Intertrochanteric Hip Fractures

Author: Richard S Goodman, MD, JD, FAAOS; Chief Editor: William L Jaffe, MD more...

Updated: Jun 2, 2011

Background

Intertrochanteric fractures are considered 1 of 3 types of hip fractures. The anatomic site of this type of hip fractureis the proximal, upper part of the femur or thigh bone. The proximal femur consists of the femoral head, femoralneck, and the trochanteric region. An intertrochanteric hip fracture occurs between the greater trochanter, wherethe gluteus medius and minimus muscles (hip extensors and abductors) attach, and the lesser trochanter, where

the iliopsoas muscle (hip flexor) attaches.[1, 2] Fractures of the femoral neck are proximal or cephalad tointertrochanteric fractures, and subtrochanteric fractures are distal or below (sub) to the trochanters. Thesefracture types are discussed in other eMedicine articles.

Normal femur anatomy.

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Stable intertrochanteric fracture.

Unstable intertrochanteric fracture.

Though all of these fractures are often referred to simply as hip fractures, the above distinctions between femoralneck fractures, intertrochanteric factors, and subtrochanteric fractures are important because the anatomy,prognosis, and management are different for these fracture types.

Femoral neck fractures are frequently treated using a prosthesis or replacement device to substitute for theproximal femoral fragment, including the residual neck fragment with the devitalized femoral head. Intertrochantericfractures are treated using an engineered metallic fixation device (internal splintage device) designed to maintainthe nondisplaced, minimally displaced, or postreduction fracture fragments in their anatomic, near-anatomic, oracceptable postreduction position. This stability assists in the healing of the fracture. In addition, postoperativecare and rates of complications, including mortality and morbidity, vary for different fractures and differentsubcategories of intertrochanteric fractures.

The current treatment of intertrochanteric fractures is surgical intervention. Despite an acceptable healing rate withnonsurgical methods, surgical intervention for intertrochanteric fractures has replaced previous nonsurgical

methods of prolonged bed rest, prolonged traction in bed, or prolonged immobilization in a full-body (spica) cast.[3,

4, 5] Though healing rates for previous nonsurgical methods may have been acceptable, they were accompanied byunacceptable morbidity and mortality rates because of frequent nonorthopedic complications associated withprolonged immobilization or inactivity. Complications included the following:

Pulmonary complications of pneumonia resulting from inactivity.Pulmonary emboli from deep vein thrombosis (DVT) caused by immobilization of an extremity.Bedsores from prolonged bed rest.Loss of motion of the lower extremity joints and muscle atrophy due to prolonged immobilization.Union of the fracture in an unacceptable position resulting in a deformity. (Known as a malunion, thefracture heals with unacceptable shortening, rotation, and/or angulation of the extremity, resulting indecreased mobility and subsequent handicap, impairment, and disability.)

Currently, with a few exceptions, surgical intervention is used to treat essentially all intertrochanteric fractures andis described as open reduction and internal fixation (ORIF). Various surgical fixation devices are now available for

the treatment of essentially all intertrochanteric fractures. Each device requires a careful match between theappropriate internal fixation device and the specific type of fracture. The correct surgical technique described bythe developer of the device should also be used. Therefore, the optimal device is chosen after a precise diagnosisof the type of intertrochanteric fracture. The indications and contraindications of the technique must also bematched with the patient's activity level, degree of osteoporosis, and realistic expected outcome.

To accomplish this match between technique and patient, at a minimum, technically adequate preoperativeradiographs of the hip are necessary, including anteroposterior (AP) view of the pelvis and involved hip and truelateral view (cross-table technique). In some cases, a frog lateral view, a computerized axial tomography (CAT)scan, or even a reconstituted CAT scan may be necessary to define the fracture in sufficient detail to accuratelyplan the surgery. Gentle traction applied during the radiograph will help define the fracture, particularly if significantshortening has occurred.

Recent studies

Anglen et al found that from 1999 to 2006, for fixation of intertrochanteric hip fractures, there was a dramaticincrease in the preference for the use of intramedullary nails that interlock proximally into the femoral head, incomparison with use of a sliding compression screw. Intramedullary nail fixation rate increased from 3% in 1999 to67% in 2006. Overall, patients managed with plate fixation had slightly less pain and deformity than those patientswho were managed with intramedullary nailing, and there were no significant differences identified regardingfunction or patient satisfaction. In addition, the authors found that patients managed with intramedullary nailing hadmore procedure-related complications, particularly bone fracture. The authors noted that this change inmanagement of intertrochanteric hip fractures has occurred despite a lack of evidence supporting the change and

despite the apparent potential for increased complications.[5]

Bhandari et al performed a meta-analysis to identify the risk of femoral shaft fracture associated with gamma nailsfollowing treatment of extracapsular hip fractures. They found that in earlier studies (1991-2000), gamma nails werefound to increase the risk of femoral shaft fracture by 4.5 times when compared with the use of compressionscrews. However, in more recent studies (2000-2005), gamma nails were not associated with significantlyincreased risk of femoral shaft fracture, and in a 2005 study, there was no difference in femoral fracture rates.According to the authors, more recent trials suggest that increased femoral shaft fracture risk associated with

gamma nails have been resolved as the result of improved implant design and improved learning curves.[6]

Sidhu et al studied 53 patients (average age, 77 y) following total hip replacement for intertrochanteric hipfractures. In the study patients, the Harris hip score at 1 month was 66 ± 7; at 3 months, 72 ± 6; at 1 year, 74 ± 5;at 3 years, 76 ± 6; and 76 ± 8 in the 27 patients who completed 5-year follow-up. The average time to return tonormal daily activities was 28 days (range, 24-33 days), and there was no loosening or infection observed. Theauthors concluded that in mentally healthy elderly patients with intertrochanteric hip fractures, total hiparthroplasty may be a valid treatment option because it offers the potential for quick recovery with little risk ofmechanical failure, it avoids the risks often associated with internal fixation, and it can enable patients to maintain

a good level of function immediately after surgery.[7]

History of the Procedure

An intertrochanteric fracture was described by Cooper in his treatise of 1851 as follows:

...fracture of the femur through the trochanter major, passes obliquely upwards and outwards from the lower portionof the neck but instead of traversing the neck completely, it penetrates the base of the trochanter major; the line offracture being such as to separate the femur into two fragments, one of which is composed of the head, neck and

trochanter major, and the other of the shaft with the remaining portions of the femur.[8]

Cooper's recommended treatment was "moderate extension and steady support of the limb in its natural

position."[8]

Cooper also contributed to the knowledge of intertrochanteric fractures in his book of 1822, in which he was thefirst to distinguish between fractures of the neck of the proximal femur (intracapsular) and those outside of the joint

capsule (extracapsular) through the trochanteric level.[9] He recognized that fractures external to the capsule

united, whereas fractures internal to the capsule did not unite. His treatment consisted of bed rest, followed by theuse of crutches and a cane, and then an elevated shoe, all in an attempt to save the patient's life if not the limb.The diagnosis and care of intertrochanteric fractures were then studied and written about by Dupuytren, Malgaigne,

Velpeau, and Whitman, among others.[3] In 1902, Royal Whitman first reported on the reduction of fractures withabduction, internal rotation, and traction under anesthesia with immobilization in a spica cast from the nipple line

to the toes.[3]

Ledbetter reported on the heel and palm test for adequate reduction, saying that "after the leg has been broughtdown in the measured degree of abduction and internal rotation, the heel of the injured leg is allowed to rest on theoutstretched palm. If the reduction is complete, the leg will not exert itself. Should there be no interlocking of the

fragments, however, the leg will slowly rotate externally."[8]

As opposed to closed treatment following the reduction of the fracture, Langenbeck attempted internal fixation ofthe reduced fracture in 1850 using an intramedullary nail. Other physicians followed with different nails but facedproblems with the procedure. Blind reduction and fixation of the fracture and blind nailing or percutaneous insertionof a nail or other internal fixation device without visualization of the tract of the nail meant that malposition of thefracture, the device, or both was frequent. Moreover, technology was unavailable to produce fixation devices withadequate tensile strength or devices that caused only a minimal or inconsequential reaction from body tissues. Inaddition, the lack of antibiotics meant that postoperative infections received only minimal treatment and resulted in

significant complications.[10, 11, 12]

Portable radiographic machines and the subsequent development of portable fluoroscopy machines with imageintensification screens and low-radiation technology resulted in control and confirmation of the fracture reduction inthe operating room. Cannulated fixation devices (eg, nails, hip screws, side plates) that are placed over temporaryguide wires allow the surgeon to more easily plan and confirm the position of the fixation device and add to thesurgeon's armamentarium.

Today, the procedure uses radiographs on an image intensifier screen to project and record a satisfactory stablereduction of the fracture. Operating room fracture tables with traction devices hold the reduced position of thefractured femur while guide wires are properly inserted to guide the eventual position of the planned fixation device.The planned device is then inserted with a lag screw or screws to hold the proximal fragment, a side plate to holdthe lag screw to the distal femur, and screws to attach the plate to the distal femur. A compression screw drawsthe lag screw into the side plate barrel and compresses the proximal and distal fragments to each other.

Problem

The literature, as noted from the early 1800s, revealed that intertrochanteric hip fractures routinely healed but weremalunited in varus, leading to deformity and decreased function secondary to a limp and hip abductor weakness.However, nonoperative care of intertrochanteric fractures had significant, unacceptable morbidity and mortalityrates because of concurrent medical problems and prolonged incumbency that prevented union from occurring.

Because of these significant problems, conservative treatment was deemed unacceptable regardless of themortality rate.

Therefore, progress in the care of intertrochanteric fractures has involved decreasing the mortality fromnonorthopedic coexisting or concurrent medical problems and decreasing the degree of malunion and possiblenonunion of these fractures.

Epidemiology

Frequency

Approximately 252,000 hip fractures occur each year in the United States. Despite the relatively small incidence,hip fractures are responsible for approximately 3.5 million hospital days in the United States; hip fractures accountfor more hospital days than tibial fractures, vertebral fractures, and pelvic fractures combined. In addition, hipfractures account for more than half of the total hospital admissions of all fractures and more than half of theambulance calls for fractures.

Etiology

The etiology of intertrochanteric fractures is the combination of increased bone fragility of the intertrochanteric areaof the femur associated with decreased agility and decreased muscle tone of the muscles in the area secondaryto the aging process. The increasing bone fragility results from osteoporosis and osteomalacia secondary to alack of adequate ambulation or antigravity activities, as well as decreased hormone levels, increased levels of

demineralizing hormones, decreased intake of calcium and/or vitamin D, and other aging processes.[13] Benignand malignant tumors, along with metastases such as multiple myeloma and other malignancies, can also lead toweakened bony structure.

The combination of increased fragility of bone and a traumatic event such as a motor vehicle accident or fall mayresult in either a direct impact or generation of a torsional force transmitted through the leg to the intertrochantericarea. When such forces are greater than the strength of the bone in the intertrochanteric area, a fracture occurs.

Presentation

Elderly patients frequently have other significant coexisting or preexisting pathologic conditions that result indecreased resistance to the stresses of anesthesia, trauma, and surgery and an increased need for extensivepostoperative rehabilitation. Coexisting or preexisting conditions that were present but unknown, undiagnosed, orsimply tolerable before the fracture include pulmonary insufficiency, cardiac insufficiency, mitral valve insufficiency,aortic valve insufficiency, cardiovascular insufficiency, hypertension, dehydration, malnutrition, and any of anumber of metabolic diseases or endocrine diseases, including diabetes and hypothyroidism. In addition,metabolic changes are consistent with the postoperative stresses from the postoperative analgesics and thepostoperative rehabilitation program. As a result of these comorbidities, a 2-stage treatment program isrecommended.

Stage 1

Identify the fracture on the basis of the history and the findings from physical examination and radiographs. Thepatient typically presents with a history of slipping on, falling on, or twisting of the lower extremity that is followedby severe pain in the affected hip area. Patients may be unable to stand or move their body or the affectedextremity without pain. Local physical examination typically reveals the affected lower extremity in a position of hipextension with the leg externally rotated, with the patient experiencing pain on any active or passive motion of thehip or any part of the extremity.

The diagnosis of an intertrochanteric fracture is confirmed by the review of appropriate radiologic images, includingan AP pelvic view and either a cross-table lateral view of the hip or a frog lateral view of the hip and a traction APhip radiograph. A full-length radiograph of the involved femur is necessary to rule out any pathologic process ordeformity that may exist distal to the fracture. These images also define the inherent stability or instability of thefracture, the need for a reduction of the fracture, and whether further manipulation is indicated to produce areduction sufficiently stable to heal before the implant fixation is lost. The stability of the fracture is defined by theamount of contact between the proximal and distal main fragments. Two-part intertrochanteric fractures are verystable, as there are only 2 fragments, which, once reduced, are impacted on each other and provide inherentstability for the implant.

The fracture stability is inversely proportional to the size of the lesser trochanteric fragment (3-part fracture).Instability occurs when more than 50% of the calcar is affected, allowing the proximal fragment to collapse intovarus position and shorten. Therefore, a fracture is considered unstable if there is a large lesser trochantericfragment or if the greater and the lesser trochanter are separate fracture fragments (4-part fracture). The moreunstable the fracture, the more difficult it is to reduce the fracture and the more likely it is that an implant, such as

a cephalomedullary nail, will be needed to stabilize the fracture and prevent collapse.[14] Stable fractures can betreated with a sliding hip screw–plate device (2- to 4-hole plate).

Stage 2

Stabilize the patient's medical condition before surgical intervention. This phase almost always requires

consultation with an internist, a primary care physician, or a hospitalist and frequently requires secondary

consultation with an internist, a primary care physician, or a hospitalist and frequently requires secondary

consultations with members of various medical subspecialties. This phase also includes the identification of anyknown preexisting medical conditions as well as any medical condition discovered at the time of hospitaladmission. If any medical conditions are discovered, appropriate preoperative care is provided to eliminate potentialpostoperative problems that may arise from such conditions. These medical conditions are determined by acomplete physical examination; cardiac, laboratory, and pulmonary studies; and any other studies that may beindicated. Preoperative tests frequently include a complete blood cell (CBC) count, a urinalysis, an SMA-12(sequential multiple analysis–12-channel biochemical profile), a chest radiograph, and an electrocardiogram.

Additional tests may be required, depending on the patient's clinical findings, past and current medical history,and results of the screening laboratory studies and images. Any medical abnormalities are treated promptly andappropriately before surgical intervention, without allowing complications to occur because of any unnecessarydelay in initiating surgery. During this period, appropriate measures are instituted to decrease the possibility of aDVT and secondary pulmonary embolism (usually considered a preoperative protocol).

The surgical procedure follows with the reduction and internal fixation of the fracture, followed by the postoperativerehabilitation phase.

Indications

Open reduction and internal fixation (ORIF) is indicated for all intertrochanteric fractures, unless the patient'smedical condition is such that any anesthesia, general or spinal, is contraindicated; if the patient is unable totolerate any surgical procedure because of an uncontrollable or uncorrectable bleeding disorder or othernoncorrectable metabolic disorder with an unacceptable mortality rate; or if the patient has a stable, nondisplacedintertrochanteric fracture, can physically and mentally tolerate nonsurgical care, and declines surgery for personalreasons.

Relevant Anatomy

The intertrochanteric area of the femur is distal to the femoral neck and proximal to the femoral shaft. It is the areaof the femoral trochanters, the lesser and the greater trochanters. The intertrochanteric area can also be seen asthe area where the femur changes from an essentially vertical bone to a bone angling at a 45° angle from the near-vertical to the acetabulum or pelvis. The femoral artery and nerve are anterior; the sciatic nerve is posterior. Theattachments of the iliopsoas and gluteus medius can cause certain displacements, depending on the fracturepatterns. These factors may make reduction difficult. The attachment of the gluteus maximus to the femoral shaftis a guide to the level of the lesser trochanter and helpful when placing a guidewire for the compression screw. Thevastus lateralis overlies the lateral cortex of the proximal femur and must be elevated to apply a side plate.

Contraindications

Contraindications to surgery include those listed in Indications and consist of medical conditions that precludeanesthesia or surgery and stable fractures in patients who can tolerate nonoperative care.

Contributor Information and DisclosuresAuthorRichard S Goodman, MD, JD, FAAOS Chair, Department of Surgery, SABA University Medical School;Consulting Staff, Department of Orthopedics, Long Island Jewish/North Shore University Hospital

Richard S Goodman, MD, JD, FAAOS is a member of the following medical societies: American Academy ofOrthopaedic Surgeons, American Bar Association, American College of Legal Medicine, American College ofSurgeons, Arthritis Foundation, Eastern Orthopaedic Association, International College of Surgeons, MedicalSociety of the State of New York, and Pan American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

James F Kellam, MD Vice-Chair, Department of Orthopedic Surgery, Director of Orthopedic Trauma andEducation, Carolinas Medical Center

James F Kellam, MD is a member of the following medical societies: American Academy of OrthopaedicSurgeons, Orthopaedic Trauma Association, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical CenterCollege of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

James J McCarthy, MD, FAAOS, FAAP Associate Professor, Consulting Orthopedic Surgeon, Department ofOrthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health;

James J McCarthy, MD, FAAOS, FAAP is a member of the following medical societies: Alpha Omega Alpha,American Academy for Cerebral Palsy and Developmental Medicine, American Academy of OrthopaedicSurgeons, American Academy of Pediatrics, American Orthopaedic Association, Limb Lengthening andReconstruction Society ASAMI-North America, Orthopaedics Overseas, Pediatric Orthopaedic Society of NorthAmerica, Pennsylvania Medical Society, Pennsylvania Orthopaedic Society, and Philadelphia County MedicalSociety

Disclosure: Nothing to disclose.

Dinesh Patel, MD, FACS Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chiefof Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of OrthopaedicSurgeons

Disclosure: Nothing to disclose.

Chief EditorWilliam L Jaffe, MD Clinical Professor of Orthopedic Surgery, New York University School of Medicine; ViceChairman, Department of Orthopedic Surgery, New York University Hospital for Joint Diseases

William L Jaffe, MD is a member of the following medical societies: American Academy of OrthopaedicSurgeons, American College of Surgeons, American Orthopaedic Association, Eastern OrthopaedicAssociation, and New York Academy of Medicine

Disclosure: Stryker Orthopaedics Consulting fee Speaking and teaching

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