What is Intertrochanteric Femur Fracture?
An intertrochanteric fracture is a type of break in the upper part of your thigh bone (or femur), which occurs between the two bony prominences known as the greater and lesser trochanters. These areas of the femur contain a dense type of bone known as trabecular bone. The greater trochanter connects to muscles such as the gluteus medius, gluteus minimus, obturator internus, piriformis, and also the origin of the vastus lateralis muscle. The lesser trochanter connects to the iliacus and psoas major muscles, often collectively referred to as the iliopsoas.
There exists a thick wall of bone called the calcar femorale which stretches from the back-inside part of the femur shaft to the back part of the femoral neck. The importance of this area lies in determining whether a fracture is stable or not. Also, with a rich blood supply in the broad metaphyseal region of the bone, fractures here tend to heal better and have less incidence of bone death compared to fractures in the femoral neck.
What Causes Intertrochanteric Femur Fracture?
These types of fractures can happen in both older and younger individuals, but they’re more frequently seen in older people with a condition called osteoporosis, which usually happens as a result of a low-impact incident. The ratio of women to men experiencing these fractures ranges from 2:1 to 8:1, and these patients are usually older than those who suffer from fractures in the area around the neck of the thigh bone.
In younger people, these fractures typically result from incidents involving high-impact forces.
Risk Factors and Frequency for Intertrochanteric Femur Fracture
Fractures in the hip area, particularly intertrochanteric fractures, are linked to serious health conditions and fatalities. Every year, a total of 280,000 fractures occur, with almost half of them being intertrochanteric fractures. Experts predict that by 2040, the annual number of fractures could skyrocket to 500,000.
Signs and Symptoms of Intertrochanteric Femur Fracture
Patients with this condition usually have a shortened lower extremity that’s rotated outward. It’s important for doctors to know their general health and lifestyle details so that they can plan the surgery and follow-up care accordingly. Doctors also assess the skin to see if the fracture is open or closed and check the blood supply and nerve function in the affected area. Due to pain, checking for mobility is usually not possible. Basic blood tests are performed to spot any abnormalities that need to be corrected before surgery. To ensure the patient is in the best health for surgery, a team of different healthcare professionals, including anesthesiologists and internists, should be involved early.
- Shortened lower extremity that’s rotated outward
- Assess skin for open or closed fracture
- Check blood supply and nerve function in affected area
- Unable to check mobility due to pain
- Perform basic blood tests
- Early involvement of healthcare team for optimization for surgery
Testing for Intertrochanteric Femur Fracture
To check for certain types of fractures, doctors often start with basic X-ray images. They’ll usually take front-view pictures of your pelvis and hip, side-view pictures of your affected hip, and long-view pictures of your affected thigh bone. Even though they might not need the pelvic pictures to diagnose the fracture, they can still be helpful when planning your surgery. The same rationale applies to the images of your thigh bone; they help doctors plan where to insert a device called an intramedullary nail and evaluate previous implants in your lower thigh.
In most cases, doctors don’t need to use a CT scan or an MRI. However, if your X-rays don’t show anything but your symptoms suggest a fracture, these types of imaging might be beneficial. An MRI can be particularly important if the fracture is in your thigh bone near the hip and doctors want to examine that region more extensively.
Lastly, a specific imaging technique that involves a doctor pulling on your injured hip could be necessary to provide a more detailed picture of the fracture and determine the best method for fixing it.
Treatment Options for Intertrochanteric Femur Fracture
Non-surgical treatment is generally not recommended for managing fractures, except in a few instances such as non-ambulatory patients, those with a high risk of complications during surgery or those opting for comfort care. However, it should be noted that this treatment method often leads to worse outcomes due to increased chances of complications like pneumonia, urinary tract infections and deep vein thrombosis.
The choice of surgical treatment is determined by the pattern and stability of the fracture. Certain fractures, specifically those involving the lateral femoral wall, require a specific surgical intervention known as intramedullary nailing. Other unstable fractures also necessitate this treatment approach. This treatment is not considered emergent, hence, there is time to manage any existing health conditions the patient may have before the surgery, in order to reduce risks.
Most fractures are treated with either a sliding hip screw or an intramedullary hip screw. The sliding hip screw is a suitable choice for stable fractures with an intact lateral wall. It has the advantage of allowing for dynamic compression and being cost-effective. However, it may result in increased blood loss and requires an open surgical technique.
Intramedullary nailing, on the other hand, can be used for a wider range of fractures, including unstable ones. It is minimally invasive, leading to less blood loss. More and more young surgeons are opting for this method despite the lack of data proving its superiority over the sliding hip screw in treating stable fractures. The choice between short or long intramedullary implants depends on the specific case.
Finally, arthroplasty, or joint replacement surgery, is typically not the first choice for fracture management. It’s usually reserved for severely crushed fractures, patients with a history of degenerative arthritis, salvage of internal fixation, and cases where the bone is so brittle it’s unlikely to hold internal fixation.
What else can Intertrochanteric Femur Fracture be?
Fractures in the femur, or your thigh bone, are often classified based on the location of the break. These fractures can happen in several areas:
Outside the hip joint capsule (extracapsular):
- Intertrochanteric femur fracture: A break in the part of your thigh bone between the two bony prominences near your hip.
- Trochanteric femur fracture: A break specifically in one of the bony prominences near your hip.
At the top of the femur (proximal):
This includes those inside the hip joint capsule (intracapsular):
- Femoral head fracture: A break in the ball part of the ball-and-socket hip joint.
- Femoral neck fracture: A break in the thin area of the thigh bone that leads to the ball.
In the main body of the femur (shaft):
- Mid-shaft femur fracture: A break in the middle portion of the thigh bone.
Possible Complications When Diagnosed with Intertrochanteric Femur Fracture
No matter which treatment method is chosen for fractures, there is still a 20% to 30% chance of death within the first year after the fracture. The rate is higher in men than in women. For patients who aren’t treated with an operation, the most frequent complications include heart and lung complications, thromboembolic events (blood clots), and severe body-wide infections.
Surgical complications can encompass anemia due to blood loss, infections, lack of bone healing, and collapse of the affected area, among other things. One well-known issue related to the failure of implants is a problem called screw cutout. This usually happens when the screw is placed more than 25 millimeters away from the tip apex distance. If this happens, young patients generally require a corrective osteotomy with open revision reduction and internal fixation, while in older patients, conversion to hip arthroplasty is generally the preferred treatment. Another known complication with the use of a long intramedullary device in older patients is the anterior perforation of the cortex of the distal femur. This typically occurs when the curvature of the femur and the implant do not match. Luckily, the incidence of nonunion, which is when the fracture does not heal, is low, at less than 2%.
Common Complications of Fractures:
- Heart and lung complications
- Thromboembolic events (blood clots)
- Serious body-wide infections
- Anemia from blood loss
- Infections
- Failure of the fracture to heal (nonunion)
- Implant-related issues, such as screw cutout and anterior perforation of the distal femur cortex
- Failure of the implant and the femur to match in curve (radius of curvature mismatch)
Recovery from Intertrochanteric Femur Fracture
The protocol following surgery consists of applying weight as comfort allows, using drugs to prevent blood clots for up to six weeks, and undergoing continuous physical therapy starting immediately after the surgery.
Preventing Intertrochanteric Femur Fracture
Patients should understand the seriousness of their injury, including the difficulties they might encounter as they try to return to their regular activities. They should be reassured that actively participating in treatment plans will not only help avoid further health problems and potential life-threatening conditions, but also assist in regaining their mobility.
