Intertrochanteric fractures are most common in the elderly. Because of osteoporosis in the elderly, fractures can occur when the lower limb is suddenly twisted or sharply and excessively abducted or adducted during a fall, or when an external force directly impacts the greater trochanter. If not treated in time, it can cause complications such as decubitus ulcers due to prolonged bed rest. Improper treatment may cause deformity healing and affect the function of the affected limb, so timely treatment is necessary.
Clinical manifestations
After trauma, local pain, swelling, pressure pain and dysfunction are obvious, sometimes subcutaneous petechial hemorrhagic spots can be seen on the lateral side of the hip, and the distal fracture segment is in extreme external
Intertrochanteric fracture of femur
The distal fracture segment is in extreme external rotation, and in severe cases, it can reach 90° external rotation. Most of the patients are elderly, and the hip is painful after the injury and cannot stand or walk. The symptoms are milder in insertion fractures without displacement or stable fractures with less displacement. On examination, elevation of the affected trochanter is seen, local swelling and ecchymosis are visible, and local pressure pain is obvious. The heel is often severely painful when the heel is buckled. X-ray examination is often required to establish the diagnosis and to perform typing according to the X-ray film.
Disease diagnosis
Diagnosis based on
(1) History of trauma
Intertrochanteric fracture of the femur
(2) The above clinical symptoms and signs: pain, pressure, pain, external rotation deformity, etc.
(3) Fracture can be seen on X-ray
Differential diagnosis
In general, intertrochanteric fractures are more serious than femoral neck fractures because of the rich local blood flow, swelling and petechiae, and more intense pain; the pressure point of the former is mostly in the greater trochanter, while the pressure point of the latter is mostly below the midpoint of the abdominofemoral ligament. x-ray can help to differentiate.
Treatment measures
Patients are mostly elderly, first of all, attention should be paid to the general condition to prevent various life-threatening complications due to bed rest after fracture, such as pulmonary
intertrochanteric fracture of the femur
The first step is to prevent life-threatening complications such as lung fracture, bed sores and urinary tract infections. The purpose of fracture treatment is to prevent hip inversion deformity, and the specific treatment methods should be adopted according to the type of fracture, displacement, patient’s age and general condition.
Traction therapy
It is suitable for all types of intertrochanteric fractures. It is especially suitable for stable fractures without displacement and for those with serious internal diseases that are not suitable for surgery. The advantage of traction is that the external rotation of the affected limb can be controlled. For type I and II stable fractures, traction is used for 8 weeks, then the joint can be moved and the limb can be lowered with an abductor, but the weight-bearing of the affected limb can only be done after 12 weeks of solid fracture healing to prevent hip inversion.
The requirements for traction of unstable fractures are: a. traction weight, about 1/7 of body weight; b. once the hip inversion deformity is corrected, traction weight of 1/7 to 1/10 of body weight should be maintained to prevent recurrence of hip inversion deformity; c. traction should be maintained for sufficient time, generally more than 8 to 12 weeks, and traction should be removed after the fracture healing is initially solid.
Internal fixation of closed transcatheter multiple Stiletto pins
First tibial tuberosity traction is performed, repositioning is performed, a systemic examination is performed, and surgery is performed on the fracture table within 3 to 7 d after the injury. Four 3.5 mm diameter Staples were used to fix the femoral neck fracture with the same multiple Staples.
Nail plate type internal fixation
This method is suitable for all types of fractures in adults, and the commonly used internal fixation are DHS (powered hip screw) and Charnley sliding compression nail.
Femoral intertrochanteric fracture
Ender nail fixation
The nail is cut from 2 cm above the medial femoral condyle, and the Ender pin is observed on the X-ray TV fluoroscope, passing through the fracture to about 0.5 cm below the articular surface of the femoral head. Several nail ends are spread out in a fan or harpoon pattern to fix the proximal bone mass. Postoperatively, skin traction or an anti-external rotation shoe is applied.
Gamma nail fixation
In the early 1990s, some countries adopted the Gamma nail, which is a locking intramedullary pin, obliquely threaded through a thick screw through the neck of the femoral head. Because the main nail passes through the medullary cavity, the line of force is close to the center of the femoral head from biomechanical analysis, therefore, the medial side of the femur of the Gamma nail can withstand greater stress and can achieve the purpose of early weight bearing on the ground.
Locking plate fixation
The newly introduced internal fixation plate, the unique process of locking plate makes it not only the role of internal fixation plate, but also more the role of internal fixation stent, the plate leaves a certain distance with the bone surface, so that the blood circulation of bone is relatively improved. Due to the relatively high price of locking plates, there are some limitations in the selection of internal fixation materials for fracture patients.
Application of PFNA in intertrochanteric fracture of femur
Abstract
PFNA
Objective To investigate the clinical efficacy of PFNa in the treatment of intertrochanteric fractures of the femur. Methods From August 2005 to September 2006, 10 cases of femoral intertrochanteric fractures were treated by making
PFNA
with PFNA internal fixation, and the fractures were staged according to Evans. Results All patients obtained 8~54 weeks of follow-up. All fractures healed with a healing time of 8 to 22 weeks, with a mean of 14 weeks, without complications such as infection, fat embolism, deep vein thrombosis, nonunion of the fracture, hip inversion and rotational deformity. Conclusion PFNa treatment of femoral trochanter fracture has the advantages of simple operation, small trauma, in line with the principle of biological fixation, firm fracture fixation, few complications and early release of patients from bed for weight bearing, which is especially suitable for elderly patients.
Surgical method
The patients were admitted to the hospital and underwent skin traction or tibial tuberosity traction, and during the traction period, all investigations were completed, medical comorbidities were actively treated, and surgery was performed after the condition was stabilized. 8 cases were treated with continuous epidural anesthesia, 1 case with combined lumbar and epidural anesthesia, and 1 case with general anesthesia. The patient was placed on an orthopedic traction bed, traction was closed and repositioned, and after successful repositioning by C-arm X-ray machine fluoroscopy, a 3-5 cm incision was made above the greater trochanter, and a trigon was used to open the femoral medullary cavity from the medial aspect of the greater trochanter tip to the direction of the femoral medullary cavity, and a guide needle was inserted after fluoroscopy saw that the trigon entry point and direction were good, and the rotor entrance was enlarged with an elastic drill, and the main nail mounted on the aimer handle was inserted into the proximal medullary cavity of the femur at a suitable depth. After adjusting the anterior tilt angle, screw a guide pin into the femoral neck through the proximal locking hole of the sighting device, with the guide pin located in the middle and lower third of the femoral neck in orthoptic fluoroscopy and in the middle of the femoral neck in lateral fluoroscopy, drill a hole along the guide pin with a hollow drill bit, drill only through the lateral cortex, drive a spiral blade in the direction of the guide pin, drive the distal 2 locking nails under the guidance of the positioner, and remove the positioner, as the incision is small and the injury is small, no drainage tube is usually placed. Postoperative treatment: antibiotics for 1-3 days, anticoagulants for 1 week, sitting up after anesthesia, muscle exercises for joint movement on the second day after surgery, walking on the ground with the help of crutches, no or partial weight-bearing on the injured limb according to the type of fracture and reset. After discharge from the hospital, the clinical healing of the fracture can be judged when the bone scabs grow well and the fracture line is blurred on monthly follow-up X-rays.
Postoperative results
Femoral intertrochanteric fracture is one of the most common fractures of the proximal femur, which mostly occurs in the elderly and is prone to osteoporosis and medical diseases. Although most of the fractures are caused by low-energy injuries, if they are not treated effectively and timely, they may leave sequelae such as hip inversion and limb shortening. Long-term bed rest is prone to serious complications such as pulmonary infection, urinary tract infection and bed sores. PFNa is a new type of internal fixation system, which is characterized by a helical blade with a diameter of the head nail and an anti-rotation locking automatically completed through the lateral incision, which only opens the lateral cortex and does not remove the bone even in patients with very serious osteoporosis. The main nail has a 6-degree external deflection for easy insertion from the top of the greater trochanter; a distal locking hole allows for static or dynamic locking; the longest possible tip and groove design allows for easy insertion of the PFNA and avoids local stress concentration; for long types of PFNAs PFNA features include: it is an intramedullary fixation, which maintains the concept of strong AO fixation, is biomechanically stable and strong, and allows early ambulation. It also reflects the essence of BO and minimally invasive surgery, the surgical incision is only 3~5cm, the operation time is short, average 60min, the bleeding is low, average 72.2ml, no blood transfusion is needed. The head nail is a spiral blade with 11L diameter, only one guide pin is needed, and the head and neck area does not need to be drilled, and the main nail can be inserted from the top of the greater trochanter with 6 degrees of external declination, which simplifies the operation, shortens the operation time and reduces the number of fluoroscopy. The extended version is available. Specific attention should be paid to the following points.
Intertrochanteric fractures of the femur
(1) Pre-operative careful review of the films to understand the fracture type and the size of the medullary cavity to determine the length and thickness of the nail.
(2) Do not overdraw during repositioning, as overdrawing makes the otherwise stable fracture unstable and the fracture end is easily displaced when the main nail is inserted.
(3) Because the proximal end of the PFNA has a 6-degree external deviation angle, the nail should be drilled from 0.5 cm inside the tip of the greater trochanter, which may lead to splitting of the greater trochanter, and from the pear-shaped fossa, which may cause fracture dislocation.
(4) After inserting the guide pin, attention should be paid to the position of the pin in the axial phase, after accurate positioning before opening the lateral cortex and inserting the main nail; once the main nail is inserted and then changed, the stability is greatly reduced due to the destruction of the femoral neck bone.
(5) To ensure smooth insertion of the caudal part of the PFNA, the rotor section needs to be enlarged and should be expanded from small to large, avoiding the use of transmural expansion and violence to prevent the rotor from splitting.
(6) PFNA is an intramedullary fixation system, the loss of medial support is not easy to occur hip inversion, so the small rotor displacement is not advocated for another reset fixation, because the reset fixation to significantly increase the trauma. In conclusion, the application of PFNA for the treatment of intertrochanteric fractures has the advantages of reliable fixation, small trauma, early bed activity, rapid fracture healing and few complications, and is an ideal device for the treatment of intertrochanteric fractures.