Inter trochanteric fractures, fracture shaft of femur

INTER TROCHANTERIC FRACTURES OF FEMUR

“Fractures in the inter trochanteric region of the proximal femur, involving either the greater or the lesser trochanter or both”

•In elderly the fracture is sustained by a sideway fall or a blow over the greater trochanter.

•In young it occurs followed by violent trauma, as in RTA.

Pathoanatomy• The distal fragment rides up so that the femoral neck-shaftangle is reduced (Coxa vera).• The fracture is generally comminuted and displaced.• Rarely it can be undisplacedfracture.

DiagnosisClinical features:-• History of a fall or RTA.• Pain in the region of the groin and inability to move the leg.• Swelling in the region of the hip, and the leg will be short and

externally rotated.• Tenderness over the greater trochanter.• Physical findings are more marked.

Radiological features:-• X-ray- presence of comminution of the medial cortex of the neck• avulsion of the lesser trochanter • extension of the fracture to the subtrochanteric region indicate an unstable fracture.

Treatment• These fractures unite readily.• The main objective is to maintain the normal femoral neck shaft

angle during the process of union.• This can be done by conservative method or by internal fixation.Conservative method:-• Used less often.• Commonly used are Russell’s traction and Thomas splint.

Operative method:-• The fracture is reduced under x-ray control and fixed with internal

fixation devices.• Most commonly used are,

Dynamic hip screw (DHS).Ender’s nails.Nails such as gamma nail, Proximal Femoral Nail (PFN).

ComplicationsMalunion:-• Failure in keeping the fragments aligned gives rise to coxa vara,

shortening and leg in external rotation.• Corrected by inter trochanteric osteotomy.Osteoarthritis:-• Pain and stiffness in the hip after symptom free period following union

of the fracture confirmed by x-ray changes.• Corrected by physiotherapy in early stages and in later stages

trochanteric osteotomy or total hip replacement may be required.

FRACTURE SHAFT OF FEMUR

• Usually sustained by a severe violence as in RTA.• Force causing the fracture may be direct (RTA) or indirect (twisting or

bending)

Pathoanatomy:-• The fracture may occur at any site and is almost equally comman in

upper, middle and lower third of the shaft.• It may be transverse, oblique, spiral or comminuted depending upon

nature of force.

Displacements:-

• The proximal fragment is flexed, abducted and externally rotated by the pull of the muscles attached to it.• Distal fragment is adducted because of attachment of adducter muscles.• Unsupported fracture ends sags because of gravity.

DiagnosisClinical features:-

History of severe violence followed by classical signs of fracture in the region of thigh – Pain, swelling, deformity, abnormal mobility.Radiological examination:-• X-ray of the femoral shaft including whole femur.• In addition X-ray of the hip for • any associated injury.

TreatmentConservative methods:-Traction- With or without splint.

Usually Thomas splint is used.Skin traction is sufficient in children, Skeletal traction by stienmann pin in adults.

Hip Spica- Plaster cast involving part of trunk and the limb It may be Single spica or one and a half.

Operative methods:-• Intramedullary nailing is preferred method.• Fracture may be reduced by open or closed methods.• Commonly used methods are,

Closed interlock nailing.Kuntscher’s clover intra-medullary nail (K-nail).Plating (Fixing with a thick strip of metal).

Deciding treatment planThe treatment plan depends upon

age of the patient,location of the fracture,type of the fracture,presence of a wound.

• In children, treatment is mostly by non operative methods.• From birth to 2 years fractures treated by Gallow’s traction.• From 2 to 16 years conservative method as mentioned above. • TENS ( Titanium Elastic Nail System) can also be used.

ComplicationsEarly Complications:-

Shock.Fat embolism.Injury to femoral artery.Injury to sciatic nerve.Infection.

Late Complications:-Delayed union.Non union.Malunion.Knee stiffness.

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