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Introduction
  • Extracapsular fractures of the proximal femur between the greater and lesser trochanters
  • Epidemiology
    • incidence
      • roughly the same as femoral neck fractures
    • demographics
      • female:male ratio between 2:1 and 8:1
      • typically older age than patients with femoral neck fractures
    • risk factors
      • proximal humerus fractures increase risk of hip fracture for 1 year
  • Pathophysiology
    • mechanism
      • elderly
        • low energy falls in osteoporotic patients
      • young
        • high energy trauma
  • Prognosis
    • nonunion and malunion rates are low
    • 20-30% mortality risk in the first year following fracture
    • factors that increase mortality
      • male gender (25-30% mortality) vs female (20% mortality)
      • higher in intertrochanteric fracture (vs femoral neck fracture)
      • operative delay of >2 days 
      • age >85 years
      • 2 or more pre-existing medical conditions
      • ASA classification (ASA III and IV increases mortality) 
    • surgery within 48 hours decreases 1 year mortality 
    • early medical optimization and co-management with medical hospitalists or geriatricians can improve outcomes 
Anatomy
  • Osteology
    • intertrochanteric area exists between greater and lesser trochanters
    • made of dense trabecular bone
    • calcar femorale
      • vertical wall of dense bone that extends from posteromedial aspect of femoral shaft to posterior portion of femoral neck
      • helps determine stable versus unstable fracture patterns
Classification
  • Stability of fracture pattern is arguably the most reliable method of classification
    • stable
      • definition
        • intact posteromedial cortex
      • clinical significance
        • will resist medial compressive loads once reduced
    • unstable
      • definition
        • comminution of the posteromedial cortex
      • clinical significance
        • fracture will collapse into varus and retroversion when loaded
      • examples
        • fractures with a large posteromedial fragment
          • i.e., lesser trochanter is displaced
        • subtrochanteric extension
        • reverse obliquity
          • oblique fracture line extending from medial cortex both laterally and distally
Presentation
  • Physical Exam
    • painful, shortened, externally rotated lower extremity
Imaging
  • Radiographs
    • recommended views
      • AP pelvis
      • AP of hip, cross table lateral
      • full length femur radiographs
  • CT or MRI
    • useful if radiographs are negative but physical exam consistent with fracture
Treatment
  • Nonoperative
    • nonweightbearing with early out of bed to chair
      • indications
        • nonambulatory patients
        • patients at high risk for perioperative mortality
      • outcomes
        • high rates of pneumonia, urinary tract infections, decubiti, and DVT
  • Operative
    • sliding hip compression screw
      • indications
        • stable intertrochanteric fractures
      • outcomes
        • equal outcomes when compared to intramedullary hip screws for stable fracture patterns
    • intramedullary hip screw (cephalomedullary nail)
      • indications
        • stable fracture patterns
        • unstable fracture patterns 
        • reverse obliquity fractures
          • 56% failure when treated with sliding hip screw
        • subtrochanteric extension
        • lack of integrity of femoral wall
          • associated with increased displacement and collapse when treated with sliding hip screw
      • outcomes
        • equivalent outcomes to sliding hip screw for stable fracture patterns
        • use has significantly increased in last decade
    • arthroplasty
      • indications
        • severely comminuted fractures
        • preexisting symptomatic degenerative arthritis
        • osteoporotic bone that is unlikely to hold internal fixation
        • salvage for failed internal fixation
Techniques
  • Sliding hip compression screw
    • technique
      • must obtain correct neck-shaft relationship
      • lag screw with tip-apex distance >25 mm is associated with increased failure rates
      • 4 hole plates show no benefit clinically or biomechanically over 2 hole plates
    • pros
      • allows dynamic interfragmentary compression
      • low cost
    • cons
      • open technique
      • increased blood loss
      • not advisable in unstable fracture patterns 
        • may result in
          • collapse
          • limb shortening
          • medialization of shaft
      • can cause anterior spike malreduction in left-sided, unstable fractures due to screw torque
  • Intramedullary hip screw
    • technique
      • short implants with optional distal locking
        • standard obliquity fractures
      • long implants
        • standard obliquity fractures
        • reverse obliquity fractures
        • subtrochanteric extension
    • pros
      • percutaneous approach
      • minimal blood loss
      • may be used in unstable fracture patterns
    • cons
      • increased incidence of screw cutout
      • periprosthetic fracture
      • higher cost than sliding hip screw
  • Arthroplasty
    • technique
      • calcar-replacing prosthesis often needed
      • must attempt fixation of greater trochanter to shaft
    • pros
      • possible earlier return for full weight bearing
    • cons
      • increased blood loss
      • may require prosthesis that some surgeons are unfamiliar with
Complications
  • Implant failure and cutout
    • incidence
      • most common complication
      • usually occurs within first 3 months
    • cause
      • tip-apex distance >45 mm associated with 60% failure rate
    • treatment
      • young
        • corrective osteotomy and/or revision open reduction and internal fixation
      • elderly
        • total hip arthroplasty
  • Anterior perforation of the distal femur
    • incidence
      • can occur following intramedullary screw fixation
    • cause
      • mismatch of the radius of curvature of the femur (shorter) and implant (longer)
  • Nonunion
    • incidence
      • <2%
    • treatment
      • revision ORIF with bone grafting
      • proximal femoral replacement
  • Malunion
    • incidence
      • varus and rotational deformities are common
    • treatment
      • corrective osteotomies
 

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