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.

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 obliquityFractures parallel to neck axis &traverse lat. cortex

Subtrochanteric Three types- Simple, Wedge , ComplexAll unstable due to relatively small contact

area

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

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

Prevention Pre-hospital care Hospital care Rehabilitation

“Manage the patient, Not the fracture”

A = Airway B = Breathing C = Circulation D = Disability of CNS E = Exposure of the patient F = Foley catheter

At risk in all unconscious patients.

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.

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

•Generalized bone diseases1.Paget’s disease of bone 2.Primary hyperparathyroidism3.Osteomalacia4.Osteoporosis

Localized bone diseases1. Metastases from carcinoma breast, lung,

kidney, and thyroid.2. Multiple myeloma3. Primary bone tumors

Malignant-OsteosarcomaChondrosarcoma

BenignOsteoclastomaBone cyst

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/C- What 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,hypoglysemia7.PDHx- Corticosteroids8.PSHx-Any previous trauma,any Sx and

complications

9.Menstual Hx-10.Allergies-11.Immunisation-eg tetanus12.Family Hx-eg-osteogenesis imperfecta osteopetrosis13.Personal Hx-smoking,alcohol,lifestyle family life (?assault)14.Dietary Hx-?protein and Vit deficiency? Inadequate Ca intake

1. General Examination

2.Examination of the Hip Joint

3. Special Examination of systems

4. Radiographical Examination

•Patient is in pain•Unable to stand•Limb is shortened and lies in external rotation •Skin wounds or obvious deformity

Ecchymosis of the proximal thigh- occasional

Inspection Skin changes- Redness, swelling ShapePositionScars Wasting of gluteal and thigh muscles Palpation Temperature, tenderness over the jointSkin, 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

Look for, •Shortening in External rotation of the involved extremity •Palpation below the ingunum elicits pain •Inability to move

1. Circulatory system2. Neurological Examination 3. Musculoskeletal System

InspectionPalpation Percussion Auscultation

•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

• AP Radiograph of the distal Pelvis•AP and Lateral Radiographs of the hip joint •Femur •Knee joint^

To Diagnose Fracture To Find Aetiology Preoperative Assessment Postoperative evaluation

X-Ray Hip Rule of 2s

2views2joints2limbs2times

Rule of AsAnatomyArticularvAlignmentAngulationApexApposition

CT Scan-Not indicated in routine evaluation

X-ray- Osteoporosis Paget’s Disease Chondrosarcoma

Lytic lesion Involves the inferior aspectof the neck and the medial intertrochanteric area.

Ewing sarcoma.

Entire proximal part of the femur isfilled with mottled scleroticdensities 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

CXR FBC Hb ECG FBS

X-ray Hip To evaluate the reduction

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

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

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 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

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 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

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

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.)Surgical2.)Non surgical

Cast bracingHip sica cast + traction

Pre operative measures

a)Assessment of the patientCormobid factors Surgical fitness

Risk for anesthesiab)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 implantsb)Intra medullary implants

Extra medullary devices1.)Sliding compression screw plate2.)Dynamic hip screw(DHS) e.g:-DCS

Indications:-Fractures with stable configurationsUnstable fractures with an intact lateral cortex

Intra medulary devices

1)Intra medullary hip screw(IMHS)Cephalomedullary nailsReconstruction nails(centromedullary)

Indications:-Shorter nail-If fracture line doesn’t extend more than 1 to 2cm distal to lesser trochanterLonger nail-unstable fractures

IMHS DHS

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 union3.) Prevent infections4.) Wound care 5.) Nutrition- high protein diet

Acute complications1. Damage to nerves and blood vessels2. Haemorrhage3. Other soft tissue damage

Long term complications1. 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,I. May unite with marked lateral rotation of the shaft.II. May develop severe coxa vera associated with shortenig.

Treatment 1. In most cases, can be accepted without treatment.2. 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 treatments1. casts -pressure ulcers -thermal burns -thrombophlebitis2. Internal fixation -infections -neurological and vascular injury -thromboembolic events -avascular necrosis -posttraumatic arthritis

Complications of immobilization1. Bed sores2. Hypostatic pneumonia3. Osteoporosis4. Hypercalcaemia5. Hypercaliuria6. Urolithiasis7. UTIs8. Muscle wasting9. Joint stiffness10.DVT11.Pulmonary embolism12.Psychological depression

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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 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

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

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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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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Advice to the patient on: Changes to the home environment Lifestyle changes

Prevention

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