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Orthopaedics & Traumatology: Surgery & Research 100 (2014) S75–S83

Available online at

ScienceDirectwww.sciencedirect.com

eview article

reatment of recent trochanteric fracture in adults

. Adam ∗

ervice de chirurgie orthopédique et de traumatologie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 67098 Strasbourg, France

a r t i c l e i n f o

rticle history:ccepted 8 November 2013

a b s t r a c t

Recent trochanteric fracture is frequent in adults, and mainly affects elderly patients who risk loss of

eywords:rochanteric fracturesnternal fixationrthroplasty

independence. Treatment is surgical, of various sorts. Open reduction internal fixation (ORIF) with intra-or extra-medullary implants is the most frequent attitude in these fractures, which usually heal easily.In elderly patients, arthroplasty is an alternative of choice for some authors. These different treatmentmodalities are presented, focusing on technical details. Possible technical difficulties and the means ofdealing with them are considered. Published results help in choosing the treatment most suitable for aparticular type of fracture in a particular patient.

urgical technique

. Introduction

Recent trochanteric fracture in adults overwhelming affectslderly subjects. Frequency is increasing with population aging [1]espite the development of treatments for osteoporosis. Preventiveeasures based on anti-shock trousers have failed to demonstrate

fficacy, due to poor compliance [2,3].In elderly subjects, fracture entails a serious risk of loss of inde-

endence best reduced with surgery (usually conservative) thathould be undertaken with minimal delay.

The two most widely used types of open reduction internal fix-tion (ORIF) are intra-medullary nailing and screw-plate fixation,ften performed by trainee surgeons due to their frequency andeputed simplicity [4,5].

. Definition

Trochanteric fracture involves the proximal femur between theervical region and the shaft. Subtrochanteric fracture, with a frac-ure line running from an area within 5 cm distal to the lesserrochanter, is usually also included in the definition [6].

. Classifications

There are numerous classifications of trochanteric fractures,

ased on fracture line location [7,8] and on displacement and theonsequences for external reduction maneuvers [9]. Two classifi-ations are particularly widely used:

∗ Tel.: +33 388 127 716.E-mail addresses: philippe.adam@chru-strasbourg.fr, phradam@gmail.com

877-0568/$ – see front matter © 2013 Elsevier Masson SAS. All rights reserved.ttp://dx.doi.org/10.1016/j.otsr.2013.11.007

© 2013 Elsevier Masson SAS. All rights reserved.

• the Evans classification [10], modified by Jensen and Michaelsen[11], is based on fracture site stability and comprises 5 types, fromnon-displaced 2-fragment (Type I) to medially and posterolater-ally comminuted fracture (Type V) (Fig. 1);

• The AO classification [12] comprises 3 groups:◦ 31A1: simple 2-fragment pertrochanteric◦ 31A2: multi-fragment pertrochanteric◦ 31A3: intertrochanteric, each subdivided into 3 subgroups

(Figs. 2–3).

Both classifications have limited inter- and intra-observerreproducibility, although this is better in the AO classification atthe level of the 3 principal groups [13].

4. Epidemiology

Trochanteric fracture mainly affects the elderly. Together withfemoral neck fracture, it constitutes the category of proximalfemoral fractures, for which more than 80,000 cases were reportedin France in 2005.

In elderly subjects, trochanteric fracture results from bonefragility associated with frequent falls, induced by certain medicaldrugs such as hypnotics and also recent antihypertensive treat-ments [14].

5. Diagnosis

Classically, trochanteric fracture affects subjects aged > 75 years,

with a distinct female predominance.

It often follows a simple high fall, resulting in total lower-limbimpotence. The classic deformity pattern of shortening, adductionand external rotation may not apply when there is no displacement.

S76 P. Adam / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S75–S83

Fig. 1. Jensen–Michaelsen classification.

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Fig. 2. AO classification.

P pelvic and lateral hip X-ray confirms diagnosis and determineslassification.

CT is indicated only to screen for occult fracture.General examination screens for comorbidities in decompensa-

ion. Screening for denutrition is important, to anticipate possibleifficulties in functional recovery [15].

. Treatment objectives

In the elderly, there is a risk of general complications and espe-ially of loss of independence and, in particular, of walking capacity.

The chosen treatment should allow verticalization and earlyeating, to avoid the serious complications associated with decubi-us.

Treatment should involve as little shock, surgery time and bloodoss as possible so as not to impair recovery.

Ideally, it should allow resumption of unrestricted weight-

earing, which is the best guarantee of conserving walking capacity.

Whatever the treatment, associated measures comprise pre-nd post-operative pain management, prevention of venous

Fig. 3. 31A3 fracture.

thromboembolism, dietary supplementation if necessary, and mus-cle exercise.

7. Treatments

7.1. Functional treatment

Functional treatment of trochanteric fracture is reserved tostrictly non-displaced fractures in cooperative patients. It com-prises non-weight-bearing for the fractured limb and limited hipflexion awaiting radiologic fusion. The main risk is of secondarydisplacement. Elderly patients are not ideal candidates, due to theserious risk of loss of independence. In case of absolute anesthesi-ological or surgical contra-indication, functional treatment may bethe only option in a situation of obligatory therapeutic abstention,but with a mortality rate exceeding that of surgery.

7.2. Conservative treatment

Conservative management was codified by Böhler, specifyingtraction time (10–14 weeks) and direction according to fractureline location and fragment displacement.

Due to the long decubitus required, conservative treatment isnowadays exceptional, reserved to rare cases of anesthesiologicalcontra-indication.

gy: Surgery & Research 100 (2014) S75–S83 S77

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Fig. 5. Frontal reduction control.

P. Adam / Orthopaedics & Traumatolo

.3. Surgical treatment

Surgical treatment is the rule. It should be performed as quicklys possible after stabilization of vital functions [16,17].

.3.1. ORIF

.3.1.1. Patient positioning. Positioning seeks to achieve at leastartial fracture site reduction. ORIF is greatly helped if the fractureite is already reduced before the procedure. These initial reductionechniques are performed closed or semi-open, under fluoroscopy.

Whichever the type of ORIF (intra-medullary nailing or screw-late), installation is on a traction table. Transosseous traction isot usually required: traction using a shoe of appropriate size isnough. Dorsal decubitus has the advantage of simplicity and goodemodynamic and ventilatory tolerance in patients whose generalealth status may be poor; some teams, however, prefer lateralecubitus, which provides good control of rotation.

It is essential to check that AP and lateral views can easily beaken by the electroradiological operator at any time. When pos-ible, use of two fluoroscopes allows simultaneous AP and lateralontrol of reduction.

Once the patient is positioned in traction along the axis of theimb, reduction is checked, comparing morphology to that of theealthy hip on AP pelvic view.

If the fractured femur is in varus relative to the healthy side,xial traction should be increased; if it is in valgus, traction shoulde relaxed.

Once femoral morphology has been satisfactorily restoredrontally, the lateral view is controlled. Lateral reduction can bedjusted by rotating the limb, starting with the patella at theenith. As there is often posterior comminution, reduction is oftenchieved in internal rotation, which should, however, be moder-te due to the risk of malunion in internal rotation, which wouldreatly hinder recovery of walking capacity [18]. Certain fracturesre reduced in external rotation, as the pelvic and trochantericuscles conserve their external rotational action on the proximal

ragment: these are what are called “extradigital” fractures [19].Thus simple limb positioning on the fracture table can adjust

arus/valgus frontally and rotation laterally (Figs. 4–6). It cannot,owever, reduce displacement of fragments in sagittal translationr flexion of the proximal with respect to the distal fragment:hese displacements require peroperative action directly on theragments themselves. Such complementary reduction should be

erformed before creating the entry points for the fixation material.uality of reduction and appropriate implant positioning deter-ine the final result [20].

Fig. 4. Trochanteric fracture.

Fig. 6. Lateral reduction control after initiation of traction.

7.3.1.2. Reduction-aid techniques. Various reduction-aid tech-niques can be used.

Posterior support: this can be used to avoid posterior translationof the distal fragment in subtrochanteric or trochanteric-diaphysealfracture, especially in obese patients (Figs. 7 and 8).

A Wagner raspatory on the anterior side of the neck reduces

proximal fragment flexion caused, notably, by non-compensatedpsoas-iliac muscle traction (Figs. 9 and 10).

Fig. 7. Posterior support.

S78 P. Adam / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S75–S83

Fig. 8. Lateral reduction with posterior support.

Fig. 9. Lateral displacement due to proximal fragment flexion.

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of the blade and the contour of the femoral head was aimed at, toensure against initial protrusion.

The monoblock design of these implants had the advantage ofmaintaining correct reduction. In case of comminution, fracture site

Fig. 10. Wagner raspatory on anterior side of proximal fragment.

A K-wire in the proximal fragment reduces rotation disorder,specially excessive external rotation of the proximal fragment.ithout prior correction, there is a major risk of malpositioning

he entry point of an intra-medullary nail and of excessive femoralnteversion.

Fig. 11. Persistent displacement in trochanteric-diaphyseal fracture.

Open reduction with positioning of a bone-holding forceps maybe necessary in subtrochanteric fracture with muscle incarcerationwithin the fracture site [21] (Figs. 11 and 12).

Temporary cerclage can prevent reduction loss during osteosyn-thesis.

Precise reduction facilitates the location of the intra-medullarynail entry point, enabling reaming to prepare the nail lodge, reduc-ing the risk of correction loss when the nail is introduced [22].

The advantages of anatomic reduction outweigh the harmfulimpact of local devascularization on fusion [23]. Optimal reductionis also important with screw-plates, to locate the entry point ofthe cervical screw and align the plate with the lateral side of theproximal shaft.

7.3.1.3. Types of internal fixation. Rather than contrasting openversus closed techniques, we shall distinguish internal fixationaccording to the extra- versus intra-medullary position of the mate-rial.

7.3.1.3.1. Extra-medullary material.7.3.1.3.1.1. Blade- and nail-plates. Historically, blade-plates

and nail-plates were the first types of internal fixation.After reduction, implantation used a lateral approach, raising

the vastus lateralis.Material angulation varied according to fracture line type: 130◦

in pertrochanteric fracture and 95◦ in intertrochanteric fracturewith horizontal line or subtrochanteric fracture.

Blade or nail position was determined using K-wires under flu-oroscopy.

For 130◦ blades, a minimum 10 mm distance between the end

Fig. 12. Reduction using bone-holding forceps.

P. Adam / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S75–S83 S79

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Fig. 13. Minimally invasive implantation of dynamic plate screw.

mpaction along the blade or nail, however, entailed a serious riskf material penetrating the joint.

7.3.1.3.1.2. Screw-plates. Screw-plates encountered great suc-ess, due to their ease of implantation and the possibility ofontrolled sliding of the cervical screw, inducing fracture sitempaction to promote fusion with a reduced risk of joint penetra-ion by the material.

The technique is as follows:

after fracture site reduction, a lateral subtrochanteric approachis performed, raising the vastus lateralis;femoral neck anteversion is estimated, and a cervical guide-wireis placed in a central position frontally and laterally using a guideangled according to the plate used (130◦, 135◦ or 140◦, dependingon the model) under fluoroscopy. In subtrochanteric fracture, anangle of 95◦ is used [24];screw length should take account of the possibility of compres-sion of the site;the trajectory of the cervical screw and of the plate barrel is pre-pared using a triple reamer;a temporary anti-rotation wire may be fitted if necessary beforeinserting the cervical screw;a flat section on the screw and plate avoids one rotating withrespect to the other;the fracture site can be compressed peroperatively; otherwise,compression is ensured by the dynamic assembly;a supplementary cervical screw may be positioned in parallelproximal to the first screw, to neutralize rotation force;in complex fracture, a lateral greater trochanter support platemay be associated, allowing extra screws for fixation.

Screw-plates may be fitted on a minimally invasive approachFig. 13), limiting blood loss [25].

Locking the distal diaphyseal screws has been recommended tomprove stability in case of osteoporosis, with encouraging exper-mental results [26]. There is, however, a risk of perforation of theead and of fracture of material in case of varization of the fractureite, due to the lack of play between plate and screws [27].

7.3.1.3.2. Intra-medullary material.7.3.1.3.2.1. Ender’s flexible nailing. Flexible nailing, following

nder, was very much in fashion in the 1970s and 1980s.Introducing a small-diameter elastic nail very remotely from

he fracture site, in the medial side of the distal femur, may stille indicated in case of pre-existing skin lesions in the trochantericegion.

With the surgeon between the lower limbs, the patient is pos-tioned with both lower limbs in abduction, enabling the site toe valgized to facilitate nailing. A large enough metaphyseal boneindow allows 3 precurved nails to be introduced.

Fig. 14. Patient positioning for intra-medullary nailing with lateral truncal inclina-tion.

Although the use of locking nails limits sliding and the occur-rence of skin problems at the knee [28], weight-bearing is notallowed and there is a high rate of malunion in external rotation.For these reasons, this technique has been abandoned in favor ofmore rigid internal fixation.

7.3.1.3.2.2. Intra-medullary nailing. Intra-medullary nailing isan effective attitude in trochanteric fracture [29]. With theoptimization of positioning instrumentation, favoring minimallyinvasive insertion, and the mechanical advantage inherent tointra-medullary material in complex fracture, nailing has becomeincreasingly widespread compared to screw-plate fixation [30,31].

After reduction, the introduction area is located under fluo-roscopy. Laterally, introduction follows the long axis of the femoralshaft, so that the trochanteric entry point can be determined onlyafter reduction.

To optimize access to the summit of the greater trochanter,the lower limb must not be placed in adduction, varizing the frac-ture site; rather, the trunk should be inclined laterally on the sideopposite the fracture (Fig. 14] and the position maintained by a lat-eral thoracic support. In obese patients, the incision is then shiftedproximally.

The angle of the nail is adapted to the morphology of the prox-imal femur, and the entry point is determined according to thespecifications for the particular nail.

There is a risk of over-reaming the lateral part of the proximalfemur, especially when the guide is lateral to the fracture site. Toavoid such excentric reaming, a slight hyper-reduction in valgusduring reaming prevents the trochanter being weakened laterallyand thus prevents varus displacement when introducing the nail[32].

The metaphyseal and proximal diaphyseal region must bereamed sufficiently, at least 2 mm more than the diameter of the

nail, to avoid the nail, which is straight whereas the proximal femuris curved, becoming stuck when it descends.

The descent of the nail determines the subsequent position ofthe cervical screw.

S80 P. Adam / Orthopaedics & Traumatology: Su

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igs. 15 and 16. Pertrochanteric fracture: planning of nail angle and cervical screwosition on frontal pelvic view. Control at bone fusion (+ 8 weeks).

On AP view:

giving the screw a low position delays joint breakage in case ofvarization of the fracture site;positioning the screw in the center of the femoral head provides amore solid bone anchorage while allowing the distance betweenthe end of the screw and the apex of the head to be reduced, toimprove stability [33] (Figs. 15–16).

On lateral view:

ideally, the screw is centered in the femoral neck and epiphysis,maximizing before cut-out [34];

excentric lateral positioning could trigger rotation of the prox-imal fragment, leading eventually to perforation of the femoralhead [35].

If the fracture line is at the base of the head, fitting an anti-otation wire before inserting the cervical screw reduces the risk ofroximal fragment rotation.

The cervical screw needs to be long enough and go far enoughnto the epiphysis (“combined tip-apex distance”: the sum of theistance measured frontally and laterally, < 25 mm), while keeping

safety margin of at least 5 mm between the top of the screw andhe projection of the femoral head on AP and lateral views [36].

The lateral end of the cervical screw should go slightly beyondhe lateral cortex of the femur, so as subsequently to be able to slide.

There are various specificities to different manufacturers’ mod-ls: the cervical screw may have the form of an “anti-rotationlade”, intended to provide better epiphyseal anchorage in poroticone [37].

rgery & Research 100 (2014) S75–S83

Associating a blocking system prevents the screw or blade rotat-ing with respect to the nail, without preventing sliding, therebyallowing compression of the fracture site. Without such locking,there is a risk of post-operative intrapelvic migration of cervicalmaterial [38,39] (Figs. 17–19).

Distal locking of short intra-medullary nails is performed usingthe nail-holder device.

A short nail may be used in pertrochanteric fracture detachingthe lesser trochanter if the fracture line does not extend more than5 cm distally to the lesser trochanter and the patient is not morbidlyobese.

For more distal fracture lines and subtrochanteric fracture andin morbidly obese patients, a long nail is required. In that case,distal targeting classically uses the “round holes” technique. Distallocking aids (e.g., the Distal Targeting Device, StrykerTM), intendedto reduce the radiation involved in distal targeting, have recentlybeen assessed.

7.3.1.3.3. Improving epiphyseal bone anchorage. Intra-osseousacrylic cement may improve epiphyseal anchorage. After an exper-imental validation phase [40,41], acrylic cement was successfullyassociated to treat unstable trochanteric fracture in severe osteo-porosis, using screw-plates or intra-medullary nails [42,43].

7.3.1.3.4. External fixation. External fixation represents aninteresting alternative for stabilizing type 31A1 or 31A2 fracturein fragile patients, as it involves little shock.

The various assemblies available all begin with reduction on thefracture table, followed by fitting two series of pins: one oblique at130◦ to the diaphyseal axis with epiphyseal fixation, and one usingbicortical diaphyseal pins.

The most frequent complication is infection on the pins, withan incidence of 7% for standard pins [44]. With the advent ofhydroxyapatite-coated pins, this complication has almost com-pletely disappeared [45].

In case of non-union, revision using internal fixation entails arisk of infection.

7.3.1.4. Hip replacement. Some teams prefer hip replacement,especially in unstable fracture in elderly patients who remain ableto walk, in whom internal fixation anchorage may be problematic.The rate of early mechanical failure in ORIF at advanced stages onthe Singh classification is indeed an indication for hip replacement,as in cervical fracture [46–49].

Mortality seems no higher after hip replacement than after ORIF[50,51]. Comparative studies between the two are, however, few,and no definite conclusion can be drawn [47,52].

Pre-operative planning and landmarking (lesser trochanter,greater trochanter, trochanteric fossa, femoral expansion of gluteusmaximus, etc.) allows lower-limb length to be almost equalized.

All approaches are feasible. In case of continuity between thegluteus medius and vastus lateralis caused by a fracture detachingthe greater trochanter, a transfracture approach provides excel-lent access to both acetabulum and femur, but requires painstakingreconstruction, repositioning the greater trochanter by cerclages ora trochanteric hook plate.

Implants may be cephalic, bipolar or total, using standard orrevision femoral components. Large heads, bipolar heads or dualmobility sockets provide extra stability, which is useful because ofthe risk of dislocation [51] (Fig. 20).

8. Clinical forms and therapeutic specificities

8.1. Fracture in young subjects

In young subjects, trochanteric fracture results from violenttrauma, and is usually displaced. Muscle incarceration in the

P. Adam / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S75–S83 S81

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Figs. 17–19. Intra-articular migration of cervical sc

racture site is not unusual and hinders reduction by isolated exter-al maneuver.

In young subjects, the greater frequency of material ablation andhe room taken up proximally by intra-medullary nails may justify

ore frequent resort to screw-plates, especially in stable fractures.

.2. Fracture of pathological bone

The proximal femur, and the metaphyseal region in particular,s a common location for bone metastasis. Absence of apparentrauma, presence of osteolysis and isolated lesser trochanteric

ue to insufficient tightening of the blocking screw.

fracture suggest tumor, especially metastatic or myelomatous inelderly subjects.

Depending on expected survival and tumor location and exten-sion, treatment may comprise resection of the affected area andimplantation of a mega-prosthesis or, if survival is more limited,internal fixation by intra-medullary nailing to reinforce the femurall the way down [53], possibly associating acrylic cement.

8.3. Fracture in osteoarthritic hip

Osteoarthritis is an argument for hip replacement. Total hipreplacement is a logical attitude in case of trochanteric fracture

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[27] Glassner P, Tejwani N. Failure of proximal femoral locking compression plate:

ig. 20. Treatment of trochanteric fracture by total hip replacement with dualobility socket and trochanteric cerclage.

ssociated with symptomatic osteoarthritis and a sufficient pre-perative Parker score. A dual mobility socket reduces the risk ofost-operative instability in this particular indication [51].

In patients with a very low pre-operative Parker score, on thether hand, ORIF is sufficient, allowing nursing care and avoidinghe problems of decubitus.

. Associated measures

In trochanteric fracture, ORIF is performed under antibiopro-hylaxis.

Thromboprophylaxis is initiated post-operatively if there is noemorrhagic syndrome.

A suction drain is reserved to wide approaches. Weight-bearingp to the pain threshold is allowed post-operatively after intra-edullary nailing or in stable fracture managed by screw-plate.Only touch weight-bearing is allowed if the assembly seems less

ecure in unstable fracture.In elderly patients, hardware is not ablated except in case of

nfectious or mechanical complications or of prosthesis replace-ent.

0. Treatment results

In trochanteric fracture, ORIF shortens the affected limb by aean 11 mm at fusion, and more in unstable fractures.For a given type of fracture, there is less shortening with intra-

edullary nailing than with a screw-plate [54].Intra-medullary nailing is increasingly used, but seems to give

etter results than screw-plates only in subtrochanteric fracture55] (Figs. 19 and 20).

Reduction defect in varus is to be avoided, using direct manoeu-res if needed, as it is more often associated with defective fusion.epending on the assessment criteria, functional results do not

ignificantly differ between hip replacement and ORIF [56].In elderly subjects, prognosis for trochanteric fracture is poor,

ith 6-month mortality exceeding 25% and lowered walking scoresnd Parker independence scores for survivors [57].

1. Conclusion

Treatment of trochanteric fracture is well codified. Risk of failurencreases with imperfect reduction, poor implant positioning and

dvanced osteoporosis.

The development of ORIF simulation, which is still in its earlytages, should reduce the rate of technical error [58].

[

rgery & Research 100 (2014) S75–S83

Disclosure of interest

Philippe Adam: Consultant for Synthes.

Acknowledgments

Thanks to Dr Taglang and Dr Ehlinger.

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