Fracture around the trochanter is one of the most common fractures of the hip especially in the elderly with osteoporotic bones, usually due to low-energy trauma like simple falls within the height of individual. The peritrochantric fractures are inherently stable and has fracture line which runs parallel to intertrochanteric line, whereas intertrochanteric fracture has fracture line runs in between the greater and lesser trochanter and are inherently unstable. The unstable trochanteric fractures have one or more features like loss of posteromedial support, severe comminution, subtrochanteric extension of the fracture, reverse oblique fracture, shattered lateral wall extension into femoral neck area. The purpose of this article is to discuss management of unstable trochanteric fractures which includes a brief overview and tips of operative reduction and fixation.
HISTORY AND EXAMINATION OF UNSTABLE TROCHANTERIC FRACTURE
Conventional history and thorough examination should be done for diagnosis. Careful history reveals the mechanism of injury and the severity of trauma. Their general examination reveals associated systemic diseases and associated injuries.
Patients should be examined supine which reveals typical external rotational attitude of the affected lower limb (Limb helplessly externally rotated as revealed by lateral border of the foot touches the bed), local ecchymosis over trochanter, local trochanteric and bi-trochanteric tenderness, painful all motions of hip and inability to do straight leg raising actively. Distal vascularity is assessed by popliteal, arteria dorsalis pedis, posterior tibial pulsations, capillary filling, pallor and paresthesia over toe tips.
Routine examination of blood should be done for hemoglobin percentage, total and differential WBC counts, fasting blood sugar, blood urea, serum creatinine, bleeding and clotting time, HIV, HCV and HbsAg. Examination of urine is required for presence of albumin and sugar and routine as well as microscopic examination for detection of infection. Blood pressure, Chest X-rays and ECG in all patients and echocardiography in selected patient are also required. All patients should get Tetanus toxoid injection and intravenous antibiotic pre-operatively.
Standard radiographs in AP and lateral views are done for confirmation of the diagnosis and also to know the type of fracture. The fracture fragments were analysed and involvement of hip (intertrochanteric region) were assessed and classified.
TREATMENT OF UNSTABLE TROCHANTERIC FRACTURE
The various conservative methods were reported but they are used in a patient who is unfit for surgery or unwilling for surgery or waiting for surgery of unstable trochanteric fractures, or where trochanteric fracture becomes a component of polytrauma, where conservative treatment is the mainstay as a damage control orthopedics.
The options are de-rotation boot, Buck’s extension skin traction, Skeletal traction, Hamilton Russell traction, Modified Russell’s traction, Fisk’s and Perkin’s method of traction. Commonly, the involved limb is immobilized in a Bohler Braun splint with skin traction with the limb, widely abducted at hip and kept elevated before operation. Pain and inflammation were managed using analgesics like paracetamol 650 mg twice daily after food with antacids. Static physiotherapy of trunk and limb muscles with chest physiotherapy and standard preventive measures of deep vein thrombosis are advised.
THE SURGICAL MANAGEMENT
Why surgery? Intertrochanteric fracture, an injury of the elderly has a high mortality rate. Rapid patient mobilization following surgical stabilization of the fracture lessens the frequency of life threatening complications such as cardio-pulmonary failure and thrombo-embolic diseases. It also minimizes the incidence of decubitus ulcers and limb contractures.
Relative contraindications to the surgery are Contaminated wound at the operative site, Septicemia, Delay in the treatment more than 3weeks and other associated conditions e.g. cardio pulmonary diseases, thrombo-embolic diseases etc. In such cases, the other options can be undertaken, like external fixation devices or Prosthetic replacement (hemi or total).
The aim and types of osteosynthesis
The main goal of treatment is stable fixation that promotes early postoperative mobilization. Extramedullary versus intramedullary devices for stabilization of proximal hip fractures have been extensively reported in the literature. Intramedullary devices appear to be highly appropriate due to their biomechanical properties. A Cochrane meta-analysis comparing extramedullary devices and older generation intramedullary nails concluded that the short term advantage of intramedullary fixation was negated by a higher incidence of operative morbidity.
Surgical tips for osteosynthesis of unstable trochanteric fracture
Most intertrochanteric fractures are four part injuries, with secondary comminution of greater and lesser trochanters. The presence of the large posteromedial fragment as well as extension of fracture line in subtrochanteric region or reverse oblique fracture line defines an unstable pattern. Biological reduction and elastic stable fixation by intramedullary implants are the key for success.
Close reduction is attempted with conventional method (Longitudinal controlled traction with gradual abduction and internal rotation for reduction, checked under fluoroscope then the limb is fixed in fracture table in scissors position with fractured limb adducted and opposite limb abducted). Successful reduction restores the osseous stability by achieving medial cortical abutment and impaction of the major fracture fragments in a normal or slight valgus alignment. Restoration of the bone opposition and stability by closed reduction on a fracture table is not possible in cases with medial comminution or trochanteric fracture of external rotation variety (proximal fragment is externally rotated when the short external rotators of hip remain attached with proximal head-neck fragment). In such cases close reduction is aided with insertion of Steinman pin in the proximal fragment for it’s derotation, or placement of Hohmann retractors for control of rotation of proximal fragment and elevation of depressed distal fragment or minimal open reduction aided with retractors or reduction clamp [Figure 1]. Prior insertion of Steinman pin also helps in derotation of proximal fragment for making accurate entry point of internal fixation device. Satisfactory reduction should be maintained throughout the procedure [Figure 2], for that fracture may sometimes need preliminary internally fixed with K wires passed through the periphery of fracture, so that the guide wire and subsequently, the original intra-medullary nail can be introduced bypassing the positions of those K wires.
Apart from proximal fixation by one (PFNA II) or two screws (Standard PFN or screw inside screw) or screw inside the screw, maintaining the standard tip-apex distance, all unstable fractures should be fixed distally by two screws either in dynamic mode or neutral mode. Distal screw fixation can be done with the help of polar screw or polar rod method to avoid penetration of anterior cortices of distal femur and proper guidance of passage of intramedullary nail. Ideal distal extent of nail should be at upper border of patella so that distal screws are fixed at the junction of lower shaft and metaphysis. Condylar placement of distal screw is discouraged to avoid screw breakage.
An ideal fixation device should permit controlled intraoperative compression of the fracture and should allow the fracture to settle in a stable position and prevent nail protrusion through the femoral head. The device should act as an internal splint. Complications arise when the surgical construct is inadequate to withstand the major forces to which the proximal femur is subjected. Some of the complications are; varus settling of the fracture, cutting out or protrusion of the nail or screw and fatigue failure of the implant.
Reconstitution of the medial buttress of unstable fractures by inter-fragmentary compression screws or strategically placement of encirclage stainless steel wire decreases the likelihood of limb shortening and abductor insufficiency [Figure 3]. Most patients under 65 years of age and active patients over 65 years of age benefit from this additional surgery. Severe medial comminution or advance osteoporosis may preclude successful inter fragmentary fixation. Cancellous bone grafting of medial cortical defects is occasionally necessary in young patients with unstable fractures.
Elderly osteoporotic patients may be managed by one of the two techniques: (i) The major head/neck and shaft fragment may be aligned on the fracture table, so that femoral length is restored. A sliding nail or screw plate implant over lateral wall allows maintenance of position in post operative period and stabilization of the fractures as necessary. (ii) Intra operative medial bony contact and stability can be obtained by medial displacement of the femoral shaft or valgus osteotomy. Although these procedures do obviate the need for anatomically nailed fractures to migrate in to stable position, they do shorten limb and abductor mechanism.
The structural instability with poor bone quality require accurate planning and judicial surgical management for their osteosynthesis by stable fixation as well as strict postoperative care to avoid fixation failure as well as functional recovery.
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