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Trochanteric fracture

Intertrochanteric Fracture

  • Extracapsular fracture of the proximal femur – between the greater and lesser trochanter

Epidemiology

  • Female preponderance
  • Proximal humerus fracture increases risk of trochanteric fracture
  • Incidence of non-union and avascular necrosis is low due to rich blood supply

Etiology/pathophysiology

  • High energy trauma in young patients
  • Low energy trauma (falls) in older patients

Anatomy

  •    Blood supply – originates from deep femoral artery, gives off two branches
    • Medial and lateral femoral circumflex arteries – they loop around the base of the femoral neck to form the extracapsular ring
    • This gives off several small ascending cervical branches which penetrate the capsule – run proximally within the joint, close to the femoral neck
    • When they reach the articular surface they form the subsynovial intracapsular ring
  • Calcar femorale – vertical ridge of dense bone
    • Originates from the postero-medial aspect of the femoral shaft, near the lesser trochanter
    • Projects laterally toward the greater trochanter
    • Provides mechanical support
    • Helps determine stable vs unstable fracture patterns

Classification

  • Stable – intact posteromedial cortex
    • Once reduced it will resist medial compressive forces
  • Unstable – comminution of posteromedial cortex
    • Once reduced, fracture will collapse into varus

Clinical features

  • Pain
  • Shortened, externally rotated leg

Diagnosis

  • X-ray
  • CT/MRI

Treatment

  • Dynamic hip compression screw – for stable fracture
  • Intramedullary hip screw
  • Arthroplasty – for severely comminuted fractures; patients with pre-existing arthritis

Subtrochanteric Fracture

  • Subtrochanteric area is up to 5cm below the lesser trochanter

Epidemiology/etiology

  • High energy trauma in young patients
  • Low energy trauma in old patients
  • Long-term use of bisphosphonates
  • More unstable than intertrochanteric fractures
  • Higher incidence of non-union than intertrochanteric fractures

Classification –  Russel-Taylor Classification

  • Type I – no extension into piriformis fossa
  • Type II – extension into greater trochanter with involvement of piriformis fossa

Clinical features

  • Hip and thigh pain
  • Inability to bear weight
  • Pain with motion
  • Deformity – varus and shortening

Diagnosis

  • X-ray
  • CT

Treatment

  • Observation and pain management – for non-ambulatory patients with co-morbidities who may not be able to tolerate surgery
  • Intramedullary nailing – preferred choice of treatment
  • Fixed angle plate – for patients with associated femoral neck fracture
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