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Symptoms,
Signs, and Classification
These fractures usually result from a fall,
often on level ground. Physical examination of a displaced fracture shows the leg to be
shortened and externally rotated from the pull of the leg muscles and gravity. Hemorrhage
from multiple bone fragments and associated soft tissue injuries can be extensive and may
cause hypovolemic shock.
Intertrochanteric hip fractures are classified
by the number of bony fragments and by the inherent stability (the ability to maintain
continuity of the weight-bearing medial femoral cortex). Typically with two-part
fractures, a single break slopes obliquely between the greater and lesser trochanters on
the anteroposterior x-ray view (see FIG. FR5). Three-part fractures also have a lesser
trochanteric fragment, and four-part fractures have a greater trochanteric fragment. As a
rule, three- and four-part fractures are inherently unstable because of comminution of the
medial femoral cortex. Fractures in the intertrochanteric region of the proximal femur
usually allow adequate blood supply to all fragments; thus, osteonecrosis and nonunion
rarely occur.
Fig. FR5.
Intertrochanteric fracture.
Treatment and Prognosis
Intertrochanteric hip fractures are treated by
surgical stabilization unless an absolute medical contraindication exists or the patient
is nonambulatory and demented, with limited pain perception. Traction does produce
healing, but it usually takes 4 to 8 wk and introduces the risks of prolonged bed rest.
Also, traction may not adequately control the deforming muscle forces around the hip, so
that the bone may heal in a shortened and externally rotated position, producing a poor
functional result.
The most common fixation device is the sliding
compression hip screw, which provides rigid stabilization while impacting the fracture
fragments, thus ensuring healing (see FIG. FR6). Postoperatively, most patients can
immediately begin full weight-bearing ambulation with a walker. Usually, they are able to
use a cane in 6 to 12 wk.
Fig. FR6.
Fixation of intertrochanteric fracture with compression screw and sideplate. |