Long questions

1. Intertrochanteric fracture and intracapsular fracture of femur
   • Clinical examination of the whole femur
   • Related topic: fat embolism syndrome
2. Supracondylar fracture of humerus
   • Related topic: Saturday night palsy

Short-answer questions

1. Non-union
2. Avascular necrosis (AVN)
3. Tuberculosis involving joints
4. Humerus: anatomy, fractures, nerve injuries, and related topics
5. Clavicle: anatomy, fracture, complications, and related topics

Intertrochanteric Fracture of Femur

Definition

Anatomy Relevant to the Fracture

• Greater trochanter laterally
• Lesser trochanter posteromedially
• Intertrochanteric line anteriorly
• Intertrochanteric crest posteriorly

Important muscle attachments and displacement

Epidemiology

• One of the commonest hip fractures in the elderly.
• More frequent in women because osteoporosis is more common.
• Usually follows a low-energy fall in an elderly person.
• In young adults, it may result from high-energy trauma such as a road traffic accident or fall from height.
• An isolated lesser trochanter fracture in an adult should raise suspicion of a pathological fracture due to malignancy.

Etiology and Mechanism of Injury

In elderly persons

In young persons

Predisposing factors

• Osteoporosis
• Old age
• Female sex
• Malnutrition
• Visual impairment
• Neurological disease or poor balance
• Sedative medication
• Previous fragility fracture
• Metastatic bone disease

Classification

1. Stable and unstable fractures

Stable intertrochanteric fracture

• Fracture is minimally comminuted.
• Posteromedial cortical buttress is intact or can be restored after reduction.
• Usually a two-part fracture.
• Resists medial displacement after fixation.

Unstable intertrochanteric fracture

• Comminuted fracture, especially of the posteromedial cortex.
• Includes displaced lesser trochanter fragment.
• Reverse oblique fracture pattern.
• Subtrochanteric extension.
• Lateral wall incompetence.
• Tends to collapse into varus and medialise the shaft.

2. Evans classification

• Type I: Stable fracture, with posteromedial support preserved after reduction.
• Type II: Unstable fracture, with posteromedial comminution and loss of support.

3. AO/OTA classification

• 31-A1: Simple, two-part pertrochanteric fracture
• 31-A2: Multifragmentary pertrochanteric fracture
• 31-A3: Reverse-obliquity or intertrochanteric fracture with subtrochanteric extension

Clinical Features

History

• Elderly patient with history of fall.
• Severe pain in hip or groin.
• Inability to stand or bear weight after injury.
• In young patients, there may be a history of high-energy trauma.

General examination

• Pallor, dehydration, shock
• Associated medical illnesses: hypertension, diabetes, cardiac disease, dementia
• Pressure sores in delayed presentation
• Associated injuries after major trauma

Local examination

Inspection

• Affected lower limb lies in external rotation.
• Limb is shortened.
• Swelling, bruising, or ecchymosis may be present over the lateral hip and upper thigh.
• In a very thin patient, prominence of the greater trochanter may be evident.

Palpation

• Tenderness over the greater trochanter and groin.
• Pain on gentle pressure over the trochanter.
• Pain on axial compression through the heel.

Movements

• All hip movements are painful and restricted.
• Active straight-leg raising is not possible.
• Passive rotation causes severe pain.

Measurement

• True shortening may be present.
• The degree of shortening is generally greater than in an impacted intracapsular fracture.

Neurovascular examination

• Dorsalis pedis and posterior tibial pulses
• Capillary refill
• Motor and sensory status of the limb

Investigations

1. Plain radiographs

• Anteroposterior view of pelvis with both hips
• Lateral view of affected hip
• Full-length femur radiograph if there is distal extension or suspicion of another fracture

• Fracture line between greater and lesser trochanters
• Comminution
• Varus displacement
• Separate lesser trochanter fragment
• Reverse-oblique pattern or subtrochanteric extension

2. MRI

• X-rays are normal or equivocal
• Clinical suspicion remains high
• Patient has persistent pain and inability to bear weight

3. CT scan

• Defining comminution
• Assessing reverse-obliquity pattern
• Planning fixation when radiographs are unclear

4. Preoperative investigations

• Complete blood count
• Blood grouping and cross-match
• Renal function tests and electrolytes
• Blood glucose
• Coagulation profile, if indicated
• ECG
• Chest radiograph when clinically indicated
• Evaluation and optimisation of comorbidities

Principles of Management

Aims

1. Relieve pain.
2. Restore alignment and stability.
3. Permit early mobilisation and weight-bearing.
4. Prevent complications of prolonged recumbency.
5. Treat osteoporosis and prevent future falls/fractures.

Initial Management

• Admit and assess by ATLS principles if trauma is major.
• Adequate analgesia.
• Consider fascia iliaca compartment block or femoral nerve block as part of multimodal analgesia.
• Intravenous fluids and correction of dehydration/electrolyte imbalance.
• Treat anaemia as needed.
• Thromboprophylaxis unless contraindicated.
• Pressure-area care.
• Antibiotic prophylaxis before surgery.
• Temporary skin traction may be used for comfort, but it should not delay surgery.
• Optimise medical comorbidities promptly.

Definitive Treatment

A. Operative treatment

Indications

Timing

1. Dynamic Hip Screw (DHS) / Sliding Hip Screw

Principle

Indications

• Stable two-part intertrochanteric fracture
• Intact or reconstructible lateral wall
• Simple fracture without reverse-oblique pattern

Advantages

• Familiar and economical technique
• Good results in stable fracture patterns
• Permits controlled collapse and compression

Disadvantages

• Requires a larger exposure
• Less suitable for unstable, reverse-oblique, and subtrochanteric extension patterns
• Excessive collapse may cause shortening and varus deformity

2. Cephalomedullary Nail / Proximal Femoral Nail (PFN)

Principle

Indications

• Unstable intertrochanteric fracture
• Reverse-oblique fracture
• Comminuted posteromedial cortex
• Lateral wall fracture
• Subtrochanteric extension
• Pathological fracture in selected cases

Advantages

• Intramedullary device has a shorter lever arm.
• Better control of medialisation of shaft.
• Better biomechanical support in unstable patterns.
• Smaller incision and potentially less soft-tissue dissection.
• Allows early weight-bearing in many patients.

Disadvantages and complications

• Iatrogenic fracture of femur
• Malposition of nail or screws
• Screw cut-out
• Varus malreduction
• Technical difficulty and radiation exposure

Essential Technical Points in Fixation

1. Obtain anatomic or near-anatomic reduction.
2. Avoid varus reduction.
3. Restore medial cortical support where possible.
4. Place the lag screw centrally or inferocentrally on AP view and centrally on lateral view.
5. Keep the tip-apex distance low, preferably below 25 mm, to reduce screw cut-out.
6. Do not place the screw too superiorly or posteriorly in the femoral head.
7. Assess fixation under image intensifier before closure.

B. Conservative Treatment

Indications

• Patient medically unfit for anaesthesia or surgery
• Terminal illness
• Very low pre-injury functional status or non-ambulatory patient
• Patient refusal of surgery

Method

• Analgesia
• Nursing in a comfortable position
• Intermittent skin traction for pain relief if required
• Chest physiotherapy
• Prevention of pressure sores and deep vein thrombosis
• Early sitting out of bed and mobilisation as tolerated

Postoperative Management

• Monitor pulse, blood pressure, urine output, haemoglobin, and wound status.
• Continue analgesia and thromboprophylaxis.
• Early physiotherapy and breathing exercises.
• Sit out of bed on the first postoperative day if possible.
• Mobilise with walker or crutches according to fixation stability and surgeon advice.
• Encourage weight-bearing as tolerated after stable fixation, particularly in elderly patients.
• Prevent pressure sores and chest complications.
• Treat osteoporosis:
  • Calcium and vitamin D if deficient
  • Anti-resorptive therapy when appropriate
  • Bone-health assessment
• Assess falls risk and provide fall-prevention advice.

Complications

Early complications

• Haemorrhagic shock, especially in comminuted fractures
• Deep vein thrombosis and pulmonary embolism
• Fat embolism syndrome
• Pneumonia and atelectasis
• Urinary tract infection
• Pressure sores
• Delirium in elderly patients
• Wound infection
• Implant-related complications

Late complications

• Malunion with coxa vara and shortening
• Varus collapse
• Implant cut-out from femoral head
• Screw penetration into hip joint
• Non-union, though uncommon
• Delayed union
• Implant breakage or failure
• Limp and abductor weakness
• Persistent hip pain
• Osteoarthritis, rarely
• Reduced independence and increased mortality in elderly patients

Important point

Differences Between Intertrochanteric and Intracapsular Fracture

Conclusion