CASE DISCUSSION

45 year old lady slips and falls on the ground.
She is unable to get up and walk. The X Ray
reveals a fracture of the femur at the lesser
trochanter.
FRACTURE OF THE FEMUR

Two types
 Extracapsular
 Intracapsular

Extra capsular
 Trochanteric
 Subtrochanteric

Trochanteric (Evan’s classification)
 Stable
# configuration – Type A & B
 Unstable # configuration – Type C & D
Type C – lateral cortex is intact
 Type D – lateral cortex is violated


Type E – Reverse obliquity
Fractures parallel to neck axis &traverse lat. cortex

Subtrochanteric
 Three
types- Simple, Wedge , Complex
All unstable due to relatively small contact area

Intra capsular
 Classification


(Low energy)
Fracture site- subcapitus, transcervical, basicervical
Inclination of the # 
Pauwel’s classification
 Type I – 30 degree
 Type II – 50
 Type III – 70

Relation of # fragment

Garden classification
 Type I – incomplete & impacted
 Type II – Complete & undisplaced
 Type III – Complete & partially displaced
(intact post.retinacular ligament)
 Type IV – completely displaced
(disruption of reti.vessels)

Classification (High Enegy)
 Type
I - undisplaced neck #
 Type II – simple displaced neck #
 Type III – Comminuted displaced neck #
 Type IV – FON + # of acetabulum or shaft of the femur
 Type V – Neck # that occur or recognized during
antegrade nailing of shaft
FIRST AID









Safe place
Reassure the person
Have the victim lie flat and rest.
Ask for help
CPR
If there is a wound remove the clothes
If there is bleeding apply direct pressure to the
wound to stop the bleeding.
Cover the wounded area with a clean cloth or
dressing.
Continue to apply pressure as long as the wound
bleeds. Add new dressings over existing ones.
Immobilize the injured area. A splint is a
good way to immobilize the affected area,
reduce pain and prevent shock.
 Effective splints can be made. The general
rule is to splint a joint above and below the
fracture.
 Or, lightly tape or tie an injured leg to the
uninjured one, putting padding between the
legs, if possible.





Check the pulse in the limb with the splint. If you
cannot find it, the splint is too tight and must be
loosened at once. Check for swelling, numbness,
tingling or a blue tinge to the skin. Any of these
signs indicate the splint is too tight and must be
loosened right away to prevent permanent injury
Keep her fasting
Inform relatives
Move to hospital
PRIMARY SURVEY AND
RESUSCITATION
CARE OF INJURY – 4 STAGES
Prevention
 Pre-hospital care
 Hospital care
 Rehabilitation

“Manage the patient, Not the fracture”
INITIAL ASSESSMENT AND RESUSCITATION
A = Airway
 B = Breathing
 C = Circulation
 D = Disability of CNS
 E = Exposure of the patient
 F = Foley catheter

AIRWAY AND BREATHING

At risk in all unconscious patients.
CIRCULATION

Blood loss is greater than the NOF fracture
and trochanteric fracture. Large volume of
blood can accumulate in the thigh.
Skin: cold , pale ,sweating
 Pulse: rate, volume, rhythm
 Blood Pressure
 JVP
Adequate fluid resuscitation.

DISABILITY OF CNS- AVPU

Head injury

Examination: Level of consciousness
External wounds
Pupils- dilated, unequal

CT scan of the brain
Damage to cervical spine

Suspected in all unconscious and head
injured patients.

In line bimanual immobilization
 Semi rigid collar
 X-ray cervical spine

Exposure :
Foley catheter :
Analgesics:
Antibiotics
DIFFERENTIAL DIAGNOSIS-
•Generalized
bone diseases
1.Paget’s disease of bone
2.Primary hyperparathyroidism
3.Osteomalacia
4.Osteoporosis
DIFFERENTIAL DIAGNOSISLocalized bone diseases
Metastases from carcinoma breast, lung, kidney,
and thyroid.
Multiple myeloma
Primary bone tumors

1.
2.
3.
MalignantOsteosarcoma
Chondrosarcoma
Benign
Osteoclastoma
Bone cyst
HISTORY


1.Name- (for identification purposes)
2.Age-important to identify the disease
since
most of the diseases have an age distribution
eg:- osteoporosis -over 50 yrs
osteosarcoma-10-25 yrs
osteoma 40-50yrs
Parosteal osteosarcoma-30- 60yrs
-imporatant to take decisions on surgical
fitness
3.Sex- Osteoporosis is more common in females
4.Occupation-exposure to radioactive radium and
thorium dioxide increases the risk of development
of osteosarcoma
5.P/CWhat has happen-(circumstance)
?accident/?deliberate harm
At what time?
After math-LOC/Numbness/Bleeding/
Inability to walk
Time of the last meal?
Intoxication?(alcohol/drugs)
Early fractures or any prolong immobilisation?
Suffering from any illness?
Wt loss (CA/TB)
Change in Ht?
Hx of renal stones?
6.PMHx-DM,HT,Asthma
Cushing’s,Hyperthyroidism,Acromegaly
CVA,fainting attack,epilepsy,hypoglysemia
7.PDHx- Corticosteroids
8.PSHx-Any previous trauma,any Sx and
complications
9.Menstual Hx10.Allergies11.Immunisation-eg tetanus
12.Family Hx-eg-osteogenesis imperfecta
osteopetrosis
13.Personal Hx-smoking,alcohol,lifestyle
family life (?assault)
14.Dietary Hx-?protein and Vit deficiency?
Inadequate Ca intake
EXAMINATION
1.
General Examination
2.Examination of the Hip Joint
3. Special Examination of systems
4. Radiographical Examination
GENERAL EXAMINATION
•Patient
is in pain
•Unable to stand
•Limb is shortened and lies in external
rotation
•Skin wounds or obvious deformity
MENTAL AND EMOTIONAL STATE
PHYSICAL ATTITUDE
GAIT
PHYSIQUE
FACE
SKIN
HANDS
FEET
NECK – LYMPH NODES, THYROID GLAND
BREAST
AXILLAE
T
PULSE
RESPIRATION
ODOURS
Ecchymosis of the proximal thigh- occasional
EXAMINATION OF THE HIP JOINT
Inspection
Skin changes- Redness, swelling
Shape
Position
Scars
Wasting of gluteal and thigh muscles
Palpation
Temperature, tenderness over the joint
Skin, soft tissue, muscles, bone
Movements
Voluntary, involuntary , crepitus
Flexion- measured with knee bent. Opposite thigh must remain in neutral position. Flex the
knee as the hip flexes.
Abduction- measured from a line that forms an angle of 90 degrees with a line joining the
ASISs .
Adduction
Rotation in flexion
Rotation in extension
Extension- attempt to extend the hip with the patient lying in the lateral or prone position
HAEMATOMA OR BRUIT OVER THE AREA SUGGEST
ARTERIAL DAMAGE .
Look for,
•Shortening in External rotation of the involved
extremity
•Palpation below the ingunum elicits pain
•Inability to move
ADDITIONAL EXAMINATIONS OF HIP
JOINT :
MEASUREMENT OF TRUE AND
APPARENT SHORTENING
SPECIAL EXAMINATION
1.
2.
3.
Circulatory system
Neurological Examination
Musculoskeletal System
1. CIRCULATORY SYSTEM
WHY? 1) CARDIOVASCULAR SYNCOPY OR
INITIAL STROKE COULD HAVE CAUSED THE
FALL
2) DETECT OTHER CARDIOVASCULAR
PROBLEMS
Inspection
Palpation
Percussion
Auscultation
PALLOR, CYANOSIS, EDEMA
PULSE, BP, JVP
PERIPHERAL PULSES- ABSENT MEANS
MAJOR VESSEL INJURY
3. MUSCULOSKELETAL SYSTEM
•Examination
of Associated Injuries
Wrist #
Head injury
Most frequently associated injuries are due to
patient’s osteoporosis in other areas of the
body.
They are sustained at the same time as the
trochanteric fracture
RADIOGRAPHIC EXAMINATION
AP Radiograph of the distal Pelvis
•AP and Lateral Radiographs of the hip joint
•Femur
•Knee joint
^
•
INVESTIGATIONS




To Diagnose Fracture
To Find Aetiology
Preoperative Assessment
Postoperative evaluation
DIAGNOSE FRACTURE

X-Ray Hip
Rule of 2s
2views
2joints
2limbs
2times
Rule of As
Anatomy
Articularv
Alignment
Angulation
Apex
Apposition

CT Scan-Not indicated in routine evaluation
FIND AETIOLOGY

X-ray- Osteoporosis
Paget’s Disease
Chondrosarcoma
Lytic lesion Involves the inferior aspect
of the neck and the medial
intertrochanteric area.

Ewing sarcoma.
Entire proximal part of the femur is
filled with mottled sclerotic
densities indicative of a diffuse
pathological process.

CXR , X-ray pelvis, Bone scan - Metastasis

Serum Ca –Hyperparathyroidism
Osteomalacia
T3,T4- Hyperthyroidism

Bone marrow biopsy- Multiple myeloma
PREOPERATIVE ASSESSMENT
CXR
 FBC
 Hb
 ECG
 FBS

POSTOPERATIVE EVALUATION

X-ray Hip
To evaluate the reduction
TREATMENT
DEFINITIVE MANAGEMENT OF THE FRACTURE

Management of fracture can be considered as,



Operative treatment
Non operative treatment
Indications for Non operative Treatment


An elderly person whose medical condition carries an
excessively high risk of mortality from anaesthesia
and surgery
Non ambulatory patient who has minimal discomfort
following fracture
NON OPERATIVE MANAGEMENT

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Skeletal traction is the most common method used to control and reduce
pain
In subtrochanteric fracture most common method to reduce the fracture is
by skeletal traction with a transcondylar Steinmann pin
90 degree flexion is used to relax the iliopsoas: correct the flexion and
external rotational deformities
period of traction ranges from 12 to 16 weeks
should be monitored with regular radiological imaging
Early removal of skeletal traction may be followed by bracing with a hip spica
cast when early callus is seen in x-ray films.
Maintenance exercise must be administered regularly to maintain the
mobility of joints and muscle strength
POSITION OF PATIENT IN TREATING SUBTROCHANTERIC FRACTURES WITH SKELETAL TRACTION
COMPLICATIONS



In elderly patients, this approach was associated with high complication
rates
typical problems included decubiti, urinary tract infection, joint contractures,
pneumonia, and thromboembolic complications, resulting in a high mortality
rate.
In addition, fracture healing was generally accompanied by varus deformity
and shortening because of the inability of traction to effectively counteract
the deforming muscular forces
SURGICAL TREATMENT




Surgical stabilization is the standard of care
Internal fixation of fractured end is widely performed.
Intramedullary nail fixation is the preferred treatment
Two methods
 Open Method
 Closed Method
OPEN METHOD





possible in fractures with minimal comminution but it demands an
extensive dissection
weight-bearing may not be possible until the fracture heals
disadvantage of the open technique is extensive soft tissue
dissection
temporarily fixed with reduction forceps or Kirschner wire (K-wire)
fixation; then fixed with lag screws
plate is fixed proximally to the femoral head and neck for maximal
stability
CLOSED METHOD







closed reduction and internal fixation
Closed reduction is usually performed with the use of a fracture
traction table with a transcondylar Steinmann pin
fixation can be carried out with percutaneous implant insertion
most common implant used is the intramedullary locked nail
does not disturb the fracture hematoma
minimum soft tissue dissection
need to use fluoroscopy and the difficulty in performing distal locking
are potential disadvantages
SLIDING HIP SCREW


This device is indicated only for very proximal fractures.
The sliding of the screw allows medialization of the distal fragment,
which reduces bending moment on fracture and implant
OTHER TREATMENT




Hence this was pathological fracture we have to find the cause and treat for
that.
metastatic tumours are the most common types of tumour deposits in this
region
So other metastatic sites should also be investigated before definitive
fixation of the fracture is performed.
In the case of primary, investigate for secondaries and follow chemotherapy
/ Radiation therapy
1.)Surgical
2.)Non surgical
Cast bracing
Hip sica cast + traction
Pre operative measures
a) Assessment of the patient
 Cormobid factors
 Surgical fitness
 Risk for anesthesia
b) Pre operative templating - for proximal
comminution the use of a fixed angle
device with the proper blade and
compression screw length
When an intramedullary device is chosen,
templating for length, canal diameter is
necessary for proper planning.
c)Measurements
Normal side femur length
Surgery
main techniques:
 external fixation
 open reduction and internal fixation
a) Extra medullary implants
b) Intra medullary implants
Extra medullary devices
1.)Sliding compression screw plate
2.)Dynamic hip screw(DHS) e.g:-DCS
Indications:Fractures with stable configurations
Unstable fractures with an intact lateral cortex
Intra medulary devices
1)Intra medullary hip screw(IMHS)
Cephalomedullary nails
Reconstruction nails(centromedullary)
Indications:Shorter nail-If fracture line doesn’t extend more
than 1 to 2cm distal to lesser trochanter
Longer nail-unstable fractures
IMHS
External fixation-
Rarely used but is indicated in severe
open fractures.
For most patients, external fixation is temporary,
and conversion to internal fixation can be made if
and when the soft tissues have healed
sufficiently.
Post operative period.
1.)Following intramedullary nailing if the bone quality
and cortical contact is adequate, 50% partial weight
bearing can be allowed immediately.
With less stability, patients can perform touchdown
weight bearing.
Following OR and plate fixation, minimal protected
weight bearing can begin immediately but is advanced
slowly beginning approximately 4 weeks after surgery,
with full weight bearing anticipated at 8-12 weeks.
Elderly patients may have difficulty with compliance with
weight bearing restrictions.
2.) Check for proper union
3.) Prevent infections
4.) Wound care
5.) Nutrition- high protein diet
COMPLICATIONS
Acute complications
1.
2.
3.
Damage to nerves and blood vessels
Haemorrhage
Other soft tissue damage
Long term complications
1.
Failure of fixation
-screws may cut out of the bone if reduction is poor or if
the fixation device is incorrectly positioned. Reduction and
fixation may have to be re-done.
2.
Malunion
-only complication that is frequent
-may occur through bending or breakage of a nail plate or
simply through compression of the soft cancellous bone with
metal.
-causes union with a slightly reduced neck-shaft angle- coxa
vara
-If neglected,
II.
May unite with marked lateral rotation of the shaft.
May develop severe coxa vera associated with shortenig.

Treatment
I.
1.
2.
In most cases, can be accepted without treatment.
In severe deformities,
-the bone is divided in the trochanteric region and the fragments
are secured in the correct position by a compressive screw plate or
other appropriate device(as in a fresh fracture.
complications due to treatments
1. casts
-pressure ulcers
-thermal burns
-thrombophlebitis
2.
Internal fixation
-infections
-neurological and vascular injury
-thromboembolic events
-avascular necrosis
-posttraumatic arthritis

Complications of immobilization
Bed sores
2. Hypostatic pneumonia
3. Osteoporosis
4. Hypercalcaemia
5. Hypercaliuria
6. Urolithiasis
7. UTIs
8. Muscle wasting
9. Joint stiffness
10. DVT
11. Pulmonary embolism
12. Psychological depression
1.
FOLLOW UP AND REHABILITATION
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FOLLOW-UP

Close follow-up is required following fixation

50% PWB can be allowed immediately

Wound is checked for proper healing 7-14
days post operatively
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
Patient should have monthly clinical
evaluations and radiographs to monitor
healing.

Quadriceps rehab to be started within 02
weeks post operatively

Most patients will have significant disability
for 4-6 months
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
Impact activities may be possible after 06
months (Should wait 01 year before returning
to full contact sports)
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REHABILITATION
Rehabilitation involves:
* Ankle pumps (to prevent DVT)
* Chest Physiotherapy (Airway clearance)
* Exercises :
Quadriceps, Hamstrings and Glutei
(Isometrics)
Heel Slides (in supine lying)
Strengthening Ex to Upper Limbs (Before
prescription of walking aids)
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Static Quadriceps Ex.
Static Hamstring Ex.
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Heel Slides
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Mobility and weight bearing
* Increase bed mobility (Supine to Sitting)
* Increase ambulation with appropriate weight
bearing (TDWB with walker -> PWB with walker)
* Perform SLR (up to 6” from the bed level in
supine lying)
* Mini Squats
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Straight Leg Raise (SLR)
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Mini Squat/Half Squat
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
Within 1-2 Weeks
* Reinforce good posture
* Add standing hip abduction, adduction,
extension and flexion with hip and knee flexion
exercises
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DISCHARGE CRITERIA

Gets out of bed independently.

Able to ambulate 50 feet independently in a
hall with assistive device.

In and out of bathroom independently.
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AFTER DISCHARGE
Advice to the patient on:
 Changes to the home environment
 Lifestyle changes


Prevention
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THANK YOU
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