Intertrochanteric fracture of the femur
[Definition]
Intertrochanteric fracture is a fracture from the base of the femoral neck to above the level of the lesser trochanter. Because of good blood supply, the fracture can heal well, but if it is not treated properly, it is very likely to develop hip inversion deformity.
[Diagnosis basis]
I. Medical history
This disease is mostly seen in the elderly, more men than women. The fracture can be caused by osteoporosis, minor trauma such as slipping on flat ground, landing on the greater trochanter, or sudden twisting of the affected limb. If this fracture occurs in young adults, it must be caused by strong violence such as car accident or fall from height.
Symptoms and signs
Pain in the hip after injury, unable to stand and walk.
Swelling of the affected hip is obvious, and there may be subcutaneous petechiae. The displaced fracture limb is shortened, internalized and externally rotated, and the pain increases when the limb is moved.
Special examination
Nelaton’s line, Bryant’s triangle and Schoemaker’s line are all positive, and Kaplan’s intersection point is biased towards the healthy side under the umbilicus.
Auxiliary examinations
Radiographs can clarify the type of fracture and displacement.
[Evidence classification]
According to the direction and location of the fracture line, it can be clinically classified into three types.
I. Inter-rotor fracture: The fracture line starts from the apex of the greater trochanter and reaches the lesser trochanter obliquely and inferiorly; the lesser trochanter either remains intact or becomes a free bone fragment. However, the bone strut at the upper end of the femur remains intact, the support of the bone is still relatively good, the hip inversion is not serious, and the displacement is less. Since the fracture line is distal to the attachment point of the joint capsule and the iliofemoral ligament, the distal segment of the fracture is in external rotation. In the crushed type, the small rotor becomes a free bone block, the large rotor and its medial bone struts are also broken, and the distal end of the fracture is obviously upwardly displaced and externally rotated.
Reverse intertrochanteric fracture: The fracture line runs obliquely upward from below the greater trochanter to the upper part of the lesser trochanter. The course of the fracture line is approximately perpendicular to the inter-rotor line or inter-rotor crest. The proximal end of the fracture is abducted and externally rotated by the contraction of the adductor and external rotator muscles, and the distal end is internally and upwardly displaced by the pull of the adductor and iliopsoas muscles.
Subtrochanteric fracture: The fracture line passes below the large and small rotors.
[Treatment]
I. Non-surgical treatment
(I) Fixation by manipulation
1. Traction fixation by manipulation
(1) Indications: Applicable to all types of intertrochanteric fractures.
(2) Operation method: general supracondylar traction of the femur. If the fracture is not well repositioned after traction, the femoral neck fracture can be rehabilitated by the method of cis-rotor fracture or the method of end lifting and squeezing (anti-rotor fracture), and then maintain supracondylar traction fixation until the fracture heals, traction Traction is usually maintained for 8 to 10 weeks.
2.Manipulation and traction with steel nail prying and compression fixation
(1) Indications: Applicable to subtrochanteric fractures.
(2) Operation method: First, supracondylar traction, then place the affected limb on the plate traction frame, flex the hip and knee 40°~50° each, abduct 30° traction, and then perform knocking and pushing after the traction is opened. If the proximal abduction, forward flexion and external rotation displacement cannot be corrected, steel needle can be added to pry and press for revision: routine skin disinfection of the hip and upper middle thigh, towel laying, local anesthesia, fluoroscopy, punching a steel needle along the lower edge of the femoral trochanter from outside to inside, making it perpendicular to the stem of the proximal fracture, with the tail of the needle at an angle of 15°~30° to the traction bed, striking into the stem, paying attention to penetrate the contralateral cortical bone, dressing the wound, and putting on the already perforated lateral femur from the tail of the needle. The wound is bandaged, and the lateral femoral splint with the hole punched is placed on the end of the needle, and the tail of the needle is lifted upward and wrenched distally to correct the external rotation and abduction displacement of the proximal end of the fracture, and a spring is placed in the inner 1/3 of the steel needle, and the tail of the needle is placed on a tripod with steps to correct the proximal flexion displacement and stabilize the proximal end of the fracture, and then a slight manipulation is applied to reset the fracture with splinting. Generally, the pin can be removed after 6 weeks, and the bone traction can be removed after 8-10 weeks.
3.Manipulation of the force arm type external fixation frame
(1)Indications: cis and reversal of intertrochanteric fractures and subrotor fractures.
(2) Operation method: Under the monitoring of the TV X-ray machine, the patient takes a flat supine position, two assistants hold the axilla and calf respectively, perform homeopathic extraction and extension traction repositioning, keep the affected limb in the abducted neutral position or slightly internally rotated position, routine skin disinfection, laying of towels, local anesthesia, respectively, two 4.0mm diameter head with silk bone round pins in the longitudinal axis of the femoral neck in an inverted “V “The third bone round pin was drilled into the femoral head 5-10 cm above the femoral condyles perpendicular to the backbone from the outside to the inside, just through the contralateral femoral cortex. A force arm type fixation frame is installed, and the three drilled pins are fixed firmly on the force arm type fixation frame with a locking pin device, generally for 8 to 12 weeks.
II. Surgical treatment
Incisional internal fixation
(1) Indications: Various types of adult intertrochanteric fractures.
(2) Operation method: The commonly used fixation methods are DHS, DCS, PFN, Gamma nail, angle plate, etc. The operation is performed on a general surgical bed or an orthopedic traction bed, and the fracture is monitored intraoperatively with the aid of C-arm X-ray fluoroscopy. The patient was placed in the supine position, and the DHS, DCS, and angled steel fixation were performed by lateral approach to the hip, with the lateral femoral muscle appropriately dissected from its posterior edge to reveal the femoral rotor, and then traction repositioned, and the main nail and plate were placed respectively. After 2 days postoperatively, the affected limb could be flexed and extended in bed, and after 4-6 weeks, the affected limb was put on the ground without weight-bearing and supported by double crutches, and weight-bearing exercises were gradually started in 8-12 weeks. For old intertrochanteric fracture, if there is no obvious healing, internal fixation by incision and cancellous bone implantation is performed; if it has healed and there is hip inversion, internal fixation by subtrochanteric abduction osteotomy is performed according to the above method.
C. Drug treatment
(A) Chinese medicine treatment
The medicine should be used according to the three stages of identification of injury. In the early stage of swelling and pain, it is advisable to activate blood circulation, eliminate blood stasis, reduce swelling and relieve pain, and the formula should be added and reduced by Tao Hong Si Wu Tang. For local and distal limb swelling, it is advisable to benefit the Qi and activate the Blood, and the medicine is Gao Wei Yi Qi Wan; for those with muscle wasting and hardness and dysfunction, it is advisable to nourish the Blood and facilitate the joints, and Blood Nourishing and Pain Relief Pill is used.
(II) Western medicine treatment
If surgical treatment, prophylactic application of antibacterial drugs half an hour before surgery, generally three days. If combined with other medical diseases, symptomatic drug treatment should be given.
IV. Rehabilitation treatment
(a) After repositioning and fixation, the quadriceps contraction and ankle extension and flexion activities can be performed.
(2) For those with external fixation and internal fixation, if the fracture end is stable, you can get out of bed after 1 week without weight-bearing lower extremity booth activities, after 4 weeks with semi-weight-bearing activities, and after 6-8 weeks with weight-bearing activities; for those with traction treatment, wait for the fracture to heal and the steel pins to be removed, and then support the double crutches with light weight-bearing activities.
(c) After half a year, the patient can gradually bear weight with the help of a single crutch.
[Efficacy evaluation criteria]
The evaluation criteria were based on the subjective symptoms, objective signs of both lower limbs and their functional recovery, and the efficacy grade was evaluated according to the total score obtained.
(A) Subjective symptoms: no pain, walking freely, 4 points; no pain at rest, occasional pain when walking, 3 points; occasional pain at rest, aggravated by walking, 2 points; frequent pain, unable to walk or requiring oral painkillers for relief, 1 point.
(B) Objective signs of both lower limbs were scored: the range of flexion and extension of the affected hip joint, whether the muscles of the affected limbs were atrophied, muscle strength and whether both lower limbs were equal in length were carefully examined, as shown in Table 1.
(iii) Functional score of both lower limbs: carefully observe the patient’s gait and ask whether the patient walked with or without crutches as well as walking up and down stairs, squatting and wearing shoes and socks. The specific scores are shown in Table 2.
(D) Assessment of patient’s efficacy: 39-44 as excellent; 28-38 as good; 18-27 as acceptable; less than 18 as poor. More serious complications such as compression screw penetration out of the femoral head, severe hip inversion deformity, internal fixation fracture or secondary femoral fracture were not involved in the scoring and were treated as poor efficacy.