INTERTROCHANTERIC FRACTURE:

• EXTRA CAPSULAR
• Occur in the region between the greater trochanter and the lesser trochanter of
femur, often extending to the subtrochanteric region.
EPIDEMIOLOGY:
• Varies from country to country
• Rising number of senior citizens
with osteoporosis.
• Advancing age
• Increasing number of comorbidities
• History of other osteoporosis
related fractures.
• Since they occur in cancellous bone with abundant blood supply no problems of
non-union and osteoporosis
MECHANISM OF INJURY:
• The fracture is caused by a fall directly onto the greater trochanter or by an
indirect twisting injury.
• The crack runs up between the lesser and greater trochanter and the proximal
fragment tends to displace in varus.

Intertrochanteric fracture are divided in to stable and unstable varieties.

a. There is poor contact between fracture fragment.
b. The fracture fragment is such that forces of weight bearing continually displace
the fragment further, as in those with a reverse oblique pattern or
subtrochanteric fracture.
c. Osteoporosis leading to poor quality grip by fixation implants.
HISTORY:
• History of pain and inability to ambulate after a fall or other injury
• Pain is localized to proximal thigh exacerbated by passive attempts at hip flexion
or rotation.

EXAMINATION:
1. Shortening of extremity and deformity of rotation in resting potential
compared with the other extremity.
2. Pain with motion/ crepitance
AUSCULTATION
LIPPMANN TEST:
 Sensitive for detection of occult fractures of proximal femur of pelvis
 Bell of stethescope on symphysis pubis and tapping on patella of both
extremities- variation in sound conduction determines discontinuity.
 Decreased tone or pitch – fracture.
X-ray:
• Undisplaced stable fractures may show no
more than a thin crack along for intertrochanteric line
• The diagnosis can be confirmed scintigraphy or MRI.
• More often the fracture is displaced
and there may be considerable communition.
• The lesser and greater trochanter
may be identified as seperate fragment.
EVANS CLASSIFICTION:
Type 1:
STABLE
• Undisplaced frature
• Displaced but after reduction overlap of
medial cortical buttress make the frature stable
UNSTABLE:
• Displaced and the medial cortical buttress
is not restored is not restored by reduction of
frature.
• Displaced and comminuted fractures in
which cortical buttress is not restored by
reduction of fracture.
Type 2
• Reverse obliquity fracture.
AO/ OTA (alphanumeric classification)
Bone=femur=3 Segment=proximal=1 Type=A1, A2, A3

A1: simple(2 part) fractures, with typical oblique fracture line extending from the
greater trochanter to the medial cortex, the lateral cortex of the greater trochanter
remains intact

A2: fractures are comminuted with the posteromedial fragment, the lateral cortex
of the greater trochanter,however, remains intact. Fractures in this group are
usually unstable, depending on the size of medial fragment.

A3: fractures are those in which the fracture line extends across both the medial
and the lateral cortices, this group includes reverse obliquity pattern or
subtrochanteric extensions
GROUP 1:
Peritrochanteric simple fracture with typical oblique fracture line extending from
the greater trochanter to medial cortex, the lateral cortex of greater trochanter
remains intact.

31-A1 PERITROCHANTERIC SIMPLE

31-A1.1 along intertrochanteric line
31-A1.2 through greater trochanter
31-A1.3 below lesser trochanter
GROUP 2:
Peritrochanteric multifragmentary -comminuted with posteromedial fragment, the
lateral cortex of greater trochanter however remaiins intact. Fractures in this group
are generally unstable, depending on the size of the medial fragment

31-A2 PERITROCHANTERIC MULTIFRAGMENTARY

31-A2.1 with one intermediate fragment
31-A2.2 with several intemediate fragment
31-A2.3 extending more than 1cm below lesser trochanter
GROUP 3:
True intertrochanteric fracture are those in which the fracture line extends across
both the medial and lateral cortices, this group includes the reverse obliquity
pattern

31-A3 INTERTROCHANTERIC
31-A3.1 simple oblique
31-A3.2 simple transverse
31- A3.3 multifragmentary
TREATMENT OPTION:
Non-operative treatment:
Indication:
• Poor medical
and surgical risk
patient
• Terminally ill

METHODS:
• Very old patient: buck’s traction
• Plaster/hip spica
• Skeletal traction through distal
femur or tibia for 10-12 weeks with
bohler-braun splint
In elderly patient, this approach was assosciated with high complication rates,
typical problem include
• Decubiti
• Urinary tract infection
• Joint contractures
• Hypostatic pneumonia
• Thromboembolic complication
• Fracture healing was generally accompanied by varus deformity anf shortening
because of inability of traction to effectively counteract the deforming muscular
forces= malunion
OPERATIVE TREATMENT:
• Intertrochanteric fracture are almost always treated by early internal fixation
• To obtain the best possible position
• Early ambulation
FIXED-ANGLE NAIL PLATING
• These devices provided stabilization of femoral head and neck fragment to
femoral shaft, they did not allow fracture impaction.

SLIDING NAIL PLATING:

• The sliding hip screw is the most widely used implant for stabilization of both
stable and unstable intertrochanteric fracture.
• The 135 degree is most commonly utilized, this angle is easier to insert in
desired central position of femoral head and neck than higher angle devices and
create less of stress.
TROCHANTERIC SLIDING PLATES:
• The trochanteric stabilizing plate and the lateral butress plate are modular
components that butress the greatrer trochanter
• These plates are placed over a 4 hole sideplate and are used to prevent
excessive slide in unstable fracture patterns
• These devices prevent telescoping of the lag screw within the plate barrel when
the proximal head and neck fragment abuts the lateral buttress plate.
PROXIMAL FEMORAL NAIL:
• The PFN nail has been shown to prevent the fractures of femoryl shaft by
having a smaller distal shaft diameter which reduces stress concentration at the
hip
• Acts as a buttress in preventing the medialisation of shaft
• The main principle of this type of fixation is based on sliding screw in femoral
neck-head fragment, attached to an intermedullary nail
• In comminuted unstable trochanteric fracture, PFN as it resists the deforming
muscle forces.
ADVANTAGES :
• Can be inserted quickly
• Less blood loss
• Early ambulation
• Sliding and limb shortening is less
• More successful in reverse oblique fractures.
COMPLICATION:
• Failed fixation screws may cut out of the osteoporotic bone if reduction is poor
or if the fixaton device is incorrectly positioned. If union is delayed, the implant
itself may break. In either event, reduction and fixation may have to be redone
• Malunion
• Coxa vara and external rotation deformities are common
• Non-union
• Traumatic osteoporosis
• Avascular necrosis.
 SUBTROCHANTERIC FRATURE:
• Subtrochanteric fracture area typically defined as a area from lesser trochanter
to 5 cm distal

• Fracture with assosciated intertrochanteric component

may be called intertrochantric frature with
subtrochantric extension or peritrochanteric fracture.

EPIDEMIOLOGY:
• Younger patient with high energy mechanism like
RTA and fall from height
• May occur in elderly patient minor slips due to osteoporosis
Iatrogenic fracture:
• Stress following previous surgery on the proximal femur
PATHOANATOMY:
• Deforming forces on the proximal fragment:

Abduction
Gluteus medius and gluteus minimus
Flexion
Iliopsoas
External rotation
Short external rotators
• Deforming forces on distal fragment:

Adduction
Hip adductors
Shortening
Quadriceps femoris and hamstrings.
RUSSELL TAYLOR CLASSIFICATION:
Based on integrity of the pyriform fossa
Designed to guide treatment of intramedullary nails using a piriformis fossa
starting point
Type 1
INTACT PYRIFORMIS FOSSA
A-lesser trochanter attached to
proximal fragment
B-lesser trochanter detached from
proximal fragment
Type 2
FRACTURE EXTENDS INTO
PYRIFORMIS FOSSA
A-stable posterior- medial buttress
B-comminution of lesser trochanter
SEINSHEIMER CLASSIFICATION:
Based on fracture pattern of proximal femoral shaft
Type 1
• less than 2mm displacement
Type 2
• A-2 part transeverse fracture
• B-spiral fracture with lesser trochanter attached to proximal fragment
• C-2 part spiral fracture with lesser trochanter attached to the distal fragment
Type 3
• A-3 part spiral fracture with lesser trochanter as a seperate fragment
• B-3 part spiral fracture with butterfly fragment
Type 4
• Comminuted fracture with 4 or more fragments
Type 5
• Fracture with proximal extension into greater trochanter
TREATMENT:
NON-OPERATIVE:
• Observation with pain management:
INDICATION:
• Non ambulatory patient with medical
co-morbidities not fit for surgery

OPERATIVE:
Intramedullary nailing
INDICATION:
• Mostly russell-taylor type 1 fractures
• Most subtrochanteric frature are treated with
• IM nailing
Fixed angle plate
INDICATION:
• Surgeon preference
• Assosciated femoral neck frature
• Narrow medullary canal
• Pre-existing femoral shaft deformity

COMPLICATION:
• Non-union
• Malunion
• Fixation failure
• Failure of implant