Intertrochanteric fractures are defined as extracapsular fractures of the proximal femur that occur between the greater and lesser trochanter.[1] Intertrochanteric fracture is one of the most common fractures of the hip especially in the elderly with porotic bones, usually due to low-energy trauma like simple falls. 

Epidemiology

The incidence of intertrochanteric fracture is rising because of increasing number of senior citizens with osteoporosis. By 2040 the incidence is estimated to be doubled. In India the figures may be much more.[2] Problems of these fractures are (a) association with substantial morbidity and mortality (b) malunion (c) implant failure, cutout of head, and penetration into hip. (d) great financial burden to the family (e) associated medical problem like diabetes, hypertension.[3] 

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 ratio 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.[4] 90% or more of hip fracture occur in the elderly from a simple fall in the house due to direct or indirect forces. 

Mechanism of Fracture

Hip fracture can occur from cyclic mechanical stresses resulting in stress fracture. These fractures are usually a result of a ground-level fall in the elderly population and are classified as either stable or unstable. Determination of stability is important as it helps determine the type of fixation required for stability. Stable fractures have an intact posteromedial cortex and will resist compressive loads once reduced.[5] In general, five factors contribute to hip fracture. (a) Person landing on the hip (b) Inadequate reflexes (c) Absence of local shock absorber - Muscles and fat around the hip and (d) Osteoporosis. Currently more attention is paid to prevention of hip fracture. Commonly, fractures are described by the number of "parts"(fragments) and instability. The presence of certain fracture characteristics such as displaced postero-medial fragment shattered lateral wall, indicate instabilit

Anatomy of the Hip Joint

The Intertrochanteric region comprises the proximal femur distal to the neck extending to the lesser trochanter. The majority of the bone in the region is cancellous, extracapsular, and highly vascularized (contrast with subcapitalfemoral neck) leading to a robust healing environment. Several anatomic features influence treatment. The greater and lesser trochanters are the points of attachment of the primary hip abductor (gluteus medius) and primary hip flexor (iliopsoas), respectively. The calcar femorale is a dense strut of posteromedial bone that supports force transfer from the neck to the shaft. 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.[6] 

Classification of Fractures

There are several classifications of these fractures. Evans has based his classification on stability of the fracture.[7] The Evans classification breaks down intertrochanteric femur fractures based on displacement, number of fragments and the type of fragment displaced. Type I are 2 part fractures, Type II are 3 part fractures and Type III are 4 part fractures. The A sub-classification in type I fractures is used for non displaced fractures while subtype B fractures are displaced. In type II fractures, the A sub-classification describes a 3 part fracture with a separate greater trochanter fragment while the B sub-classification describes a 3 part fracture with a lesser trochanter fragment. Type III fractures are 4 part fractures. Jansen further modified Evans classification into three groups. (a) Stable (b) Unstable (c) Very unstable. Gotfried and Kyle[8] each  added a new variety of intertrochanteric fracture. Using Evan-Jansen's and AO/OTA classification and adding the new varieties described by Gotfried and Kyle, a new treatment oriented classification has been proposed. Type I: Stable fractures consists of nondisplaced, stable intertrochanteric fractures without comminution. Fractures are stable, minimally comminuted and displaced. Reduction of these fractures leads to a stable construct. Stable fractures heal well with any fixation device. These can be very well treated by dynamic hip screw (DHS) with excellent results. Type I A is undisplaced, 2 stable piece fracture, type I B is displaced, reducible, stable, 2 piece fracture, Type I C is displaced, but reducible, stable fracture with a small piece of lesser trochanter. Type II- Unstable fractures: These, the so-called problem fractures are unstable and are 3 piece or 4 piece fractures with a large displaced postero-medial fragment which includes lesser trochanter. Type III: Very unstable fractures: this fracture type includes 1. reverse oblique 2. trochanteric fractures with subtrochanteric extension 3. Comminuted trochanteriic fracture with extension into neck of the femur.

Management

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.[9] Previous nonsurgical treatments were fraught with the complications associated with prolonged bed rest and immobilization such as decubitus ulcers, thromboembolic events, and pneumonia. Surgical fixation is the standard of care unless contraindicated. The timing of surgery is still controversial; in general, delays are associated with higher mortality¹⁰, but it may be that sicker patients are disproportionately delayed. The optimal time for surgery has not yet been defined. Based on our interpretation of the literature, operative fixation in a few days of the injury, after medical comorbidities have been addressed, is the best course.[10] Urgent surgery without medical evaluation on the one extreme, and semi-elective scheduling for the surgeon’s convenience (as might be done with an ankle fracture) at the other do not seem justified.

The fixation method is guided by the fracture pattern; standard options include the sliding hip screw, intramedullary nail, or fixed angle plate. Stable fractures traditionally have been fixed with a sliding hip screw (lateral plate with a fixed barrel through which a large screw enters the femoral head). These devices are called “sliding” or “dynamic” as the fracture is expected to collapse and shorten in line with the angle of the barrel-this impaction is thought to stabilize the bone.  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. Alternatively, a lateral plate can be used with fixed-angle screws after intraoperative fracture compression, promoting healing but preventing additional shortening.[11] 

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.[11] 

Assessment of Treatment Outcomes

Outcome of the treatment of these fractures vary depending upon the implant, the surgical technique, the type of fixation, the biomaterials, the patient’s age, and numerous other factors. It is of crucial importance, that irrespective of the type of fracture and surgery done, the patient needs to start walking as early as possible to avoid respiratory complications and other complications that arise due to immobility. However, sometimes, it is not possible due to the patient’s general state of health. Cardiovascular stability is one of the main determinants of success of early walking after hip fracture surgery and early gait has been found to be an important determinant for an increase of the patients' functionality, as compared to the late gait group.[12] Exercises performed with weight bearing, certainly following the weight-bearing restrictions set by the physician in charge, have shown themselves to be advantageous and have also increased dynamic balance as well as functional performance. [13] Standard Harris Hip Score (HHS) is a validated and the most commonly used tool to measure the functional capacity of an individual before and after a surgical procedure.⁷ It has been used extensively in many studies for evaluating functional outcomes of THRs.[14] However, HHS includes a component of physical examination, which can vary widely among examining surgeons.[15] Subsequently to minimise this variability, modified HHS was developed in which the clinical evaluation part was removed. Modified HHS has been used in the past to assess functional outcome of THR over telephone[16] and for assessing functional outcome in non-traumatic indications of THR.[17] 

The authors declare that they have no conflict of interest

No funding sources

The study was approved by the Indira Gandhi Medical College, Shimla, Himachal Pradesh, India

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