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 (Evans 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 obliquity

Fractures parallel to neck axis &traverse lat. cortex

Subtrochanteric
Three types- Simple, Wedge , Complex
All 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 diseases
1.Pagets disease of bone
2.Primary hyperparathyroidism
3.Osteomalacia
4.Osteoporosis

Localized bone diseases

1. Metastases from carcinoma breast, lung,
kidney, and thyroid.
2. Multiple myeloma
3. Primary bone tumors

MalignantOsteosarcoma
Chondrosarcoma
Benign
Osteoclastoma
Bone 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/CWhat 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
Cushings,Hyperthyroidism,Acromegaly
CVA,fainting
attack,epilepsy,hypoglysemia
7.PDHx- Corticosteroids
8.PSHx-Any previous trauma,any Sx and
complications

9.Menstual Hx10.Allergies11.Immunisation-eg tetanus

12.Family Hx-eg-osteogenesis imperfecta
osteopetrosis
13.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 thighoccasional

Inspection
Skin changes- Redness, swelling
Shape
Position
Scars
Wasting of gluteal and thigh muscles
Palpation
Temperature, tenderness over the joint
Skin, 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

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

1.
2.
3.

Circulatory system
Neurological Examination
Musculoskeletal System

Inspection
Palpation
Percussion
Auscultation

Examination

of Associated Injuries

Wrist #
Head injury
Most frequently associated injuries are
due to patients 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
2views
2joints
2limbs
2times

Rule of As
Anatomy
Articularv
Alignment
Angulation
Apex
Apposition

CT Scan-Not indicated in routine

evaluation

X-ray- Osteoporosis
Pagets Disease
Chondrosarcoma

Lytic lesion Involves the inferior aspect

of the neck and the medial
intertrochanteric area.

Ewing sarcoma.

Entire proximal part of the femur is

filled with mottled sclerotic
densities indicative of a diffuse
pathological process.

CXR , X-ray pelvis, Bone scan Metastasis

Serum Ca Hyperparathyroidism
Osteomalacia
T3,T4Hyperthyroidism

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.)Surgical
2.)Non surgical
Cast bracing
Hip sica cast + traction

Pre operative measures

a)Assessment of the patient
Cormobid factors
Surgical fitness
Risk for anesthesia
b)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 implants
b)Intra medullary implants

Extra medullary devices

1.)Sliding compression screw plate
2.)Dynamic hip screw(DHS) e.g:-DCS
Indications:Fractures with stable configurations
Unstable fractures with an intact lateral cortex

Intra medulary devices

1)Intra medullary hip screw(IMHS)
Cephalomedullary nails
Reconstruction nails(centromedullary)
Indications:Shorter nail-If fracture line doesnt extend more
than 1 to 2cm distal to lesser trochanter
Longer nail-unstable fractures

IMHS

External fixationRarely 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 union

3.) Prevent infections
4.) Wound care
5.) Nutrition- high protein diet

Acute complications
1.
2.
3.

Damage to nerves and blood vessels

Haemorrhage
Other soft tissue damage

Long term complications

1.

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,
II.

May unite with marked lateral rotation of the shaft.

May develop severe coxa vera associated with shortenig.

Treatment

1.

In most cases, can be accepted without treatment.

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.

I.

2.

complications due to treatments

1. casts
-pressure ulcers
-thermal burns
-thrombophlebitis
2.

Internal fixation
-infections
-neurological and vascular injury
-thromboembolic events
-avascular necrosis
-posttraumatic arthritis

Complications of immobilization

Bed sores
2. Hypostatic pneumonia
3. Osteoporosis
4. Hypercalcaemia
5. Hypercaliuria
6. Urolithiasis
7. UTIs
8. Muscle wasting
9. Joint stiffness
10. DVT
11. Pulmonary embolism
12. Psychological depression
1.

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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

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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

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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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