Intertrochanteric Hip Fractures Treatment & Management
- Author: James F Kellam, MD, FRCSC, FACS, FRCS(Ire); Chief Editor: William L Jaffe, MD more...
Indications and contraindications
Open reduction and internal fixation (ORIF) is indicated for all intertrochanteric fractures, unless the patient's medical condition is such that any anesthesia, general or spinal, is contraindicated.
Total hip arthroplasty has a limited role in treatment and is usually reserved for patients with coexisting severe symptomatic arthritis of the hip. External fixation is also rarely indicated but is useful as a quick procedure in patients who may not tolerate general or spinal anesthesia and can only tolerate local techniques. Medial displacement osteotomy and valgus reduction are no longer practiced, because of the severe deformities they produced and because of substantial advances in the understanding of fracture fixation.
Surgery is contraindicated if the patient has an uncontrollable or uncorrectable bleeding disorder or another noncorrectable metabolic disorder with an unacceptable mortality. It is also contraindicated if the patient has a stable, nondisplaced intertrochanteric fracture, can physically and mentally tolerate nonsurgical care, and declines surgery for personal reasons.
A device known as the sliding hip screw was the standard implant for trochanteric fracture fixation. Problems of fracture construct failure and malunion stimulated a need to develop a better implant. In the late 1980s, the concept of intramedullary nail fixation was proposed as an answer to these problems. This proposal stimulated subsequent changes in the management of trochanteric fractures.
Anglen et al found that from 1999 to 2006, for fixation of trochanteric fractures, there was a dramatic increase in the preference for the use of intramedullary nails that interlock proximally into the femoral head, in comparison with the use of a sliding compression screw. The intramedullary nail fixation rate rose from 3% in 1999 to 67% in 2006. Overall, patients managed with plate fixation had slightly less pain and deformity than those managed with intramedullary nailing, and no significant differences were identified with regard to function or patient satisfaction.
In addition, the authors found that patients managed with intramedullary nailing had more procedure-related complications, particularly femoral shaft fracture. They noted that this change in management of trochanteric hip fractures occurred despite a lack of evidence supporting the change and the apparent potential for increased complications and cost.
Bhandari et al performed a meta-analysis to identify the risk of femoral shaft fracture associated with short cephalomedullary nails after treatment of extracapsular hip fractures. They found that in studies published between 1991 and 2000, gamma nails increased the risk of femoral shaft fracture by 4.5 times when compared with compression screws.
In subsequent studies (2000-2005), however, gamma nails were not associated with significantly increased risk of femoral shaft fracture, and in a 2005 study, there was no difference in femoral fracture rates. According to Bhandari et al, the more recent trials suggest that the increased femoral shaft fracture risk associated with gamma nails has been resolved as the result of improved implant design and better surgical technique.
Sidhu et al studied 53 patients (average age, 77 years) after total hip replacement for trochanteric hip fractures. 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 at the completion of 5-year follow-up (n = 27), 76 ± 8. The average time to return to normal daily activities was 28 days (range, 24-33 days), and no loosening or infection was observed.
Sidhu et al concluded that in mentally healthy elderly patients with trochanteric hip fractures, total hip arthroplasty may be a valid treatment option because it offers the potential for quick recovery with little risk of mechanical 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.
Subsequent studies have shown that the dynamic helical hip system results in outcomes that are comparable to those achieved with the dynamic sliding hip screw, and its blade is more resistant to vertical or rotational displacement.[22, 23]
The future of intertrochanteric fracture repair focuses, in part, on preventing such fractures by means of antiosteoporosis treatments, including medications and health programs. Another focus includes fixation devices that require smaller incisions and are more forgiving, with retention of the fixation, regardless of whether the fracture is ideally reduced or has an element of instability. A final goal is to eliminate or substantially decrease the mortality and morbidity of postoperative deep vein thrombosis (DVT) and pulmonary embolism (PE) by developing a better understanding of the clotting mechanism and the genetic, metabolic, serologic, and hormonal factors that affect the likelihood of developing PE.
Stages of Treatment
In view of the potential for comorbidities or other injuries (see Presentation), a four-stage treatment program is recommended.
In stage 1, identify the fracture on the basis of the history and the findings from physical examination and radiography. A patient with a low-energy fracture typically presents with a history of slipping on, falling on, or twisting the lower extremity that is followed by severe pain in the affected hip area.
A high-energy injury is secondary to a motor vehicle collision, a fall from a height of more than 3 m, or other significant trauma. Patients will be unable to stand or move their body or the affected extremity without pain. Local physical examination typically reveals the affected lower extremity in a position of hip extension with the leg externally rotated, with the patient experiencing pain on any active or passive motion of the hip or any part of the extremity.
The diagnosis of an intertrochanteric fracture is confirmed by the review of appropriate radiologic images, including an anteroposterior (AP) pelvic view, an AP view of the involved hip, and either a cross-table lateral view of the hip or a frog lateral view of the hip, as well as a traction AP hip radiograph if the surgeon does not fully understand the fracture pattern. A full-length radiograph of the involved femur is necessary to rule out any pathologic process or deformity that may exist distal to the fracture.
These images also define the inherent stability or instability of the fracture, the need for a reduction of the fracture, and whether further manipulation is indicated to produce a reduction sufficiently stable to heal before the implant fixation is lost.
In 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 consultations with members of various medical subspecialties. This phase also includes identification of any known preexisting medical conditions, as well as any medical condition discovered at the time of hospital admission.
If any medical conditions are discovered, appropriate preoperative care is provided to eliminate potential postoperative problems that may arise from such conditions. These medical conditions are determined by means of a complete physical examination; cardiac, laboratory, and pulmonary studies; and any other studies that may be indicated. Preoperative tests frequently include a complete blood count (CBC), urinalysis, an SMA-12 (sequential multiple analysis–12-channel biochemical profile), chest radiography, and electrocardiography (ECG).
Additional tests may be required, depending on the clinical findings, the past and current medical history, and the results of screening laboratory studies and imaging. Any medical abnormalities are treated promptly and appropriately before surgical intervention to ensure that complications do not occur because of any unnecessary delay in initiating surgery. Appropriate measures are instituted to decrease the possibility of DVT and secondary PE (usually considered a preoperative protocol).
Stabilization must be carried out expeditiously. Patients do best if the fracture is stabilized surgically within 24-48 hours of admission to the hospital. This does not mean that these cases are emergencies, but in most instances (unless the patient is critically ill), workup and stabilization must be done and the patient in the operating room (OR) by 48 hours. A patient with a high-energy fracture needs a trauma workup and clearance by the hospital trauma team. Surgery is performed as soon as the patient is stable and the right operating team is available.
Stage 3 includes the surgical procedure and postoperative recovery in the acute care hospital. Comanagement of elderly patients by both orthopedic surgery and internal medicine or geriatrics is best. Each specialty is responsible for its specific areas of care; with joint management, the patient receives the best care. At discharge, arrangement for follow-up are made. Standard postoperative follow-up care is necessary for all patients. Patients with low-energy fragility fractures should also have follow-up osteoporosis care.
Stage 4 consists of patient rehabilitation, either in the outpatient setting or in a rehabilitation facility. The aim is to achieve the best possible outcome that the injury will allow. In the elderly group, emphasis must be placed on preventing falls and following appropriate exercise and dietary programs.
The patient with an intertrochanteric fracture is ready to proceed with surgery after the medical or trauma evaluation has been completed and the medical conditions have been stabilized without undue delay.
In September 2014, the American Academy of Orthopaedic Surgeons released a clinical practice guideline for the management of hip fractures in elderly patients. Recommendations included the following:
Preoperative regional analgesia to reduce pain in hip fracture patients (a strong recommendation)
Hip fracture surgery within 48 hours of hospital admission
Intensive physical therapy following hospital discharge to improve functional outcomes
An osteoporosis evaluation, as well as vitamin D and calcium supplements, for patients following a hip fracture
After appropriate surgical consent has been obtained, the patient is taken to the OR. Correct side identification and patient identification are completed. According to the judgment of the anesthesiologist, the patient is given either general anesthesia or spinal anesthesia. When adequate anesthesia has been administered, the patient is transferred to an orthopedic or fracture table.
The lower extremities are usually attached to the traction apparatus through boots on the feet. The surgeon must confirm that the boots are well fitting, padded, and tightened to ensure that the foot will not pull out with traction. Use of the well leg holder for the nonfractured leg, placing it in a position of hip flexion, abduction and external rotation, should be avoided for fear of postoperative compartment syndrome. The scissors position (both legs out straight, with the fractured side in neutral extension and the well side extended at the hip and knee and dropped dorsally) is safer.
After the patient is positioned on the table, a closed reduction of the fracture is performed. The sequence for reduction commences with longitudinal traction in a well-relaxed patient. The fracture is fully extended when the top of the greater trochanter is at the center of the femoral head; at this point, the normal neck shaft angle is restored. The leg is then internally rotated to align the neck with the shaft in the lateral view and to ensure proper anteversion. Appropriate images are obtained with one or two fluoroscopic imaging (C-arm) machines.
If the reduction is not satisfactory, adjustments are made by changing the rotation, abduction, or amount of traction on the affected extremity. Surgery proceeds when an adequate, stable, or near-anatomic reduction is obtained, with correction of any problems with rotation, leg length, lateral angulation, and AP angulation.
Certain fracture patterns cannot be reduced in a closed manner; in such cases, open reduction is required.
A high-energy two-part intertrochanteric fracture is usually widely displaced or impacted in an unreduced position. Both of these situations demand an open reduction. It is sometimes easier to do this without a fracture table and with the patient on a radiolucent table in the supine position with a bump under the hip. Carr has reported on a percutaneous technique for disengaging the medial calcar from the distal shaft and reducing the posterior sag so often seen with these fractures.
If a fracture table is used and placement of a sliding hip screw or short intramedullary hip screw is planned, the lateral hip and femur are prepared and draped with a special drape. If an intramedullary device is used, the whole leg down to the midcalf is prepared and draped to allow distal locking of the nail. Draping will require that the whole leg and body from the costal margin on the involved site be prepared sterilely and draped.
Compression hip screw (sliding hip screw)
A compression hip screw device consists of a screw, pin, or nail inserted into a premade tapped drill hole in the femoral neck and head and an angled side plate placed over the distal end of the screw and fixed with screws to the proximal femoral shaft. The side plate provides a more stable attachment of the device (pin, sliding nail, or screw) in the neck of the femur with the distal femoral shaft as well as allows it to collapse in a controlled manner (see the image below.)
The proximal femur is exposed through an incision extending from the greater trochanter for approximately 8-10 cm distally. The lateral femur is exposed, and a guide wire is drilled from the lateral femur into the femoral head, so that the guide wire is centered in the femoral neck in both the lateral view and the AP view, as shown on the fluoroscopic images.
The angle between the wire and the femoral shaft must equal the angle of the proposed fixation device (usually 135°). The tip of the guide wire must lie in the center of the femoral head and 1 cm from the subchondral line on both the AP and lateral views. This is the tip apex distance (TAD), as described by Baumgaertner. The TAD must be less than 2.5 cm for a minimal screw cutout.
If the guide wire is placed appropriately, the drilled hole is enlarged with the cannulated reamers supplied with the fixation device over the already placed guide wire. The lag screw is inserted into the femoral head after tapping of the drilled channel. Tapping is particularly important in younger patients because the bone in the femoral head is very dense and strong.
The side plate and barrel are placed over the screw, and the guide wire is removed. The side plate is then attached to the femoral shaft with the appropriate screws. Fluoroscopic images are taken throughout the repair to ensure the maintenance of the reduced fracture position and the proper positioning of the fixation device.
Percutaneous hip screw and plate insertion can be accomplished with an implant designed to allow this approach. A prospective, randomized, single-blind study involving patients with A1 and A2 AO/OTA intertrochanteric proximal femoral fractures found that treatment with the Gotfried percutaneous compression plate yielded significantly shorter operating time, significantly shorter incision length, and significantly less blood loss than treatment with the sliding hip screw.
In this study, the patients treated with the Gotfried plate had lower levels of pain with activity, improved quality of life, and a better percent chance of walking independently, but these differences were not significant. Given that this study did not differentiate between unstable and stable intertrochanteric fractures, the use of these techniques should be undertaken with caution in unstable fractures.
The cephalomedullary nailing technique is a treatment alternative for intertrochanteric fractures. Multiple thin-diameter solid nails (Enders nails) inserted from the knee in a retrograde fashion were popular in the 1970s and 1980s (see the image below). This technique, however, led to excessive external rotation and knee pain and has been abandoned.
The use of antegrade nails inserted through the greater trochanter, with a compression hip screw inserted through the proximal portion of the nail into the femoral head, is now being used, especially for unstable fracture patterns.[30, 31] (See the image below.)
Cephalomedullary fixation may help with reduction of unstable fractures and prevent excessive shortening from collapse, in that the nail acts as a calcar rand lateral wall replacement to support the femoral neck. This percutaneous technique has the potential for less blood loss, earlier full weight-bearing, and better reductions. However, it is technically demanding and has had a high rate of femoral shaft fractures below the nail tip; modifications of nail design have reduced this complication.
After the appropriate fixation device has been placed, the muscles, fascia, and skin are closed. The patient is then transferred to a recovery room.
After an intertrochanteric fracture repair, any nonorthopedic conditions the patient may have continue to be treated. Preventive DVT protocol is followed with an appropriate combination or selection of antiembolism stockings and anticoagulants. The anticoagulants include, but are not limited to, aspirin, heparin or a heparin derivative, and warfarin or a warfarin derivative.
Anticoagulants require appropriate monitoring to ensure adequate dosage and to prevent overmedication and bleeding. With each medication or protocol, the dosage is different, the length of treatment is different, and the combination of medications and use of anticoagulant socks vary. Each treating surgeon needs to ensure that he or she has a protocol for DVT prophylaxis.
Physical therapy is instituted to allow the patient to ambulate with the aid of physical therapists or other nursing personnel. Equipment includes walkers, crutches, four-post canes, and other canes as recommended by the physical therapist and surgeon.
The physical therapist guides therapy and the use of assisted ambulatory supports on the basis of proper instructions from the surgeon. The surgeon indicates the differences between nonweightbearing, toe touching, partial weightbearing, and full weightbearing therapies and the proper techniques for use of various ambulatory devices. In patients of advanced age, it may be difficult to institute therapy beyond full weight-bearing.
In a randomized, controlled pilot study in patients unable to leave home by 6 months post fracture, Mangione et al found that a 10-week home-based progressive resistance exercise program supervised by physical therapists yielded moderate-to-large improvements in physical performance and quality of life. Compared with control subjects, who received transcutaneous electrical nerve stimulation and mental imagery, patients in the leg exercise group were more likely to have meaningful changes in gait speed and 6-minute walk test distance at 1 year.
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