INTERTROCHANTERIC FRACTURES

Hip fractures can be divided into two groups: intra-capsular femoral neck fractures (further localized as subcapital, transcervical or bicervical) and extra-capsular peri-trochanteric fractures, namely the intertrochanteric and subtrochanteric fractures. An intertrochanteric hip fracture occurs between the greater trochanter, where the gluteus medius and minimus muscles (hip extensors and abductors) attach, and the lesser trochanter, where the iliopsoas muscle (hip flexor) attaches.

ANATOMY OF THE FERMUR

The femur is the largest bone in the body. It is 45 cm in length. The femoral head faces upwards, medially and forwards. The neck is about 5cm long and is set at an angle of 125° to the shaft. The junction between the neck and the shaft is marked anteriorly by the trochanteric line, laterally by the greater trochanter, medially and somewhat posteriorly by the lesser trochanter and posteriorly by the prominent trochanteric crest, which unites the two trochanters.

 The femur connects to the pelvis by way of a ball and socket joint to form the hip joint. This allows it to have a variety of movement. The movements possible in the hip are: flexion, extension, abduxion, adduction, internal and external rotation and circumduction. The muscles involved in the excursion of these movements are:

·         Flexors= iliacus and psoas major assisted by rectus femoris, Sartorius, pectineus;◊◊

·         Extensors=gluteus maximus, the hamstrings;

·         Adductors = adductor longus, brevis and magnus assisted by gracilis and pectineus;

·         Abductors=gluteus medius and minimus, tensor fasciae latae;

·         Lateral rotators= gluteus maximus assisted by the obturators, gemelli and quadratus femoris;

·         Medial rotators — tensor fasciae latae and anterior fibres of gluteus medius and minimus.

 

Arterial supply to these muscles is the femoral artery which is the chief artery to the lower limb. The femoral artery is a continuation from the external iliac artery which enters the femoral triangle deep to the mid point of the inguinal ligaments. As it descends downwards it gives arterial tributaries like deep femoral artery (profunda femoris)-the chief artery to the thigh, circumflex femoral artery and the obturator artery.

 The hip receives nervous supply from the femoral, sciatic and obturator nerves. These nerves also supply the knee joint.

 CAUSES AND PRESENTENTION

Different people have different fracture presentations, Intertrochanteric fractures are often seen in frail older people after low energy falls (i.e., from a standing height). Although the kinetic energy of such a fall is far more than is needed to break the bone, most falls do not lead to fracture. It should be understood that the elderly have reduced activity and their stability is already compromised. This makes them easy victims to falling.

The health of an individual also matters. In his article said, Elderly patients frequently have other significant coexisting or preexisting pathologic conditions that result in decreased resistance to the stresses of anesthesia, trauma, and surgery and an increased need for extensive postoperative rehabilitation. Coexisting or preexisting conditions that were present but unknown, undiagnosed, or simply tolerable before the fracture include pulmonary insufficiency, cardiac insufficiency, mitral valve insufficiency, aortic valve insufficiency, cardiovascular insufficiency, hypertension, dehydration, malnutrition, and any of a number of metabolic diseases or endocrine diseases, including diabetes and hypothyroidism.

In young persons, hip fractures generally result from trauma associated with significant force. For example, 75% of all femoral head fractures, more common among young patients, occur as a result of motor vehicle collisions.

In older persons, more than 90% of hip fractures result from trauma or torsion associated with a minor fall or, occasionally, in the absence of any obvious traumatic event.ostioporosis is the leading cause of hip fracture.

Other risk factors for hip fracture include the following:

    • Neurological impairment
    • Caucasian race
    • Cigarette smoking
    • Institutional living
    • Maternal history of hip fracture
    • Previous hip fracture
    • Physical inactivity
    • Tall stature
    • Alcohol abuse
    • Previous Coles or vertebral fracture attributed to osteoporosis
    • Low body weight
    • Impaired vision
    • Prolonged corticosteroid use
    • Use of medications that decrease bone mass, including furosemide, thyroid hormone, Phenobarbital, and phenytoin.
    • In patients with intertrochanteric fractures there is significant swelling, with tenderness to palpation in the proximal thigh region. The leg may lie in internal or external rotation. The patient cannot flex the hip or abduct the leg. Hemorrhage into the injured thigh may also be substantial.

 

INCIDENCE, PREVALENCE AND EPIDEMYOLOGY

Intertrochanteric fractures are very common in children who have high energy of running up and down. They are also common in young athletes like dancers, runners, high jumpers etc. The elderly are among the people who suffer the effect of intertrochanteric fractures due to frequent falls. This is because as one grows old they happen to loose balance.

 

Hip fracture occurs in approximately 80 per 100,000 persons or approximately 250,000 persons each year. The rate of hip fracture increases with age, doubling each decade after age 50 years. Nearly half of all hip fractures occur in adults older than 80 years. Hip fracture at a young age is rare and is usually the result of a high-velocity injury or, rarely, secondary to bone pathology.

 

The US frequency of hip fracture, when age and sex are adjusted, ranks the highest in the world. Western Europe and New Zealand also have reported high rates, with the lowest rates occurring in the South African Bantu people and in East Asian countries, where the incidence of osteoporosis is low.

 

ETIOLOGY

The etiology of intertrochanteric fractures is the combination of increased bone fragility of the intertrochanteric area of the femur associated with decreased agility and decreased muscle tone of the muscles in the area secondary to the aging process. The increasing bone fragility results from osteoporosis and osteomalacia secondary to a lack 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.

 

PROGNOSIS

Hip fractures are very dangerous episodes especially for elderly and frail patients. The risk of dying from the stress of the surgery and the injury in the first few days is about 10%. If the condition is untreated the pain and immobility imposed on the patient increase that risk. Problems such as pressure sores and chest infections are all increased by immobility. The prognosis of untreated hip fractures is very poor.

 DIAGNOSIS

Diagnosis of intertrochanteric fractures is done in the same as that of other fractures of the hip.  Care must be taken to rule out the more benign isolated fracture of the greater trochanter; an MRI or CT may be needed for that purpose. An isolated fracture of the greater trochanter may occur as an avulsion by the gluteus medius, and needs only symptomatic (palliative) treatment . Other radiographic materials like x-rays also help in the diagnosis of these fractures. Physically, there may be abnormal painful movement at the hip especially if there is a complete fracture. Hemorrhage is usually indicated by swelling of the thigh and an increase in girth of the proximal thigh when compared to the normal leg.

 

COMPLICATIONS

 Patients with hip fractures are rested in bed to a point where there is proof of callus formation at the fracture. Complications of prolonged bed rest in elderly patients include bronchopneumonia, deep venous thrombosis and pulmonary thrombo-embolus, urinary retention, decubitus ulcers, joint contractures and mental confusion. Due to reduced movement there is reduced muscle tone and strength. Contractures are non-exceptional especially before commencement of physiotherapy. In case of the elderly, malunion is another complication because of other predisposing factors like osteoporosis and poor nutrition. Though fractures of the femoral neck will interrupt completely the blood

Supply from the diaphysis, fractures of the intertrochanter does not have an effect on the supply of blood to the head of femur.

 

PREVENTION

Prevention of intertrochanteric fracture involves prevention of frequency of falls in the children and the elderly as they are the most affected subjects. Young sports men should ergonomically be advised on how they should prevent traumatic injuries. The elderly who have balance problems can be provided with walking aids like a frame or crutches. Improving the social and economical status of the people in the community also helps improve the diet and hence prevention of osteoporosis.

 

MANAGEMENT

Most hip fractures are treated by orthopedic surgery, which involves implanting an orthosis. The surgery is a major stress on the patient, particularly in older people. Pain is significant, forcing the patient to remain immobilized. Since prolonged immobilization can be more of a health risk than the surgery itself, post-operative patients are encouraged to become mobile as soon as possible, often with the assistance of physical therapy (physiotherapy).

If operative treatment is refused or the risks of surgery are considered to be too high the main emphasis of treatment is on pain relief. Skeletal or skin traction may be considered in the elderly or children for long term treatment. Aggressive chest physiotherapy is needed to reduce the risk of pneumonia and skilled nursing to try to avoid pressure sores and DVT/pulmonary embolism most patients will be bedbound for several months. Non-operative treatment is no longer an alternative in developed countries with modern health care. This called the conservative approach to fracture treatment.

TREATMENT

Treatment of trochanteric fractures is in three stages i.e. medical, surgery and physiotherapy.

SURGICAL TREATMENT

 In any patient who hopes to get out of bed, the treatment of intertrochanteric fractures is surgical followed by the postoperative rehabilitation phase. Surgery is currently the main approach that is used to reduce trochanteric fractures. This increases the rate at which healing takes place and, thus, the patient mobilizes early. Stabilize the patient's medical condition before surgical intervention. The traditional treatment in recent decades is the sliding hip screw. This device has a large screw in the femoral head and neck engages a plate fixed to the shaft, with sliding of the screw allowed if and when the fracture impacts.

Traction

Still safe and predictable but prolonged hospitalization is required. This is both expensive and exposes the wound to infection.

 

External Fixation

This is rarely indicated. It is used mainly in cases where ORIF is not feasible or if there is a severe open wound.

 

Plating

This is now seldom performed, but may be useful when IM nailing is not possible but may be suitable in children.

 Intramedullary Nail

It is regarded as the best technique, allowing early mobilization, thus avoiding prolonged hospitalization and infection.

 

MEDICAL TREATMENT

 Many of patients are unwell before breaking a hip; it is common for the break to have been caused by a fall due to some illness, especially in the elderly. Nevertheless, the stress of the injury, and a likely surgery, does increase the risk of medical illness including heart attack, stroke, and chest infection.  

 Patients are immobilized and in bed for many days; they are frequently catheterized though this causes Urinary tract infection (UTI) to occur.  Blood clots may also result into Deep Venous Thrombosis (DVT) when blood in the leg veins clots and causes pain and swelling.                                                                                                                                                                                                                            Mental confusion is extremely common following a hip fracture.

Medical treatment of all of these medical conditions is mainly pharmacological.

 In the case of treating UTIs and other chest infections, chemotherapeutic drugs like aminoglycosides beta-lactam compounds and sulfonamides and many more drugs depending on the individuals problem of the patient. NSAIDs are used to releave the pain that comes due to the fracture. Pressure mattresses  advocated to avoid pressure sores.

 

PHYSIOTHERAPY MANAGEMENT

 

Many clinical practitioners have recommended that physiotherapy as a very useful approach to the treatment of fractures.

Effects of Physiotherapy                 

          I.            Muscle Balance Assessment and Exercise

Following immobilization muscles surrounding the fracture site lose bulk, length and strength. It is very important that a safe exercise program is prescribed and progressed under the supervision of a physiotherapist to restore muscle length and balance and prevent secondary complications occurring.

 

        II.            Joint Mobilization

Joint stiffness often occurs when a limb is not allowed to move for several weeks. Physiotherapists are trained in techniques which can improve and restore range of movement of the affected joints once the fracture has healed.

      III.            Massage:

The release of tight bands and trigger points that occur within

Muscles following splinting or casting has been shown to reduce pain

and restore muscle length.

     IV.            Heat and Electrotherapy:

It is very common for stiffness within soft tissues to occur following

Prolonged immobilization. Heat and Electrotherapy have been shown

To be useful adjuncts to manual treatment and exercise therapy in

Relieving pain and restoring muscle length.

       V.            Gait Education:

A fracture requires the use of gait aids such as crutches then the physiotherapist can advise with the most appropriate equipment and way of walking that promotes optimal healing and safety.