Summary Intertrochanteric femur fractures are extracapsular fractures of the proximal femur at the level of the greater and lesser trochanter, most commonly seen following ground level falls in the elderly population. Diagnosis is made with orthogonal radiographs of the hip in patients that present with inability to bear weight. Treatment is operative with sliding hip screw versus cephalomedullary nail depending on fracture stability and fracture orientation. Epidemiology Incidence common 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 Etiology Pathophysiology mechanism elderly low energy falls in osteoporotic patients young high energy trauma 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 thinner lateral wall thickness measured from 3 cm distal from innominate tubercle at 135 degrees to the fracture site <20.5 mm suggests risk of postoperative lateral wall fracture should be treated with intramedullary implant rather than sliding hip screw 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 MRI useful to evaluate intertrochanteric extension with isolated greater trochanteric fracture patterns 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 more cost-effective in stable patterns than cephalomedullary nail 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 increased risk of lateral wall fracture with decreasing lateral wall thickness 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 no violation of hip abductors 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 periprosthetic fracture higher cost than sliding hip screw requires violation of hip abductors for insertion 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) posterior starting point on the greater trochanter Nonunion incidence <2% treatment revision ORIF with bone grafting proximal femoral replacement Malunion incidence varus and rotational deformities are common treatment corrective osteotomies Prognosis Nounion 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) Factors that decrease mortality Surgery within 48 hours decreases 1 year mortality early medical optimization and co-management with medical hospitalists or geriatricians can improve outcomes
Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Intertrochanteric Fracture ORIF with Cephalomedullary Nail Orthobullets Team Trauma - Intertrochanteric Fractures Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Femoral Neck Fracture ORIF with Dynamic Hip Screw Orthobullets Team Trauma - Femoral Neck Fractures
QUESTIONS 1 of 29 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ18TR.2) What is the most cost-effective implant indicated for the injury shown in Figures A and B, assuming the hospital purchases the implants at-cost from the manufacturer? QID: 211122 FIGURES: A B Type & Select Correct Answer 1 Long cephalomedullary nail 2% (25/1537) 2 Short cephelomedullary nail 8% (130/1537) 3 Sliding hip screw 76% (1170/1537) 4 Hemiarthroplasty 1% (21/1537) 5 Cannulated screws 11% (170/1537) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ18.206) An 87-year-old female sustained the injury shown in Figure A. Which of the following is/are factor(s) that increase the risk of perforation of the anterior cortex during surgical treatment with a long cephalomedullary nail? QID: 213102 FIGURES: A Type & Select Correct Answer 1 Radius of curvature mismatch between the bone and the implant 2% (36/1980) 2 Anterior starting point on the greater trochanter 1% (27/1980) 3 Posterior starting point on the greater trochanter 3% (56/1980) 4 Answers 1 and 2 18% (351/1980) 5 Answers 1 and 3 75% (1487/1980) L 4 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ18.240) A 78-year-old patient presents with right hip pain and inability to bear weight after an unwitnessed fall at a nursing home. Figures A and B are the radiographs of the hip and pelvis. Which statement is true regarding the treatment of these injuries? QID: 213136 FIGURES: A B Type & Select Correct Answer 1 Smaller lateral wall thickness favors sliding hip screw constructs 2% (35/2247) 2 Unstable fractures are best treated with sliding hip screw constructs 2% (36/2247) 3 Avoiding distal locking screws in intramedullary implants protects against refracture 1% (30/2247) 4 Stable fractures have no differences in outcomes between sliding hip screws and intramedullary implants 89% (1991/2247) 5 Implant stability has a greater impact on outcomes rather than reduction quality 3% (74/2247) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ18.239) An 82-year-old female sustains the fracture shown in Figure A as the result of a ground level fall. Which of the following has been shown to be a reliable predictor of postoperative lateral wall fracture for this injury after treatment with a sliding hip screw? QID: 213135 FIGURES: A Type & Select Correct Answer 1 Reverse obliquity fracture pattern 19% (372/1939) 2 Lateral wall thickness 61% (1180/1939) 3 Previous contralateral hip fracture 1% (27/1939) 4 DEXA T-score <-2.0 6% (108/1939) 5 Calcar comminution 12% (232/1939) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ13.2) A 86-year-old man slips on the ice and falls sustaining the injury shown in Figure A. He has Type 2 diabetes mellitus, atrial fibrillation, coronary artery disease, end-stage renal disease on dialysis and chronic obstructive lung disease. All of the following variables are associated with increased mortality at one year after injury EXCEPT? QID: 4637 FIGURES: A Type & Select Correct Answer 1 Intertrochanteric fracture 5% (205/4520) 2 Two or more pre-existing medical conditions 1% (60/4520) 3 Age of eighty-five years or more 2% (75/4520) 4 Male gender 10% (451/4520) 5 Operative fixation within 48 hours 82% (3711/4520) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (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? QID: 3595 Type & Select Correct Answer 1 Summation of the distance between the end of the screw and the apex of the femoral head on AP and lateral radiographs 95% (3417/3610) 2 Distance from the acetabular teardrop to the tip of the screw on an AP radiograph of the hip 1% (52/3610) 3 Multiplication of the distance between the end of the screw and the apex of the femoral head on AP and lateral radiographs 1% (47/3610) 4 Distance from the center of the lesser trochanter to the tip of the screw on an AP hip radiograph 1% (32/3610) 5 Summation of the distance between the tip of the greater trochanter and end of the screw on AP and lateral hip radiographs 1% (42/3610) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (OBQ11.189) Which of the following deformities is most likely to occur with dynamic hip screw fixation of unstable left sided standard obliquity hip fractures? QID: 3612 Type & Select Correct Answer 1 Posterior spike displacement of the proximal fragment 8% (167/2162) 2 Anterior spike displacement of the proximal fragment 63% (1354/2162) 3 Lateral displacement of the proximal fragment relative to the distal fragment 11% (229/2162) 4 Shortening of the proximal fragment relative to the distal fragment 4% (90/2162) 5 Medial displacement of the proximal fragment in relation to the distal fragment 14% (309/2162) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (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 most increases her risk of subsequently sustaining which of the following fractures in the future? QID: 3105 FIGURES: A Type & Select Correct Answer 1 Sacral fracture 2% (38/1995) 2 Hip fracture 64% (1282/1995) 3 Distal radius fracture 17% (330/1995) 4 Distal fibula fracture 1% (12/1995) 5 Distal humerus fracture 16% (328/1995) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ09TR.45.1) Which of the following is an advantage of sliding hip screws compared to cephalomedullary nails for the treatment of appropriate intertrochanteric femur fractures? QID: 211031 Type & Select Correct Answer 1 Decreased risk of deep venous thrombosis 1% (20/2417) 2 Biomechanically advantageous under physiologic loading 14% (350/2417) 3 Decreased blood loss 10% (244/2417) 4 Decreased risk of nonunion 2% (57/2417) 5 None of the above 72% (1732/2417) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ09.233) Which of the following statements is true regarding treatment of intertrochanteric hip fractures with an intramedullary nail versus a sliding hip screw? QID: 3046 Type & Select Correct Answer 1 The use of intramedullary nail has increased in the last ten years 84% (790/937) 2 The use of sliding hip screws has increased in the last ten years 4% (37/937) 3 Medicare reimbursement is more for a sliding hip screw 1% (10/937) 4 Intramedullary nails have demonstrated superior outcomes in randomized-controlled studies 8% (73/937) 5 Sliding hip screw is superior for treatment of reverse obliquity intertrochanteric fractures 3% (24/937) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (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? QID: 3035 Type & Select Correct Answer 1 lag screw cutout 96% (1515/1575) 2 osteonecrosis 1% (13/1575) 3 osteoarthritis 1% (13/1575) 4 peri-prosthetic fracture 1% (12/1575) 5 lag screw breakage 1% (18/1575) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (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? QID: 2816 Type & Select Correct Answer 1 Age of the patient 1% (26/3205) 2 Intrinsic stability of the fracture 4% (142/3205) 3 Tip-apex distance 92% (2939/3205) 4 Quality of reduction 2% (77/3205) 5 Angle of the sideplate 0% (13/3205) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (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? QID: 524 FIGURES: A Type & Select Correct Answer 1 Non-weight bearing 1% (4/780) 2 Valgus proximal femoral osteotomy 7% (52/780) 3 Total hip arthroplasty 81% (634/780) 4 Revision open reduction and internal fixation 11% (83/780) 5 Proximal femoral resection 1% (4/780) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ07.246) A 72-year-old male sustains the injury shown in Figure A as a result of a fall from a ladder. Which of the following factors has been shown to be associated with increased collapse or sliding displacement? QID: 907 FIGURES: A Type & Select Correct Answer 1 Use of a long intramedullary device 1% (8/914) 2 Use of a short intramedullary device 6% (58/914) 3 Use of external fixation 3% (24/914) 4 Postoperative weight bearing status 6% (59/914) 5 Intraoperative fracture of the lateral femoral wall 83% (763/914) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ07.153) Anterior perforation of the distal femur from antegrade femoral nailing has been attributed to what factor? QID: 814 Type & Select Correct Answer 1 Non-anatomic reduction 2% (62/2886) 2 Mismatch of the radius of curvature of implant and bone 91% (2631/2886) 3 Usage of too large an implant 2% (58/2886) 4 Lateral patient positioning 1% (19/2886) 5 Lateral proximal starting point 4% (106/2886) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ07.86) Which of the following is not an appropriate implant for treatment of the fracture seen in Figure A? QID: 747 FIGURES: A Type & Select Correct Answer 1 Cephalomedullary nail 7% (178/2439) 2 External fixation 8% (197/2439) 3 Proximal femoral locking plate 2% (60/2439) 4 95 degree blade plate 1% (36/2439) 5 Sliding hip screw 80% (1963/2439) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ06.157) Which of the following is a recognized predictor of mortality after hip fracture? QID: 343 Type & Select Correct Answer 1 American Society of Anesthesiologist (ASA) classification 73% (991/1359) 2 Post-operative weight bearing status 23% (316/1359) 3 Fracture comminution 2% (30/1359) 4 Fixation device used 0% (6/1359) 5 Type of anesthetic used 1% (13/1359) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (OBQ05.262) When treating a stable 2-part intertrochanteric hip fracture with a sliding hip screw construct, what is the minimum number of screw holes that are needed in the side plate for successful fixation? QID: 1148 Type & Select Correct Answer 1 One 2% (21/918) 2 Two 80% (735/918) 3 Three 13% (120/918) 4 Four 4% (35/918) 5 Five 0% (1/918) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ05.210) All of the following implants offer adequate fracture fixation of the injury shown in Figure A EXCEPT: QID: 1096 FIGURES: A Type & Select Correct Answer 1 Trochanteric entry point cephalomedullary nail 3% (72/2429) 2 Piriformis fossa entry point cephalomedullary nail 3% (70/2429) 3 Dynamic hip screw 84% (2052/2429) 4 Fixed angle blade plate 2% (50/2429) 5 95 degree dynamic condylar screw 7% (178/2429) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (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? QID: 1047 FIGURES: A Type & Select Correct Answer 1 Total hip arthroplasty 1% (11/1479) 2 Bipolar hemi-arthroplasty 1% (9/1479) 3 Sliding hip screw 3% (43/1479) 4 Percutaneous screw fixation 1% (8/1479) 5 Cephalomedullary nail fixation 95% (1403/1479) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic
All Videos (11) Podcasts (2) Login to View Community Videos Login to View Community Videos 2018 Orthopaedic Summit Evolving Techniques 77-Year-Old Status Post Intermedullary Nail For An IT Hip Fracture, Now Needing A Total Hip Replacement - Oh The Problems, Are They Real, Should The Patient Have Had A Sliding Hip Screw - Simon C. Mears, MD, PhD, FAOA (OSET 2018) Simon Mears Trauma - Intertrochanteric Fractures D 8/12/2019 463 views 3.0 (1) Login to View Community Videos Login to View Community Videos 2018 Orthopaedic Summit Evolving Techniques Pro: Read The Literature: The IM Nail, It Is The Right Answer - Get Them Up Out Of Bed Today - David B. Weiss, MD (OSET 2018) David B. Weiss Trauma - Intertrochanteric Fractures A 8/12/2019 676 views 3.8 (4) Login to View Community Videos Login to View Community Videos 2018 Orthopaedic Summit Evolving Techniques Pro: Wake Up! It Is The Blade Plate, You Just Don’t Know How To Do It! The Lost Art With Better Success - Michael J. Gardner, MD (OSET 2018) Team Orthobullets (5) Trauma - Intertrochanteric Fractures A 8/12/2019 690 views 5.0 (4) Trauma | Intertrochanteric Fractures Trauma - Intertrochanteric Fractures Listen Now 20:12 min 10/19/2019 1457 plays 4.9 (15) Question Session | Intertrochanteric Fractures & Legg-Calve-Perthes Disease Orthobullets Team Trauma - Intertrochanteric Fractures Listen Now 17:50 min 11/11/2019 145 plays 5.0 (2) See More See Less
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