynamic condylar screws over the sliding (or dynamic) hip screws. Reverse obliquity intertrochanteric fractures of the femur are recognized as biomechanically different from standard intertrochanteric fractures. The rate of failure of internal fixation for this fracture pattern was higher than the rates in most reports of internal fixation of intertrochanteric fractures devices. Currently, cephalomedullary nails are used widely for reverse obliquity fractures because they limit medialization of the shaft fragment unlike sliding hip screws.

REFERENCES:

1. Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL., American Academy of Orthopaedic Surgeons, 2002, pp 407-416

2. Haidukewych GJ, Israel TA, Berry DJ: Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am 2001;83:643-650 PMID:11379732 (Link to Abstract)

Question Authors:

Greg Galano MD,

Please Rate Educational Value!

4.0

Average 4.0 of 13 Ratings

TAG

(OBQ05.262) When treating a stable 2-part intertrochanteric hip fracture with a sliding hip screw construct, what is the minimum amount of screw holes that are needed in the side plate for successful fixation? Topic

Review Topic

1. One
2. Two
3. Three
4. Four
5. Five

PREFERRED RESPONSE ▶

DISCUSSION: A two part stable intertrochanteric femur fracture can be treated with a sliding hip screw, with good biomechanical and clinical results.

The referenced article by Bolhofner et al reviews a series of 69 patients with a sliding hip screw and two hole side plate and notes that they did not have any failure of the side plate construct.

The referenced article by McLoughlin et al is a biomechanical evaluation of 2 versus 4 hole plates and found that peak load in the failure test was not found to be statistically different between the two-hole and four-hole designs. In cyclic testing, the two-hole configuration exhibited statistically smaller fragment migration in both shear and distraction than the four-hole design.

REFERENCES:

1. Kellam JF, Fischer TJ, Tornetta P III, et al: Orthopaedic Knowledge Update: Trauma 2. AAOS 2000 pg 125-131

2. Bolhofner BR, Russo PR, Carmen B. Results of intertrochanteric femur fractures treated with a 135-degree sliding screw with a two-hole side plate. J Orthop Trauma 1999;13:5-8 PMID:9892117 (Link to Abstract)

3. McLoughlin SW, Wheeler DL, Rider J, Bolhofner B. Biomechanical evaluation of the dynamic hip screw with two- and four-hole side plates. J Orthop Trauma 2000;14:318-23 PMID:10926237 (Link to Abstract)

Question Authors:

Ben Taylor MD, Dave Marcu MD,

Please Rate Educational Value!

3.0

Average 3.0 of 14 Ratings

Cases

	Cut Out ( intramedullary nailing ) (C1508) Recon - Treatment Consult - Intertrochanteric Fractures HPI - Intertrochanteric fracture 10.2013 , intramedullary nailing with 1 distal screw.... What is your treatment?	1 week ago 164 responses 4
	old trochanteric fracture (C1050) Trauma - - Intertrochanteric Fractures HPI - History of trauma what to do for this case? 75 yrs male patient presented with history of le...	7/26/2011 8 responses 5
	Basicervical hip fx malreduction (C1195) Trauma - Surgical Complications - Intertrochanteric Fractures HPI - 69 yr old obese female with left hip basicervical fx after fall. Patient has hx... What would you do next?	5/2/2012 38 responses 5
	implant failure in case of 4 month old operated intertrochanteric femur (C1257) Trauma - Treatment Consult - Intertrochanteric Fractures HPI - 4 months back operated with pfn for fracture subtrochanter. no h/o fall or traum... treatment options	8/23/2012 74 responses 5
	multitrauma (C1264) Trauma - Treatment Consult - Intertrochanteric Fractures HPI - pt s/p mva last night with left segmental femur, right distal femur left proxima... how would you treat left segmental femur	9/8/2012 50 responses 3
	pfn screw failure (C1280) Trauma - Treatment Consult - Intertrochanteric Fractures HPI - c/o pain in hip since 15 days. h/o hit by a bike. what would be further treatment options	9/27/2012 182 responses
	Proximal femoral nail failure (C1297) General - Treatment Consult - Intertrochanteric Fractures HPI - Pain hip. Original surgery performed 4 years ago. Mobility poor with frame.On la... What do you think is the cause of failure of this fixation by short gamma3...	10/18/2012 52 responses
$http://upload.orthobullets.com/cases/1300/bim it frac post op.jpg$	intertroch fracture (C1300) General - Treatment Consult - Intertrochanteric Fractures HPI - h/o fall at home xrays at 1 month should weight bearing be discontinued	10/20/2012 160 responses 4
	GSW to Thigh (C1368) Trauma - Treatment Consult - Intertrochanteric Fractures HPI - A 40-year-old female with h/o gun shot injury to left gluteal region. What fixation method would you use?	12/30/2012 1283 responses 4
	Nonunion fracture proximal end femur (C1408) Trauma - Treatment Consult - Intertrochanteric Fractures HPI - Road side accident JUNE 2012 resulting in fracture proximal end femur Closed re... What should be the treatment option of this eight month old nonunion	2/10/2013 177 responses

See More Cases

Groups

ABOS II: Intertrochanteric Fractures

General - Oral Boards Review

7/29/2011

0 responses

See More Groups

Evidence & References Show References

Level of Evidence 1 (Randomized Control Trial)

Sadowski C, Lübbeke A, Saudan M, Riand N, Stern R, Hoffmeyer P. Treatment of reverse oblique and transverse intertrochanteric fractures with use of anintramedullary nail or a 95 degrees screw-plate: a prospective, randomized study.J Bone Joint Surg Am. 2002 Mar;84-A(3):372-81. PMID:11886906 (Link to Abstract)

Level of Evidence 2 (Prospective Cohort Study)

Clinton J, Franta A, Polissar NL, Neradilek B, Mounce D, Fink HA, Schousboe JT, Matsen FA 3rd. Proximal humeral fracture as a risk factor for subsequent hip fractures. J Bone Joint Surg Am. 2009 Mar 1;91(3):503-11. PMID:19255209 (Link to Abstract)
Schousboe JT, Fink HA, Lui LY, Taylor BC, Ensrud KE. Association between prior non-spine non-hip fractures or prevalent radiographic vertebral deformities known to be at least 10 years old and incident hip fracture. J Bone Miner Res. 2006 Oct;21(10):1557-64. PMID:16995810 (Link to Abstract)

Level of Evidence 4 (Case Series)

Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am. 1995 Jul;77(7):1058-64. PMID:7608228 (Link to Abstract)
Kyle RF, Gustilo RB, Premer RF. Analysis of six hundred and twenty-two intertrochanteric hip fractures. J Bone Joint Surg Am. 1979 Mar;61(2):216-21. PMID:422605 (Link to Abstract)
Johnell O, Kanis JA, Odén A, Sernbo I, Redlund-Johnell I, Petterson C, De Laet C, Jönsson B. Fracture risk following an osteoporotic fracture. Osteoporos Int. PMID:14691617 (Link to Abstract)
Palm H, Jacobsen S, Sonne-Holm S, Gebuhr P; Hip Fracture Study Group. Integrity of the lateral femoral wall in intertrochanteric hip fractures: an important predictor of a reoperation. J Bone Joint Surg Am. 2007 Mar;89(3):470-5. PMID:17332094 (Link to Abstract)
Gotfried Y. The lateral trochanteric wall: a key element in the reconstruction of unstable pertrochanteric hip fractures. Clin Orthop Relat Res. 2004 Aug;(425):82-6. PMID:15292791 (Link to Abstract)
Bolhofner BR, Russo PR, Carmen B. Results of intertrochanteric femur fractures treated with a 135-degree sliding screw with a two-hole side plate. J Orthop Trauma 1999;13:5-8 PMID:9892117 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Ostrum RF, Levy MS. Penetration of the distal femoral anterior cortex during intramedullary nailing for subtrochanteric fractures: a report of three cases. J Orthop Trauma. 2005 Oct;19(9):656-60. PMID:16247312 (Link to Abstract)
Lindskog DM, Baumgaertner MR. Unstable intertrochanteric hip fractures in the elderly. J Am Acad Orthop Surg. 2004 May-Jun;12(3):179-90. PMID:15161171 (Link to Abstract)
Haidukewych GJ, Israel TA, Berry DJ. Reverse obliquity fractures of theintertrochanteric region of the femur. J Bone Joint Surg Am. 2001May;83-A(5):643-50. PMID:11379732 (Link to Abstract)
McLoughlin SW, Wheeler DL, Rider J, Bolhofner B. Biomechanical evaluation of the dynamic hip screw with two- and four-hole side plates. J Orthop Trauma 2000;14:318-23 PMID:10926237 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Koval KJ, Zuckerman JD. Intertrochanteric fractures. In: Bucholz RW, Heckman JD, eds. Rockwood and Green's Fractures in Adults. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:1635-1663.
Kellam JF, Fischer TJ, Tornetta P III, et al: Orthopaedic Knowledge Update: Trauma 2. AAOS 2000 pg 125-131

Undefined

Mohan R, Karthikeyan R, Sonanis SV. Dynamic hip screw: does side make a difference? Effects of clockwise torque on right and left DHS. Injury. 2000 Nov;31(9):697-9. PMID:11084157 (Link to Abstract)
Koval KJ. Intertrochanteric fractures. Use of a sliding hip screw. In: Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006;233-248.
Baumgaertner MR, Curtin SL, Lindskog DM, et al: The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am 1995;77:1058-1064 PMID:7608228 (Link to Abstract)
Kyle RF, Gustilo RB, Premer RF: Analysis of six hundred and twenty-two intertrochanteric hip fractures. J Bone Joint Surg Am 1979;61:216-221 PMID:422605 (Link to Abstract)
Koval KJ, Zuckerman JD: Intertrochanteric fractures, in Bucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 1635-1663
Baumgaertner MR, Solberg BD: Awareness of tip-apex distance reduces failure of fixation of trochanteric fractures of the hip. J Bone Joint Surg Br 1997;79:969-971 PMID:9393914 (Link to Abstract)
Templeman D, Baumgaertner MR, Leighton RK, et al: Reducing complications in the surgical treatment of intertrochanteric fractures. Instr Course Lect 2005;54:409-415 PMID:15948470 (Link to Abstract)
Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am. 1995 Jul;77(7):1058-64. PMID:7608228 (Link to Abstract)
Anglen JO, Weinstein JN: American Board of Orthopaedic Surgery Research Committee. Nail or plate fixation of intertrochanteric hip fractures: Changing pattern of practice. A review of the American Board of Orthopaedic Surgery Database. J Bone Joint Surg Am 2008;90:700-707 PMID:18381305 (Link to Abstract)
Forte ML, Virnig BA, Kane RL, et al: Geographic variation in device use for intertrochanteric hip fractures. J Bone Joint Surg Am 2008;90:691-699 PMID:18381304 (Link to Abstract)
Barton TM, Gleeson R, Topliss C, Greenwood R, Harries WJ, Chesser TJ. A comparison of the long gamma nail with the sliding hip screw for the treatment of AO/OTA 31-A2 fractures of the proximal part of the femur: a prospective randomized trial. J Bone Joint Surg Am. 2010 Apr;92(4):792-8. PMID:20360500 (Link to Abstract)
Haidukewych GJ, Berry DJ. Salvage of failed treatment of hip fractures. J Am Acad Orthop Surg. 2005 Mar-Apr;13(2):101-9. PMID:15850367 (Link to Abstract)
Orthopaedic Knowledge Update 3: Hip and Knee, Barrack R, Booth R, Looner J, American Academy of Orthopaedic Surgeon, Rosemont IL, 2006
Haidukewych GJ, Israel TA, Berry DJ. Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am. 2001 May;83-A(5):643-50. PMID:11379732 (Link to Abstract)
Sanders R, Regazzoni P. Treatment of subtrochanteric femur fractures using the dynamic condylar screw. J Orthop Trauma. 1989;3(3):206-13. PMID:2809821 (Link to Abstract)
Browner BD, Jupiter JB, Levine AM (eds): Skeletal Trauma, ed 2. Philadelphia PA, WB Saunders, 1998, pp 1833-1881
Richmond J, Aharonoff GB, Zuckerman JD, Koval KJ. Mortality risk after hip fracture. J Orthop Trauma. 2003 Jan;17(1):53-6. PMID:12499968 (Link to Abstract)
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL., American Academy of Orthopaedic Surgeons, 2002, pp 407-416
Haidukewych GJ, Israel TA, Berry DJ: Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am 2001;83:643-650 PMID:11379732 (Link to Abstract)

Topic Comments

Subscribe status: On Off

Recent on Bottom | Recent on Top

Page:1

Intertrochanteric Fractures

Qbank (14 Questions)

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Cases

Groups

Evidence & References Show References

Topic Comments