Because of that geometry, these fractures are more prone to failure when fixed with traditional sliding screws: the shaft displaces medially and the fracture does not compress as the screw "slides". In reverse obliquity fractures, the fracture line courses laterally as it extends from proximal to distal and typically reaches the subtrochanteric region. Other options for these types include varus fixed angle devices such as a blade plate or a 95 degree sliding hip screw or more recently a locked proximal femoral plate. Intra-medullary fixation may be preferable for reverse obliquity fractures of those with sub-trochanteric extension. Intra-medullary devices (cephalomedulary nails) theoretically offer less soft tissue dissection and a shorter moment arm (the vertical device, ie the nail, is closer to the hip center than the plate would be). This device has a large screw in the femoral head and neck engage a plate fixed to the shaft, with sliding of the screw allowed if and when the fracture impacts. The traditional treatment in recent decades is the sliding hip screw. In any patient who hopes to get out of bed, the treatment of intertrochanteric fractures is surgical. These should be identified and optimized as well as can be done without delaying surgery unnecessarily. A patient with hip pain after a fall whose xrays are (apparently) negative needs admission to the hospital and an MRI.Īs noted, medical co- morbidities can be expected. Occult fractures are rare but not impossible. An isolated fracture of the greater trochanter may occur as an avulsion by the gluteus medius, and needs only symptomatic (palliative) treatment DiagnosisĬare 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. Patients with hip fractures are typically sick, but they were sick in the moments preceding the fracture as well, in all likelihood. This is not so much an academic debate about causality but a warning to clinicians to expect -and seek, if not initially found?medical co-morbidities. This gives rise to the conjecture that poor soft tissue padding, poor reflexes and weakness are actually what causes the fracture. 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. Intertrochanteric fractures are often seen in frail older people after low energy falls (ie, from a standing height). The key criterion of any robust classification is whether the fracture can be considered stable or unstable. Even if there is no comminution and even if the fracture line does not reach the subtrochanteric region, this fracture is unstable and prone to displacement with conventional sliding screws, as the fracture line is parallel to the course of the sliding screw and displaces as the screw slides. In reverse obliquity fractures, the fracture line courses laterally as it extends from proximal to distal, running perpendicular to the intertrochanteric line. IV displaced with lesser trochanteric (posteromedial) andĪ special category is the "reverse obliquity fracture". III displaced with greater trochanteric (posterolateral) comminution Intertrochanteric fractures can be classified (Evans, 1949) as the following Types: The adductors attach to the shaft below the intertrochanteric region, possibly displacing the shaft medial relative to the proximal fragment(s). The abductors and short external rotators attach to the greater trochanter the iliopsoas to the lesser. AnatomyĪs the name implies, an intertrochanteric fracture is one where the fracture line lies between the greater and lesser trochanters.
Unlike a subtrochanteric fracture, it can be (but not always is) inherently stable. Unlike a femoral neck fracture, the intertrochanteric region has good blood supply to cancellous bone, and thus has good healing potential. See Hip fractures for a general discussion. Hip fractures can be divided into two groups: intra-capsular femoral neck fractures (further localized as subcapital, transcervical or basicervical) and extra-capsular peri-trochanteric fractures, namely the intertrochanteric and subtrochanteric fractures.
0 kommentar(er)
