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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
    • 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
    • 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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Technique Guides (2)
Questions (19)
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(OBQ06.157) Which of the following is a recognized predictor of mortality after hip fracture? Review Topic

QID: 343
1

American Society of Anesthesiologist (ASA) classification

72%

(381/529)

2

Post-operative weight bearing status

24%

(127/529)

3

Fracture comminution

2%

(9/529)

4

Fixation device used

0%

(2/529)

5

Type of anesthetic used

2%

(9/529)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(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? Review Topic

QID: 3595
1

Summation of the distance between the end of the screw and the apex of the femoral head on AP and lateral radiographs

95%

(2487/2630)

2

Distance from the acetabular teardrop to the tip of the screw on an AP radiograph of the hip

2%

(40/2630)

3

Multiplication of the distance between the end of the screw and the apex of the femoral head on AP and lateral radiographs

1%

(31/2630)

4

Distance from the center of the lesser trochanter to the tip of the screw on an AP hip radiograph

1%

(22/2630)

5

Summation of the distance between the tip of the greater trochanter and end of the screw on AP and lateral hip radiographs

1%

(33/2630)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1
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(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? Review Topic

QID: 907
FIGURES:
1

Use of a long intramedullary device

1%

(6/483)

2

Use of a short intramedullary device

7%

(33/483)

3

Use of external fixation

3%

(15/483)

4

Postoperative weight bearing status

7%

(32/483)

5

Intraoperative fracture of the lateral femoral wall

82%

(397/483)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(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? Review Topic

QID: 1148
1

One

1%

(5/528)

2

Two

79%

(416/528)

3

Three

16%

(85/528)

4

Four

3%

(18/528)

5

Five

0%

(0/528)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

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

QID: 3046
1

The use of intramedullary nail has increased in the last ten years

90%

(342/382)

2

The use of sliding hip screws has increased in the last ten years

3%

(12/382)

3

Medicare reimbursement is more for a sliding hip screw

1%

(3/382)

4

Intramedullary nails have demonstrated superior outcomes in randomized-controlled studies

4%

(15/382)

5

Sliding hip screw is superior for treatment of reverse obliquity intertrochanteric fractures

3%

(10/382)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(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? Review Topic

QID: 3035
1

lag screw cutout

97%

(970/1005)

2

osteonecrosis

1%

(6/1005)

3

osteoarthritis

0%

(5/1005)

4

peri-prosthetic fracture

1%

(8/1005)

5

lag screw breakage

1%

(14/1005)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

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

QID: 1096
FIGURES:
1

Trochanteric entry point cephalomedullary nail

2%

(43/1828)

2

Piriformis fossa entry point cephalomedullary nail

3%

(50/1828)

3

Dynamic hip screw

87%

(1596/1828)

4

Fixed angle blade plate

1%

(26/1828)

5

95 degree dynamic condylar screw

6%

(110/1828)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
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(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? Review Topic

QID: 524
FIGURES:
1

Non-weight bearing

0%

(2/440)

2

Valgus proximal femoral osteotomy

7%

(32/440)

3

Total hip arthroplasty

80%

(352/440)

4

Revision open reduction and internal fixation

11%

(50/440)

5

Proximal femoral resection

0%

(2/440)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(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? Review Topic

QID: 1047
FIGURES:
1

Total hip arthroplasty

1%

(6/1016)

2

Bipolar hemi-arthroplasty

0%

(4/1016)

3

Sliding hip screw

2%

(22/1016)

4

Percutaneous screw fixation

0%

(4/1016)

5

Cephalomedullary nail fixation

96%

(976/1016)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(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? Review Topic

QID: 3612
1

Posterior spike displacement of the proximal fragment

8%

(140/1665)

2

Anterior spike displacement of the proximal fragment

67%

(1122/1665)

3

Lateral displacement of the proximal fragment relative to the distal fragment

7%

(111/1665)

4

Shortening of the proximal fragment relative to the distal fragment

2%

(41/1665)

5

Medial displacement of the proximal fragment in relation to the distal fragment

15%

(244/1665)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(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 sustaining which of the following fractures? Review Topic

QID: 3105
FIGURES:
1

Sacral fracture

2%

(27/1310)

2

Hip fracture

58%

(754/1310)

3

Distal radius fracture

15%

(195/1310)

4

Distal fibula fracture

1%

(10/1310)

5

Distal humerus fracture

25%

(321/1310)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

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

QID: 814
1

Non-anatomic reduction

2%

(39/2228)

2

Mismatch of the radius of curvature of implant and bone

93%

(2062/2228)

3

Usage of too large an implant

1%

(33/2228)

4

Lateral patient positioning

1%

(12/2228)

5

Lateral proximal starting point

3%

(74/2228)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

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

QID: 747
FIGURES:
1

Cephalomedullary nail

6%

(118/1826)

2

External fixation

7%

(136/1826)

3

Proximal femoral locking plate

3%

(48/1826)

4

95 degree blade plate

1%

(26/1826)

5

Sliding hip screw

82%

(1495/1826)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(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? Review Topic

QID: 2816
1

Age of the patient

1%

(13/1842)

2

Intrinsic stability of the fracture

4%

(73/1842)

3

Tip-apex distance

93%

(1711/1842)

4

Quality of reduction

2%

(34/1842)

5

Angle of the sideplate

0%

(7/1842)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
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