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http://emedicine.medscape.

com/article/1247210-overview Background
Intertrochanteric fractures are considered 1 of 3 types of hip fractures. The anatomic site of this type of hip fracture is the proximal, upper part of the femur or thigh bone. The proximal femur consists of the femoral head, femoral neck, and the trochanteric region. 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. [1, 2] Fractures of the femoral neck are proximal or cephalad to intertrochanteric fractures, and subtrochanteric fractures are distal or below (sub) to the trochanters. These fracture types are discussed in other Medscape Reference articles.

Normal femur anatomy.

Stable intertrochanteric

fracture.

Unstable intertrochanteric fracture.

Though all of these fractures are often referred to simply as hip fractures, the above distinctions between femoral neck 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 the proximal femoral fragment, including the residual neck fragment with the devitalized femoral head. Intertrochanteric fractures are treated using an engineered metallic fixation device (internal splintage device) designed to maintain the nondisplaced, minimally displaced, or postreduction fracture fragments in their anatomic, near-anatomic, or acceptable postreduction position. This stability assists in the healing of the fracture. In addition, postoperative care and rates of complications, including mortality and morbidity, vary for different fractures and different subcategories of intertrochanteric fractures. The current treatment of intertrochanteric fractures is surgical intervention. Despite an acceptable healing rate with nonsurgical 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 by unacceptable morbidity and mortality rates because of frequent nonorthopedic complications associated with prolonged 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, the fracture heals with unacceptable shortening, rotation, and/or angulation of the extremity, resulting in decreased mobility and subsequent handicap, impairment, and disability.) Currently, with a few exceptions, surgical intervention is used to treat essentially all intertrochanteric fractures and is 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 the appropriate internal fixation device and the specific type of fracture. The correct surgical technique described by the developer of the device should also be used. Therefore, the optimal device is chosen after a precise diagnosis of the type of intertrochanteric fracture. The indications and contraindications of the technique must also be matched with the patient's activity level, degree ofosteoporosis, and realistic expected outcome. To accomplish this match between technique and patient, at a minimum, technically adequate preoperative radiographs of the hip are necessary, including anteroposterior (AP) view of the pelvis and involved hip and true lateral 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 accurately plan the surgery. Gentle traction applied during the radiograph will help define the fracture, particularly if significant shortening has occurred.

Recent studies
Anglen et al found that from 1999 to 2006, for fixation of intertrochanteric hip 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 use of a sliding compression screw. Intramedullary nail fixation rate increased from 3% in 1999 to 67% in 2006. Overall, patients managed with plate fixation had slightly less pain and deformity than those patients who were managed with intramedullary nailing, and there were no significant differences identified regarding function or patient satisfaction. In addition, the authors found that patients managed with intramedullary nailing had more procedure-related complications, particularly bone fracture. The authors noted that this change in management 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 nails following treatment of extracapsular hip fractures. They found that in earlier studies (1991-2000), gamma nails were found to increase the risk of femoral shaft fracture by 4.5 times when compared with the use of compression screws. However, in more recent studies (2000-2005), 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 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 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 76 8 in the 27 patients who completed 5-year follow-up. The average time to return to normal daily activities was 28 days (range, 24-33 days), and there was no loosening or infection observed. The authors concluded that in mentally healthy elderly patients with intertrochanteric 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.[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 portion of the neck but instead of traversing the neck completely, it penetrates the base of the trochanter major; the line of fracture 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 the first 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 the use 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 with abduction, 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 brought down in the measured degree of abduction and internal rotation, the heel of the injured leg is allowed to rest on the outstretched 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 of the reduced fracture in 1850 using an intramedullary nail. Other physicians followed with different nails but faced problems with the procedure. Blind reduction and fixation of the fracture and blind nailing or percutaneous insertion of a nail or other internal fixation device without visualization of the tract of the nail meant that malposition of the fracture, the device, or both was frequent. Moreover, technology was unavailable to produce fixation devices with adequate tensile strength or devices that caused only a minimal or inconsequential reaction from body tissues. In addition, 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 image intensification screens and low-radiation technology resulted in control and confirmation of the fracture reduction in the operating room. Cannulated fixation devices (eg, nails, hip screws, side plates) that are placed over temporary guide wires allow the surgeon to more easily plan and confirm the position of the fixation device and add to the surgeon's armamentarium. Today, the procedure uses radiographs on an image intensifier screen to project and record a satisfactory stable reduction of the fracture. Operating room fracture tables with traction devices hold the reduced position of the fractured 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 hold the lag screw to the distal femur, and screws to attach the plate to the distal femur. A compression screw draws the 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 were malunited 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 mortality rates 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 the mortality rate. Therefore, progress in the care of intertrochanteric fractures has involved decreasing the mortality from nonorthopedic coexisting or concurrent medical problems and decreasing the degree of malunion and possible nonunion 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 account for more hospital days than tibial fractures, vertebral fractures, and pelvic fractures combined. In addition, hip fractures account for more than half of the total hospital admissions of all fractures and more than half of the ambulance calls for fractures.

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.[13]Benign and malignant tumors, along with metastases such as multiple myelomaand other malignancies, can also lead to weakened bony structure. The combination of increased fragility of bone and a traumatic event such as a motor vehicle accident or fall may result in either a direct impact or generation of a torsional force transmitted through the leg to the intertrochanteric area. 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 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 addition, metabolic changes are consistent with the postoperative stresses from the postoperative analgesics and the postoperative rehabilitation program. As a result of these comorbidities, a 2-stage treatment program is recommended.

Stage 1
Identify the fracture on the basis of the history and the findings from physical examination and radiographs. The patient typically presents with a history of slipping on, falling on, or twisting of the lower extremity that is followed by severe pain in the affected hip area. Patients may 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 AP pelvic view and either a cross-table lateral view of the hip or a frog lateral view of the hip and a traction AP hip radiograph. 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. The stability of the fracture is defined by the amount of contact between the proximal and distal main fragments. Two-part intertrochanteric fractures are very stable, as there are only 2 fragments, which, once reduced, are impacted on each other and provide inherent stability 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 into varus position and shorten. Therefore, a fracture is considered unstable if there is a large lesser trochanteric fragment or if the greater and the lesser trochanter are separate fracture fragments (4-part fracture). The more unstable 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 be treated with a sliding hip screwplate 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 consultations with members of various medical subspecialties. This phase also includes the 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 a complete physical examination; cardiac, laboratory, and pulmonary studies; and any other studies that may be indicated. Preoperative tests frequently include a complete blood cell (CBC) count, a urinalysis, an SMA-12 (sequential multiple analysis12-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 and appropriately before surgical intervention, without allowing complications to occur because of any unnecessary delay in initiating surgery. During this period, appropriate measures are instituted to decrease the possibility of a DVT 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 postoperative rehabilitation phase.

Indications
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; if the patient is unable to tolerate any surgical procedure because of an uncontrollable or uncorrectable bleeding disorder or other noncorrectable metabolic disorder with an unacceptable mortality rate; or if the patient has a stable, nondisplaced intertrochanteric fracture, can physically and mentally tolerate nonsurgical care, and declines surgery for personal reasons.

Relevant Anatomy
The intertrochanteric area of the femur is distal to the femoral neck and proximal to the femoral shaft. It is the area of the femoral trochanters, the lesser and the greater trochanters. The intertrochanteric area can also be seen as the 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. The attachments of the iliopsoas and gluteus medius can cause certain displacements, depending on the fracture patterns. These factors may make reduction difficult. The attachment of the gluteus maximus to the femoral shaft is a guide to the level of the lesser trochanter and helpful when placing a guidewire for the compression screw. The vastus 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 preclude anesthesia or surgery and stable fractures in patients who can tolerate nonoperative care.