Executive Editor: Joseph Schatzker, Peter Trafton

Authors: Ernst Raaymakers, Inger Schipper, Rogier Simmermacher, Chris van der Werken

Proximal femur - Trochanteric fracture, pertrochanteric, multifragmentary

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Glossary

General considerations

In extracapsular fractures there is minimal risk of osteonecrosis of the femoral head.

In multifragmentary pertrochanteric fractures the fracture line can start laterally anywhere on the greater trochanter and runs towards the medial cortex which is broken in two places. This results in the detachment of a third fragment which includes the lesser trochanter.

These fractures cause significant shortening and tend to be unstable after reduction and fixation, because the medial buttress is compromised.

These fractures may be treated with a sliding hip screw and plate, or a cephalomedullary nail. The sliding hip screw is designed to allow controlled collapse. The collapse is limited as the base of the neck comes to rest on the greater trochanter. If the greater trochanter is very comminuted control of the collapse is lost. A trochanteric supporting plate (TSP) may be used to restore the supporting effect of the greater trochanter.

In case of a simple pertrochanteric fracture with a lesser trochanter fragment, a 4-hole DHS plate without TSP might be sufficient. For fractures with an incompetent lateral wall, extramedullary devices are only second choice, as they lack necessary stability.

Note: Because healing of these fractures may take 12 or more weeks, if contraindications can be corrected soon enough, operative treatment of the fracture may be beneficial even if delayed.

If definitive treatment will be delayed for more than 2 or 3 weeks, temporary skeletal traction might be considered to help maintain alignment.

MIO - Sliding hip screw
Main indication Skill Equipment
Adequate reduction and bone contact Some specialized surgical experience Simple surgical and imaging resources

Indications

  • All fractures which can be reduced closed
  • Sufficient fracture stability with sliding hip screw alone

Contraindications

  • Large zone of comminution 
  • Lateral cortical disruption (preoperative or occurring during surgery)
  • Irreducible fracture 
  • Significant hip joint arthritis 
  • Patient not fit for surgical treatment 
  • Severe soft-tissue problems in surgical area (pressure sores, acute infection, burns etc)

Advantages

  • Less expensive implant than IM nail
  • May convert to ORIF for reduction or improved fixation
  • Fracture stability 
  • Early mobilization
  • Semi-open procedure, fracture site left untouched

Disadvantages

  • Risk of secondary displacement 
  • Challenging application of sliding hip screw
  • Risks of surgery
  • May not be sufficient to allow full weight bearing
MIO - Sliding hip screw with plate
Main indication Skill Equipment
Insufficient fracture stability with sliding hip screw alone Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Indications

  • Fractures which can be reduced closed
  • Insufficient fracture stability with sliding hip screw alone
  • Lateral cortical disruption (preoperative or occurring during surgery)

Contraindications

  • Large zone of comminution 
  • Irreducible fracture 
  • Significant hip joint arthritis 
  • Patient not fit for surgical treatment 
  • Severe soft-tissue problems in surgical area (pressure sores, acute infection, burns etc)

Advantages

  • TSP can be added to sliding hip screw intraoperatively if necessary
  • Improved fracture stability with reduced risk of secondary displacement compared to sliding hip screw alone
  • Early mobilization 
  • Semi-open procedure, fracture site left untouched

Disadvantages

  • More prominent hardware; may need removal for pain 
  • Risk of secondary displacement 
  • Challenging application of sliding hip screw
  • Risks of surgery
  • May not be sufficient to allow full weight bearing
Nailing
Main indication Skill Equipment
Surgeon's preference, fracture instability Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Indication

  • Fractures which can be reduced closed

Contraindications

  • Bone deformity or previous surgery that prevents nailing 
  • Irreducible fracture 
  • Significant hip joint arthritis 
  • Severe soft-tissue problems in surgical area (pressure sores, acute infection, burns etc)
  • Patient not fit for surgical treatment

Advantages

  • Improved fixation stability, with reduced risk  of secondary displacement
  • Early mobilization
  • Semi-open procedure, fracture site left untouched
  • Small incision

Disadvantages

  • Difficult technique, especially if greater trochanter comminution is present 
  • More expensive implant than sliding hip screw
  • Risks of surgery
  • Risk of secondary displacement
*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v2.0 2010-11-14