Introduction
Intertrochanteric fractures are defined as extracapsular fractures of the proximal femur that occur between the greater and lesser trochanter. The intertrochanteric aspect of the femur is located between the greater and lesser trochanters and is composed of dense trabecular bone. The greater trochanter serves as an insertion site for the gluteus medius, gluteus minimus, obturator internus, piriformis, and site of origin for the vastus lateralis. The lesser trochanter serves as an insertion site for the iliacus and psoas major, commonly referred to as the iliopsoas. The calcar femorale is the vertical wall of dense bone that extends from the posteromedial aspect of the femur shaft to the posterior portion of the femoral neck. This structure is important because it determines whether or not a fracture is stable. The vast metaphyseal region has a more abundant blood supply, contributing to a higher union rate and less osteonecrosis compared to femoral neck fractures.[1][2]
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Etiology
These fractures occur both in the elderly and the young, but they are more common in the elderly population with osteoporosis due to a low energy mechanism. The female to male ration is between 2:1 and 8:1. These patients are also typically older than patients who suffer femoral neck fractures. In the younger population, these fractures typically result from a high-energy mechanism.[3]
[2]Nonoperative treatment is rarely indicated and should only be considered for non-ambulatory patients and patients with a high risk of perioperative mortality or those pursuing comfort care measures. The outcomes of this method of treatment are poor due to an increased risk of pneumonia, urinary tract infection, decubiti, and deep vein thrombosis
The type of surgical treatment is based on the fracture pattern and its inherent stability, as the failure rate is highly correlated with the choice of implant and fracture pattern. Fractures with involvement of the lateral femoral wall are considered an indication for intramedullary nailing and would not be treated with a sliding hip screw. Unstable fracture patterns such as fractures with comminution of the posteromedial cortex, a thin lateral wall, displaced lesser trochanter fractures, subtrochanteric extension of the fracture and reverse obliquity fractures are also indications for intramedullary nailing.
Operative management of these fractures is considered urgent, not emergent. This allows the many comorbidities with which patients often present to be optimized preoperatively, to reduce morbidity and mortality. Most of these fractures are treated operatively with either a sliding hip screw or intramedullary hip screw, although arthroplasty is a rare option. Indications for the sliding hip screw include stable fracture patterns with an intact lateral wall. When used for the appropriate fracture pattern, this treatment affords outcomes similar to intramedullary nailing. The advantages of the dynamic hip screw are that they allow for dynamic interfragmentary compression and are low cost compared to intramedullary devices. The main disadvantages include increased blood loss and open technique. Implant failure can occur due to a lack of integrity of the lateral wall or the placement of the screw, which should be placed at a tip apex distance of less than 25 millimeters.
Intramedullary nailing can be used to treat a broader range of intertrochanteric fractures, including the more unstable patterns such as reverse obliquity pattern. One proposed advantage of the intramedullary hip screw is its minimally invasive approach which minimizes blood loss. Although there are is no data suggesting that an intramedullary hip screw is more effective than a sliding hip screw in treating stable fracture patterns, it is becoming more and more commonly used by young surgeons. The choice for short or long intramedullary implants is debatable in these fractures.
Arthroplasty is typically not indicated as primary management and is reserved for severely comminuted fractures, patients with a history of degenerative arthritis, salvage of internal fixation, and osteoporotic bone that is unlikely to hold internal fixation.
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