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Fractures of the Trochanteric Region of the Femur
Fractures of the Trochanteric Region of the Femur KENNETH T. HUBBARD, M.D., F.A.C.S.*
Not much has been written on the subject of intertrochanteric fractures when compared to the wealth of literature on intracapsular fractures. It is rather perfunctorily admitted that they heal almost with certainty if the patient survives. Since they occur as a rule, however, in patients about 472 years older than the average for intracapsular fractures the importance of effective "survival" treatment to the geriatric patient is very great. Fractures in the region of the trochanters may be grouped to include subtrochanteric, peritrochanteric and intertrochanteric varieties. Grouping them and calling them "trochanteric" fractures, as Hugh Smith does, is completely justified, both from the point of view of prognosis and modern treatment. Included are fractures from the extracapsular part of the neck to 2 inches distal to the lesser trochanter. Theories of defective circulation of the head, neck and trochanteric region of the femur are manifold. The time-honored theory is that ischemia of the head and neck is present and progresses in some persons to the point of fracture. In contradistinction to intracapsular fractures, we do know that we can practically guarantee healing of the trochanteric variety provided the patient survives and the fracture is not pathological. It is logical in these circumstances to postulate that fractures in this region are not due to circulatory deficiency and are therefore usually traumatic in origin. In the case of intracapsular fractures we know the circulation is deficient; fracture is merely an episode along the road of ischemia; and unphysiological trauma mayor may not enter into its production. On this basis, it would almost seem legitimate to regard the intracapsular fractures as pathological and explain the poor prognosis on the basis of continuing ischemia with a liminal margin of repair potential. Appealing as this may be, the recent work of Trueta indicates that there is no quantitative
* Attending Surgeon, West Suburban Hospital, Oak Park, Illinois; Attending Staff, Westlake Hospital, Melrose Park, Illinois
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decrease in circulation within the femoral head with advancing age, so that revision in thinking may be necessary. Historically, trochanteric fractures are, of course, confused with intracapsular fractures, although Ambroise Pare (1510-1590) was supposed to have differentiated fractures of the neck of the femur as a separate entity and treated them with longitudinal traction. Sir Astley Cooper (17681841) definitely distinguished between intracapsular and extracapsular fractures and also recognized the difference in prognosis. He went contrary to the practice of extension splinting, which was the accepted practice of his time, and concentrated on saving lives by more mobilization even if fewer unions eventuated. The treatment continued on down the years with modifications in methods of extension and traction and no differentiation in treatment of intra- and extracapsular fractures. It is interesting to note, even in Jones and Lovett's Orthopedic Surgery (Second Edition), that fractures of the neck are classed as "basal" and "subcapital" instead of extra- and intracapsular; and all others are considered as shaft fractures. All these fractures are treated by them, when fresh, by manipulation and a spica cast, or splint, in abduction and internal rotation. Standard treatises on fractures of the years 1949 to 1955 still advocate traction as a preferable treatment except in certain instances, usually concerned with inadequate nursing or other facilities involved in the care of the aged.
MECHANISM AND CLASSIFICATION
The mechanics involved in and around the hip joint are, of course, very complex. From the point of view of the present article we may reduce them to simple forces and stresses on bone in weight bearing. One notes that the weight of the individual in the simple vertical plane is carried through an oblique member to an offset vertical column, and the stress trabeculae of the trochanter and neck are aligned to give maximum strength to support this offset (Fig. 1). The calcar femorale is the key member in the problems of both normal physiological support and internal fixation of intracapsular fractures, as will be noted later. From this it is also noted that mechanically there is the least offset and the least angular stress applied in the femora with the greatest valgus position to the neck. The mechanism of fracture in the senior citizen is an interesting problem for speculation. As noted previously, trochanteric fractures are probably due primarily to direct trauma. Seldom is a patient seen with one of these fractures who has not fallen directly on the trochanter. Also, it is interesting to note that fractures about the hip are almost always either completely intracapsular or extracapsular. There may be extensive comminution to the trochanteric fracture but it never involves the intracapsular neck portion. We may go back to our previous theory and say that the
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trochanteric region fracture is the hip fracture characteristic of patients with comparatively normal circulation in the femoral neck and headotherwise they would have had an intracapsular fracture at an earlier age. This consideration also pushes the intracapsular fracture farther into the pathological realm and establishes the trochanteric fracture as opposed to the pathological neck fracture. Boyd and Griffin have classified fractures about the trochanter into four types, as follows (Fig. 2): TYPE 1. Fractures extending along the intertrochanteric line from the greater to the lesser trochanter. Reduction of this type of fracture is usually simple and is maintained with little difficulty. Results are generally satisfactory. TYPE II. Comminuted fractures, the main fracture line being along the intertrochanteric line but with multiple fractures in the cortex. Reduction of these fractures is more difficult since the comminution may vary from slight to extreme. A particularly deceptive form is the fracture in which an anteroposterior linear intertrochanteric fracture line occurs, as in
Figure 1. X-ray of a normal pelvis in an older person showing how trabecular patterns in the trochanter, neck, head and acetabulum develop in response to stress placed upon them.
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Type I
Type II
Type III
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Type IV
Figure 2. Four types of fractures about the trochanters according to classification of Boyd and Griffin. (From Boyd, H. B., and Griffin, L. L.: A.M.A. Arch. Surg. 58: 853, 1949.)
Type I, but with an additional fracture in the coronal plane, seen on the lateral roentgenogram. TYPE III. Fractures that are basically subtrochanteric, with at least one fracture line passing across the proximal end of the shaft just distal to or at the lesser trochanter. Varying degrees of comminution are associated. These fractures are usually much more difficult to reduce and result in more complications, both at operation and during convalescence. TYPE IV. Fractures of the trochanteric region and the proximal shaft, with fracture lines in at least two planes. If open reduction and internal fixation are used, two-plane fixation is required because of the spiral, oblique, or butterfly fracture of the shaft. Supposedly Type III and Type IV account for only about one-third of all the trochanteric fractures. As mentioned previously, the probability of healing of fractures about the trochanter is, as others have found, practically 100 per cent in the cases not complicated by pathological processes. In the author's present series consisting of 92 recent consecutive cases of trochanteric fractures, there were only two which did not proceed to union when the patient survived. One of these was due to septic involvement and the other could not be ascribed to anything except that the fracture was really probably a low intracapsular fracture and there was definitely movement about the fixation device. Of this group, all survived the surgical procedure as such; one with cardiac disease expired the day of operation, two others expired on the first postoperative day, but all the rest known to have expired did so after recovery from the surgery.
TREATMENT BY TRACTION
Fractures through the intertrochanteric region occur at any age. In the younger age groups they are traumatic in origin. In children they are
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usually in the low femoral neck region, probably the extracapsular portion. There is seldom any displacement here and immobilization in a plaster spica for six to eight weeks gives good union. However, these fractures are reputed to have a surprisingly high incidence of complicating avascular necrosis of the femoral head which manifests itself as, and must be treated like, Perthes' disease. In the middle-aged healthy person, since immobilization carries no great threat to life and the prognosis for healing is so good, Buck's skin type traction or skeletal traction is completely acceptable. This type of fracture must have good, effective traction. Whereas intracapsular fractures ordinarily maintain an intact capsule and the loss in continuity of the femoral neck results primarily in a varus and moderate rotational deformity, in the intertrochanteric and lower fractures we have to contend with the unopposed action of the abductors, external rotators, and flexors. This fact makes a good effective traction-countertraction set-up necessary in order to maintain satisfactory alignment. This may be achieved in a satisfactory manner with Buck's extension in a Russell set-up or a counterbalanced Thomas splint with a Pearson attachment (Figs. 3 and 4). In using Russell's traction it should always be borne in mind that the actual longitudinal pull on the leg is twice the weight used, owing to the multiple pulley ("block-and-tackle") effect, hence the "pull" is twice the "lift." Thus, in a system in which the leg is horizontal and the sling is vertical, a resultant pull of 2.2 times the weight is acting at about 26 degrees to the horizontal. In other words, if 8 pounds of traction weight are used, there is actually 18 pounds of longitudinal traction. This is a point frequently not considered by many workers who use this traction system repeatedly. On the other hand, the pull of Buck's extension on a leg over a bent-knee, balancedtraction system will similarly be reduced in the line of the femur. Thus the same 8-pound weight would give only about 7 pounds of traction in the line of the femur if the hip and knee were flexed at the same 26 degrees. This type of treatment is the method of choice by many eminent orthopedists in younger as well as older patients with fractures about the trochanters. One indication for open reduction in younger persons is the possibility of interposition of soft tissues which will lead to nonunion.
TREATMENT BY INTERNAL FIXATION
Internal fixation has come a long way since Langenbeck, in 1850, first attempted to fix a femoral head by a nail through the trochanter. Many additional attempts were made to do this over the next 75 years-all ending either in complete failure or very questionable success. Bick attributes this lack of success to two causes: One was "aim" with lack of fixation and improper reduction, and the other was rotatory motion of the femoral head on any nail. Both of these problems were therefore purely mechanical,
Fig. 3
Fig. 4 Figure 3. A "balanced" Thomas splint with Buck's extension for longitudinal traction. Figure 4. Russell's traction. A simple and effective traction especially for short term use. (Both illustrations from Scuderi, Carlo: Atlas of Orthopaedic Traction Procedures. C. V. Mosby, St. Louis, 1954.)
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relating (1) to the technique of reduction and fixation and (2) to the design of equipment. A third large factor was also present-one of metallurgy, namely, obtaining a physiologically inert alloy. Through the years, after satisfactory fixation hardware was available for fractures of the femoral neck, it was natural that attempts should be made to use the same devices for extracapsular fractures. A moment's consideration of the problem will show why this type of fixation will be unsatisfactory. The trochanter is cancellous bone with a rather thin cortex even distally where fixation pins or a nail would enter. Success for any of these penetrating nails depends upon the presence of an intact calcar femorale for support to give the nail angular stability (Fig. 5, A). If this calcar is gone there is no way of holding a solid angle of inclination (Fig. 5, B) without anchoring the piece to the shaft by some device that rigidly fixes the angle (Fig. 5, C). If one were to classify devices in use about the hip, they might be broadly divided into "unanchored" and "anchored" types. In the first group we would include the single nails of the flanged or other varieties and the multiple pins, screws, wires and similar devices put through the lateral trochanteric cortex into the neck and head of the femur. In the "anchored" class would be included the blade or nail-plate varieties which have fixed angles or angles which can be altered by forceful bending. These may be one- or multiple-piece devices which have a plate attached by screws to the femoral shaft for the "anchoring" member, and an upper fixation portion which may be a flanged or telescoping nail, or pins or screws. There are also a few devices that have an adjustable angle which may be fitted to the requirement of the case. What are the requirements of the ideal intertrochanteric fixation device? A consideration of what we are attempting to do will help answer this question. Weare trying to fix this fracture site with a minimum of
A
B
( Calcar femoralis)
Figure 5. Drawing showing the (A) need for nailing intracapsular fractures so that calcar femorale is utilized; (B) the futility of hoping to fix an intertrochanteric fracture with nail only, and (C) the type of anchoring mechanism necessary for firm fixation of these fractures.
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surgical manipulation in this elderly patient and a maximum of strength of fixation so that he may be mobilized as soon as possible. Therefore, we want a nail designed for maximum strength. In general, the three- or fourflanged nails of the Smith-Petersen type, or a telescoping nail of sufficient diameter will adequately serve the purpose. One of the most recently developed nails has a cross section of an "H"-beam and is claimed to have remarkable strength. Another requirement is that the plate be of adequate strength. It should be long enough and rigid enough to give good anchorage and possiblyalso serve to fix comminuted fragments or to cross a subtrochanteric fracture line. One of the most important considerations is the strength of the appliance at the angle. This is where most of the stress on weight bearing is concentrated and where the weight of the patient will be carried if he walks before bony healing is complete. It seems reasonable to assume that any device that permits adjustment of the angle by bending with simple tools cannot possibly be strong enough to bear the patient's weight should circumstances require it. Any suitable appliance should have an effective triangular bracketing reinforcement about the angle. The employment of an adjustable angle in the assembly is optional with the operator. Many of us feel that, by permitting adjustment of the angle of the appliance to fit whatever angle is present after a satisfactory reduction and guide wire position has been obtained, it is of definite advantage to the patient by decreasing operating time. A final requirement is that the appliance interfere as little as possible with the internal bony structure as well as the external bony configuration. We hope that it is superfluous to caution here against the re-use of any hardware used in a previous fixation, regardless of its external appearance. If it has been used even once, its surface is excoriated and it is well along the road to the end point of fatigue. Internal fixation in older people cannot be regarded as elective surgery. It is at least a semi-emergency and frequently has to be done in the face of what would be definite contraindications to an elective procedure. In many of the debilitated persons, a wait of one to two weeks while the internist "gets them into better shape" for surgery may well be fatal. The need to get them mobilized and keep them mobilized is often of compelling urgency-far more than the need for medications. It may well be said that the more debilitated the patient is, the less will he be able to tolerate immobilization in bed. The situation should always be explained to the family so that they understand the relative risks. The patient is ordinarily put in Russell's traction with 8 pounds of weight, and rotation maintained so that the thigh is in neutral position as judged by the position of the patella. A complete work-up including routine portable chest x-rays is then done and the patient is usually ready for operation in one to three days. The question of routine transfusions in surgery is frequently debated.
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The tendency now is to give additional blood only if absolutely necessary; but it is a good policy to order blood routinely preoperatively so that it will be readily available if needed-and it frequently is needed. Adequate operating room personnel and facilities are very important if this procedure is to be accomplished in the minimum time. First and foremost, an experienced anesthesiologist is a "must." Anesthesia in geriatric patients is a science and art of its own. Spinal anesthesia may in some instances be necessary but also is not without risk. The operation is possible entirely under local anesthesia but it is not advised. A fracture table with attachments for applying traction and controlled rotation to the leg is necessary. It is also highly desirable to have adequate x-ray facilities in the operating room. An ideal arrangement is to have a fixed overhead x-ray tube and a cassette tunnel on the table to take the anteroposterior views; and a portable x-ray head either clamped to the table or wheeled into position and draped off, which is used for the translateral check x-rays. Film-developing facilities must be close by. Small portable developing tanks with thermostatic temperature controls can be purchased and used in any dark closet. The Polaroid Company has a tensecond processing unit which can be used in the operating room but it gives a print instead of the familiar negative. The total amount of time for taking and developing all the necessary x-rays should not exceed ten to 15 minutes in the average case. Surgical Techniques and Pitfalls
The technique of operation in these fractures is a product of personal experience and success. One should strive for a technique which is, in his hands and with his available facilities, the least traumatic, most rapid, and gives the firmest fixation. Contrary to some writers, this one does not believe it advisable to enter the joint capsule in open reductions of any hip fractures unless, of course, he is inserting a primary prosthesis. A posterolateral approach has been employed by J. A. Caldwell and by Horwitz so that the fracture may be reduced under direct vision. They find it to be quite bloodless and more rapid than the lateral approach; however, the patient is prone and this may make anesthesia a problem., It has, moreover, been this writer's experience that a complete exposure of the fracture site is not necessary in order to accomplish an adequate reduction and good solid union. One of the most popular and successful approaches to the trochanteric region is the direct lateral approach. The patient is mounted upon a fracture table in the usual supine position. Ordinarily, reduction of the fracture may be accomplished by adjusting the traction, rotating the hip externally and then gently rotating internally. Usually the fracture has already been quite adequately reduced by the traction in bed during the preliminary work-up. Detailed descriptions of the operation using the lateral approach and
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guide wires may be found in standard operative orthopedic reference books but comments on various aspects will be made here. Initially, take a set of x-ray views after the patient is mounted on the table and traction is applied. It will usually be found that the best reduction is obtained when the femur is in a position of neutral rotation, with the patella facing straight up. If these x-rays indicate a change in the amount of traction and rotation, this can still be made. If the reduction is satisfactory, the lateral view will be valuable in orienting the operator as to the angle which the neck and head make with the horizontal, thereby aiding him later in estimating the proper direction of insertion of the guide wire. In the more comminuted types of fractures in which the head and neck are a separate fragment, it is important, in order to obtain a reduction, to have a proper rotation of the controllable fragment in relation to the uncontrollable fragment; however, this is not the only factor concerned. The rotation as seen in anteroposterior and translateral views may appear quite acceptable when the patient is lying on a table with the buttocks supported on an x-ray tunnel. However, when he is supported only on a saddle, and has an especially large, heavy thigh, the head and neck will be supported by the saddle, capsule and possibly short rotators, and the distal shaft falls posteriorly purely from the weight of the thigh (Fig. 6). Under these circumstances it is necessary to support the distal shaft somehow while fixation is being accomplished. In trying to correct this type of deformity, one may improve the x-ray appearance insofar as approximation is concerned by increasing rotation, which if excessive causes a tightening of the soft tissues across the fracture site. The end result in an extreme case is fixation of the fractured surface of the proximal fragment to the anterior surface of the trochanter. In less extreme cases the anterior portion of the fracture is approximated, whereas the posterior portion is wide open. The question of placement of guide wires is also important. In these fractures there is no mechanical advantage in having the nail ride on the calcar femorale. The optimal position for the nail is with the end solidly in the femoral neck and head. In picking a location to insert the guide wire, the author finds that he can usually palpate the base of the neck through the lateral incision and then observe the contour of the lateral trochanteric region. The desired point of insertion in the shaft is where it starts to flare out at the greater trochanter. If fixed angle devices are used, guides of various sorts must be employed to set the guide wire at the proper angle, and there is no flexibility in the procedure from this point on. When adjustable angle equipment is used, placement of the guide wire is much simplified. One can drill a hole larger than the wire; then, using the wire as a probe, he may feel for the central canal of the neck. Then the wire is driven into the head until a change in tone as the wire is pounded indicates that the proper depth has been reached. Some other considerations in the use of guide wires may also be noted.
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The guide wire may with impunity be put through the fracture site, provided it ends up in the region desired and the possible subsequent complications are prevented, as discussed later. If there is any doubt about the proper location of the wire, one may place two wires and then choose the best one as shown by the x-ray check-up. Before a nail is driven over the guide wire, it is highly advisable either to use a reamer to cut a larger hole or to cut a window around the guide wire. Gross comminution may result from forcefully inserting the nail over the wire. If the upper fragment should be accidentally split, there is ordinarily no great cause for alarm as long as the fragment remains stable or is made so. In fact, the more highly comminuted fractures heal with a much greater volume of callus and apparently just as rapidly. In driving a nail over a guide wire, one must be sure to align the nail-driver assembly with the wire and continue to hold this alignment insofar as possible during the driving. In other words, do not depend upon the guide to be a guide in spite of the operator. In the main, there are two rather common aggravations which result from this type of neglect. If the end of the wire is firmly embedded in the head and the nail catches the shaft and forces it at a different angle, the end result shown in Figure 7,
Figure 6. Lateral view x-rays demonstrating 2 types of deformity of a fracture site. These are caused primarily by weight of the thigh on an unstable fracture site when the hip is lying unsupported on a traction table. A, Complete posterior displacement of the distal fragment. B, Increase in anteversion of neck on trochanter.
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Figure 7. A, B, Two types of difficulties resulting from driving a nail with incorrect alignment over a guide wire.
A, is obtained. If the nail catches on the shaft farther laterally, it may just force the wire ahead of it and one ends up with a rather disconcerting x-ray of a wire penetrating the acetabulum and often the abdomen (Fig. 7, B). If, at any stage, driving is met with excessive resistance, the operator must stop and assess the situation and make the necessary corrections. For this reason it is preferable to use smooth, unnicked guide wires and not the so-called measured wires that have rings etched around them at intervals. The nicks or etchings make it that much easier for a nail to catch the wire and cause some of the above complications. In the use of the angle fixation devices the fact that the fracture site happens to pass through the region where the guide wire or nail is placed is quite immaterial since the effectiveness of the fixation depends upon a firm grip on the head-neck complex and the shaft. It is nevertheless important that, in these completely separated fractures, the proximal fragment should be prevented from drifting down on the device so that the nail or blade penetrates the acetabulum. This may be accomplished by using either auxiliary buttressing equipment or a plate designed to prevent this deformity from occurring (Figs. 8 and 9). Much of our modern success with metal implants is due to research in physiology and metallurgy. Although the metals used are practically inert physiologically, different alloys may still develop enough potential between them so that over a long period of time destructive effects may occur. Consequently, alloys should not be mixed in the same implant. Also, in using metals, it is necessary to remember the limitations of such physical equipment. Metal is subject to fatigue and if excess stress or motion is applied it will sooner or later break. In hips, therefore, allow weight bearing in accordance with the physical characteristics of the equipment used. Do not •.try to force a plate or device into a configuration not intended for it;
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Figure 8. Extra buttress used to prevent sliding of proximal fragment down on nail. (From Boyd, H. B., and Anderson, L. D.: Burg., Gynec. & Obst. 112: 633, 1961, by permission.)
Figure 9. Model showing the "buttressing" effect which is part of the plate in one type of naIl-plate assembly.
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Figure 10. A case of failure of union probably due to distraction of the fracture site by the nail. A, Original fracture. B, Fixation 8 weeks postoperatively. C, Fourteen weeks postoperatively. Note fracture of last screw. D, Twenty-two weeks postoperatively. Note fractures of 4 of the 5 screws. E, Lateral view shows the distraction. F, Exactly 1 year later.
failure is bound to result. Use a tap drill of correct size for screws, then do not try to tighten the screws to the limit of the personal strength of the operator-snug them down comfortably tight and stop. In the case of nonpathological fracture, lack of successful bony healing is due either to failure of bone to unite or to failure of the equipment, or to both. One occasionally sees cases of nonunion or bony absorption with settling down on the nail in cases which apparently were technically well handled. Failure of bony healing in the vast majority of unsuccessful cases is due to a combination of both causes. The original nailing was not well enough fixed, or excessive stress was put on the nail too soon afterward, or the nail caused distraction. This resulted in delay in bony union which forced the equipment beyond its limit of fatigue or stress. Figure 10 shows this situation progressing step by step. Other causes for failure are pathological fractures, postoperative infections, and uncontrollable postoperative routine.
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Postoperative Care The postoperative management of these fractures is quite simple but must be fitted to the individual. On the second or third day the patient is put into a wheel chair. As soon as he is able to tolerate the discomfort, usually about the third or fourth postoperative day, he is started on active exercise in flexion and extension in this hip as well as quadriceps knee exercises. A bit of prodding and reassurance is usually needed to get this routine started. The patient is started in a walker with no weight bearing on the affected leg as soon as his general condition permits. How soon partial weight bearing is allowed is somewhat dependent upon the apparatus used. In general, weight bearing is prohibited until three months postoperatively. Then, if x-rays show satisfactory union, it is started and rapidly increased to complete weight bearing.
SUMMARY Fractures about the trochanters of the femur have a very good prognosis, supposedly because of the good circulation present. Treatment by traction is acceptable provided that the patient's age or condition warrants it, but it must be used only where constant, expert care is available. Typically, these fractures occur in an older age group than do the intracapsular variety so it is that much more important to keep the patient mobilized while healing takes place. Therefore, operation is regarded as a semi-emergency. In this age group it is also necessary to reduce the operating time to a minimum. This is done by having at hand (1) an experienced anesthesiologist, (3) adequate equipment, including x-ray facilities, and (3) experienced surgical assistance. Choice of an internal fixation device depends primarily upon strength of the device and experience and facility in its insertion. An understanding of the mechaniCs involved in each individual case is essential. Postoperative care is simple in principle but often difficult in execution. The patient should be given active exercises as soon as possible and allowed up with no weight bearing on the affected leg. Weight bearing is permitted when there is x-ray evidence of firm union.
REFERENCES Albright, F. and Reifenstein, E. C., Jr.: The Parathyroid Glands and Metabolic Bone Disease. Baltimore, Williams & Wilkins Co., 1948. Bick, E.: Source Book of Orthopaedics. Baltimore, Williams & Wilkins Co., 1948.
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Campbell's Operative Orthopaedics. 4th Ed. St. Louis, C. V. Mosby Co., 1963. Horwitz, Thomas: The posterolateral approach in the surgical management of basilar neck, intertrochanteric and subtrochanteric fractures of the femur. Surg. Gynec. & Obst. 95: 45, 1952. Howorth, M. B.: Textbook of Orthopedics. Philadelphia, W. B. Saunders Co., 1952. Hubbard, K. T.: A "contoured" device for fixation of intertrochanteric fractures. J. Bone & Joint Surg. 44A: 1170, 1962. Jones, Sir Robert and Lovett, R. W.: Orthopedic Surgery. 2nd Ed. New York, William Wood & Co., 1933. Magnuson, P. B. and Stack, J. K.: Fractures. 5th Ed. Philadelphia, J. B. Lippincott Co., 1949. Mercer, Sir Walter: Orthopaedic Surgery. 5th Ed. Baltimore, Williams & Wilkins Co., 1959. Scuderi, Carlo: Atlas of Orthopaedic Traction Procedures. St. Louis, C. V. Mosby Co., 1954. Trueta, Joseph: The normal vascular anatomy of the human femoral head during growth. J. Bone & Joint Surg. 39B: 358, 1957. Trueta, J. and Harrison, M. H. M.: The normal vascular anatomy of the femoral head in adult man. J. Bone & Joint Surg. 35B: 442, 1953. Turek, S. L.: Orthopaedics. Philadelphia, J. B. Lippincott Co., 1959. Watson-Jones, Sir Reginald: Fractures and Joint Injuries. 4th Ed. Baltimore, Williams & Wilkins Co., 1955. 715 Lake Street Oak Park, lllinois
Not much has been written on the subject of intertrochanteric fractures when compared to the wealth of literature on intracapsular fractures. It is rather perfunctorily admitted that they heal almost with certainty if the patient survives. Since they occur as a rule, however, in patients about 472 years older than the average for intracapsular fractures the importance of effective "survival" treatment to the geriatric patient is very great. Fractures in the region of the trochanters may be grouped to include subtrochanteric, peritrochanteric and intertrochanteric varieties. Grouping them and calling them "trochanteric" fractures, as Hugh Smith does, is completely justified, both from the point of view of prognosis and modern treatment. Included are fractures from the extracapsular part of the neck to 2 inches distal to the lesser trochanter. Theories of defective circulation of the head, neck and trochanteric region of the femur are manifold. The time-honored theory is that ischemia of the head and neck is present and progresses in some persons to the point of fracture. In contradistinction to intracapsular fractures, we do know that we can practically guarantee healing of the trochanteric variety provided the patient survives and the fracture is not pathological. It is logical in these circumstances to postulate that fractures in this region are not due to circulatory deficiency and are therefore usually traumatic in origin. In the case of intracapsular fractures we know the circulation is deficient; fracture is merely an episode along the road of ischemia; and unphysiological trauma mayor may not enter into its production. On this basis, it would almost seem legitimate to regard the intracapsular fractures as pathological and explain the poor prognosis on the basis of continuing ischemia with a liminal margin of repair potential. Appealing as this may be, the recent work of Trueta indicates that there is no quantitative
* Attending Surgeon, West Suburban Hospital, Oak Park, Illinois; Attending Staff, Westlake Hospital, Melrose Park, Illinois
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decrease in circulation within the femoral head with advancing age, so that revision in thinking may be necessary. Historically, trochanteric fractures are, of course, confused with intracapsular fractures, although Ambroise Pare (1510-1590) was supposed to have differentiated fractures of the neck of the femur as a separate entity and treated them with longitudinal traction. Sir Astley Cooper (17681841) definitely distinguished between intracapsular and extracapsular fractures and also recognized the difference in prognosis. He went contrary to the practice of extension splinting, which was the accepted practice of his time, and concentrated on saving lives by more mobilization even if fewer unions eventuated. The treatment continued on down the years with modifications in methods of extension and traction and no differentiation in treatment of intra- and extracapsular fractures. It is interesting to note, even in Jones and Lovett's Orthopedic Surgery (Second Edition), that fractures of the neck are classed as "basal" and "subcapital" instead of extra- and intracapsular; and all others are considered as shaft fractures. All these fractures are treated by them, when fresh, by manipulation and a spica cast, or splint, in abduction and internal rotation. Standard treatises on fractures of the years 1949 to 1955 still advocate traction as a preferable treatment except in certain instances, usually concerned with inadequate nursing or other facilities involved in the care of the aged.
MECHANISM AND CLASSIFICATION
The mechanics involved in and around the hip joint are, of course, very complex. From the point of view of the present article we may reduce them to simple forces and stresses on bone in weight bearing. One notes that the weight of the individual in the simple vertical plane is carried through an oblique member to an offset vertical column, and the stress trabeculae of the trochanter and neck are aligned to give maximum strength to support this offset (Fig. 1). The calcar femorale is the key member in the problems of both normal physiological support and internal fixation of intracapsular fractures, as will be noted later. From this it is also noted that mechanically there is the least offset and the least angular stress applied in the femora with the greatest valgus position to the neck. The mechanism of fracture in the senior citizen is an interesting problem for speculation. As noted previously, trochanteric fractures are probably due primarily to direct trauma. Seldom is a patient seen with one of these fractures who has not fallen directly on the trochanter. Also, it is interesting to note that fractures about the hip are almost always either completely intracapsular or extracapsular. There may be extensive comminution to the trochanteric fracture but it never involves the intracapsular neck portion. We may go back to our previous theory and say that the
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trochanteric region fracture is the hip fracture characteristic of patients with comparatively normal circulation in the femoral neck and headotherwise they would have had an intracapsular fracture at an earlier age. This consideration also pushes the intracapsular fracture farther into the pathological realm and establishes the trochanteric fracture as opposed to the pathological neck fracture. Boyd and Griffin have classified fractures about the trochanter into four types, as follows (Fig. 2): TYPE 1. Fractures extending along the intertrochanteric line from the greater to the lesser trochanter. Reduction of this type of fracture is usually simple and is maintained with little difficulty. Results are generally satisfactory. TYPE II. Comminuted fractures, the main fracture line being along the intertrochanteric line but with multiple fractures in the cortex. Reduction of these fractures is more difficult since the comminution may vary from slight to extreme. A particularly deceptive form is the fracture in which an anteroposterior linear intertrochanteric fracture line occurs, as in
Figure 1. X-ray of a normal pelvis in an older person showing how trabecular patterns in the trochanter, neck, head and acetabulum develop in response to stress placed upon them.
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Type I
Type II
Type III
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Type IV
Figure 2. Four types of fractures about the trochanters according to classification of Boyd and Griffin. (From Boyd, H. B., and Griffin, L. L.: A.M.A. Arch. Surg. 58: 853, 1949.)
Type I, but with an additional fracture in the coronal plane, seen on the lateral roentgenogram. TYPE III. Fractures that are basically subtrochanteric, with at least one fracture line passing across the proximal end of the shaft just distal to or at the lesser trochanter. Varying degrees of comminution are associated. These fractures are usually much more difficult to reduce and result in more complications, both at operation and during convalescence. TYPE IV. Fractures of the trochanteric region and the proximal shaft, with fracture lines in at least two planes. If open reduction and internal fixation are used, two-plane fixation is required because of the spiral, oblique, or butterfly fracture of the shaft. Supposedly Type III and Type IV account for only about one-third of all the trochanteric fractures. As mentioned previously, the probability of healing of fractures about the trochanter is, as others have found, practically 100 per cent in the cases not complicated by pathological processes. In the author's present series consisting of 92 recent consecutive cases of trochanteric fractures, there were only two which did not proceed to union when the patient survived. One of these was due to septic involvement and the other could not be ascribed to anything except that the fracture was really probably a low intracapsular fracture and there was definitely movement about the fixation device. Of this group, all survived the surgical procedure as such; one with cardiac disease expired the day of operation, two others expired on the first postoperative day, but all the rest known to have expired did so after recovery from the surgery.
TREATMENT BY TRACTION
Fractures through the intertrochanteric region occur at any age. In the younger age groups they are traumatic in origin. In children they are
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usually in the low femoral neck region, probably the extracapsular portion. There is seldom any displacement here and immobilization in a plaster spica for six to eight weeks gives good union. However, these fractures are reputed to have a surprisingly high incidence of complicating avascular necrosis of the femoral head which manifests itself as, and must be treated like, Perthes' disease. In the middle-aged healthy person, since immobilization carries no great threat to life and the prognosis for healing is so good, Buck's skin type traction or skeletal traction is completely acceptable. This type of fracture must have good, effective traction. Whereas intracapsular fractures ordinarily maintain an intact capsule and the loss in continuity of the femoral neck results primarily in a varus and moderate rotational deformity, in the intertrochanteric and lower fractures we have to contend with the unopposed action of the abductors, external rotators, and flexors. This fact makes a good effective traction-countertraction set-up necessary in order to maintain satisfactory alignment. This may be achieved in a satisfactory manner with Buck's extension in a Russell set-up or a counterbalanced Thomas splint with a Pearson attachment (Figs. 3 and 4). In using Russell's traction it should always be borne in mind that the actual longitudinal pull on the leg is twice the weight used, owing to the multiple pulley ("block-and-tackle") effect, hence the "pull" is twice the "lift." Thus, in a system in which the leg is horizontal and the sling is vertical, a resultant pull of 2.2 times the weight is acting at about 26 degrees to the horizontal. In other words, if 8 pounds of traction weight are used, there is actually 18 pounds of longitudinal traction. This is a point frequently not considered by many workers who use this traction system repeatedly. On the other hand, the pull of Buck's extension on a leg over a bent-knee, balancedtraction system will similarly be reduced in the line of the femur. Thus the same 8-pound weight would give only about 7 pounds of traction in the line of the femur if the hip and knee were flexed at the same 26 degrees. This type of treatment is the method of choice by many eminent orthopedists in younger as well as older patients with fractures about the trochanters. One indication for open reduction in younger persons is the possibility of interposition of soft tissues which will lead to nonunion.
TREATMENT BY INTERNAL FIXATION
Internal fixation has come a long way since Langenbeck, in 1850, first attempted to fix a femoral head by a nail through the trochanter. Many additional attempts were made to do this over the next 75 years-all ending either in complete failure or very questionable success. Bick attributes this lack of success to two causes: One was "aim" with lack of fixation and improper reduction, and the other was rotatory motion of the femoral head on any nail. Both of these problems were therefore purely mechanical,
Fig. 3
Fig. 4 Figure 3. A "balanced" Thomas splint with Buck's extension for longitudinal traction. Figure 4. Russell's traction. A simple and effective traction especially for short term use. (Both illustrations from Scuderi, Carlo: Atlas of Orthopaedic Traction Procedures. C. V. Mosby, St. Louis, 1954.)
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relating (1) to the technique of reduction and fixation and (2) to the design of equipment. A third large factor was also present-one of metallurgy, namely, obtaining a physiologically inert alloy. Through the years, after satisfactory fixation hardware was available for fractures of the femoral neck, it was natural that attempts should be made to use the same devices for extracapsular fractures. A moment's consideration of the problem will show why this type of fixation will be unsatisfactory. The trochanter is cancellous bone with a rather thin cortex even distally where fixation pins or a nail would enter. Success for any of these penetrating nails depends upon the presence of an intact calcar femorale for support to give the nail angular stability (Fig. 5, A). If this calcar is gone there is no way of holding a solid angle of inclination (Fig. 5, B) without anchoring the piece to the shaft by some device that rigidly fixes the angle (Fig. 5, C). If one were to classify devices in use about the hip, they might be broadly divided into "unanchored" and "anchored" types. In the first group we would include the single nails of the flanged or other varieties and the multiple pins, screws, wires and similar devices put through the lateral trochanteric cortex into the neck and head of the femur. In the "anchored" class would be included the blade or nail-plate varieties which have fixed angles or angles which can be altered by forceful bending. These may be one- or multiple-piece devices which have a plate attached by screws to the femoral shaft for the "anchoring" member, and an upper fixation portion which may be a flanged or telescoping nail, or pins or screws. There are also a few devices that have an adjustable angle which may be fitted to the requirement of the case. What are the requirements of the ideal intertrochanteric fixation device? A consideration of what we are attempting to do will help answer this question. Weare trying to fix this fracture site with a minimum of
A
B
( Calcar femoralis)
Figure 5. Drawing showing the (A) need for nailing intracapsular fractures so that calcar femorale is utilized; (B) the futility of hoping to fix an intertrochanteric fracture with nail only, and (C) the type of anchoring mechanism necessary for firm fixation of these fractures.
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surgical manipulation in this elderly patient and a maximum of strength of fixation so that he may be mobilized as soon as possible. Therefore, we want a nail designed for maximum strength. In general, the three- or fourflanged nails of the Smith-Petersen type, or a telescoping nail of sufficient diameter will adequately serve the purpose. One of the most recently developed nails has a cross section of an "H"-beam and is claimed to have remarkable strength. Another requirement is that the plate be of adequate strength. It should be long enough and rigid enough to give good anchorage and possiblyalso serve to fix comminuted fragments or to cross a subtrochanteric fracture line. One of the most important considerations is the strength of the appliance at the angle. This is where most of the stress on weight bearing is concentrated and where the weight of the patient will be carried if he walks before bony healing is complete. It seems reasonable to assume that any device that permits adjustment of the angle by bending with simple tools cannot possibly be strong enough to bear the patient's weight should circumstances require it. Any suitable appliance should have an effective triangular bracketing reinforcement about the angle. The employment of an adjustable angle in the assembly is optional with the operator. Many of us feel that, by permitting adjustment of the angle of the appliance to fit whatever angle is present after a satisfactory reduction and guide wire position has been obtained, it is of definite advantage to the patient by decreasing operating time. A final requirement is that the appliance interfere as little as possible with the internal bony structure as well as the external bony configuration. We hope that it is superfluous to caution here against the re-use of any hardware used in a previous fixation, regardless of its external appearance. If it has been used even once, its surface is excoriated and it is well along the road to the end point of fatigue. Internal fixation in older people cannot be regarded as elective surgery. It is at least a semi-emergency and frequently has to be done in the face of what would be definite contraindications to an elective procedure. In many of the debilitated persons, a wait of one to two weeks while the internist "gets them into better shape" for surgery may well be fatal. The need to get them mobilized and keep them mobilized is often of compelling urgency-far more than the need for medications. It may well be said that the more debilitated the patient is, the less will he be able to tolerate immobilization in bed. The situation should always be explained to the family so that they understand the relative risks. The patient is ordinarily put in Russell's traction with 8 pounds of weight, and rotation maintained so that the thigh is in neutral position as judged by the position of the patella. A complete work-up including routine portable chest x-rays is then done and the patient is usually ready for operation in one to three days. The question of routine transfusions in surgery is frequently debated.
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The tendency now is to give additional blood only if absolutely necessary; but it is a good policy to order blood routinely preoperatively so that it will be readily available if needed-and it frequently is needed. Adequate operating room personnel and facilities are very important if this procedure is to be accomplished in the minimum time. First and foremost, an experienced anesthesiologist is a "must." Anesthesia in geriatric patients is a science and art of its own. Spinal anesthesia may in some instances be necessary but also is not without risk. The operation is possible entirely under local anesthesia but it is not advised. A fracture table with attachments for applying traction and controlled rotation to the leg is necessary. It is also highly desirable to have adequate x-ray facilities in the operating room. An ideal arrangement is to have a fixed overhead x-ray tube and a cassette tunnel on the table to take the anteroposterior views; and a portable x-ray head either clamped to the table or wheeled into position and draped off, which is used for the translateral check x-rays. Film-developing facilities must be close by. Small portable developing tanks with thermostatic temperature controls can be purchased and used in any dark closet. The Polaroid Company has a tensecond processing unit which can be used in the operating room but it gives a print instead of the familiar negative. The total amount of time for taking and developing all the necessary x-rays should not exceed ten to 15 minutes in the average case. Surgical Techniques and Pitfalls
The technique of operation in these fractures is a product of personal experience and success. One should strive for a technique which is, in his hands and with his available facilities, the least traumatic, most rapid, and gives the firmest fixation. Contrary to some writers, this one does not believe it advisable to enter the joint capsule in open reductions of any hip fractures unless, of course, he is inserting a primary prosthesis. A posterolateral approach has been employed by J. A. Caldwell and by Horwitz so that the fracture may be reduced under direct vision. They find it to be quite bloodless and more rapid than the lateral approach; however, the patient is prone and this may make anesthesia a problem., It has, moreover, been this writer's experience that a complete exposure of the fracture site is not necessary in order to accomplish an adequate reduction and good solid union. One of the most popular and successful approaches to the trochanteric region is the direct lateral approach. The patient is mounted upon a fracture table in the usual supine position. Ordinarily, reduction of the fracture may be accomplished by adjusting the traction, rotating the hip externally and then gently rotating internally. Usually the fracture has already been quite adequately reduced by the traction in bed during the preliminary work-up. Detailed descriptions of the operation using the lateral approach and
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guide wires may be found in standard operative orthopedic reference books but comments on various aspects will be made here. Initially, take a set of x-ray views after the patient is mounted on the table and traction is applied. It will usually be found that the best reduction is obtained when the femur is in a position of neutral rotation, with the patella facing straight up. If these x-rays indicate a change in the amount of traction and rotation, this can still be made. If the reduction is satisfactory, the lateral view will be valuable in orienting the operator as to the angle which the neck and head make with the horizontal, thereby aiding him later in estimating the proper direction of insertion of the guide wire. In the more comminuted types of fractures in which the head and neck are a separate fragment, it is important, in order to obtain a reduction, to have a proper rotation of the controllable fragment in relation to the uncontrollable fragment; however, this is not the only factor concerned. The rotation as seen in anteroposterior and translateral views may appear quite acceptable when the patient is lying on a table with the buttocks supported on an x-ray tunnel. However, when he is supported only on a saddle, and has an especially large, heavy thigh, the head and neck will be supported by the saddle, capsule and possibly short rotators, and the distal shaft falls posteriorly purely from the weight of the thigh (Fig. 6). Under these circumstances it is necessary to support the distal shaft somehow while fixation is being accomplished. In trying to correct this type of deformity, one may improve the x-ray appearance insofar as approximation is concerned by increasing rotation, which if excessive causes a tightening of the soft tissues across the fracture site. The end result in an extreme case is fixation of the fractured surface of the proximal fragment to the anterior surface of the trochanter. In less extreme cases the anterior portion of the fracture is approximated, whereas the posterior portion is wide open. The question of placement of guide wires is also important. In these fractures there is no mechanical advantage in having the nail ride on the calcar femorale. The optimal position for the nail is with the end solidly in the femoral neck and head. In picking a location to insert the guide wire, the author finds that he can usually palpate the base of the neck through the lateral incision and then observe the contour of the lateral trochanteric region. The desired point of insertion in the shaft is where it starts to flare out at the greater trochanter. If fixed angle devices are used, guides of various sorts must be employed to set the guide wire at the proper angle, and there is no flexibility in the procedure from this point on. When adjustable angle equipment is used, placement of the guide wire is much simplified. One can drill a hole larger than the wire; then, using the wire as a probe, he may feel for the central canal of the neck. Then the wire is driven into the head until a change in tone as the wire is pounded indicates that the proper depth has been reached. Some other considerations in the use of guide wires may also be noted.
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The guide wire may with impunity be put through the fracture site, provided it ends up in the region desired and the possible subsequent complications are prevented, as discussed later. If there is any doubt about the proper location of the wire, one may place two wires and then choose the best one as shown by the x-ray check-up. Before a nail is driven over the guide wire, it is highly advisable either to use a reamer to cut a larger hole or to cut a window around the guide wire. Gross comminution may result from forcefully inserting the nail over the wire. If the upper fragment should be accidentally split, there is ordinarily no great cause for alarm as long as the fragment remains stable or is made so. In fact, the more highly comminuted fractures heal with a much greater volume of callus and apparently just as rapidly. In driving a nail over a guide wire, one must be sure to align the nail-driver assembly with the wire and continue to hold this alignment insofar as possible during the driving. In other words, do not depend upon the guide to be a guide in spite of the operator. In the main, there are two rather common aggravations which result from this type of neglect. If the end of the wire is firmly embedded in the head and the nail catches the shaft and forces it at a different angle, the end result shown in Figure 7,
Figure 6. Lateral view x-rays demonstrating 2 types of deformity of a fracture site. These are caused primarily by weight of the thigh on an unstable fracture site when the hip is lying unsupported on a traction table. A, Complete posterior displacement of the distal fragment. B, Increase in anteversion of neck on trochanter.
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Figure 7. A, B, Two types of difficulties resulting from driving a nail with incorrect alignment over a guide wire.
A, is obtained. If the nail catches on the shaft farther laterally, it may just force the wire ahead of it and one ends up with a rather disconcerting x-ray of a wire penetrating the acetabulum and often the abdomen (Fig. 7, B). If, at any stage, driving is met with excessive resistance, the operator must stop and assess the situation and make the necessary corrections. For this reason it is preferable to use smooth, unnicked guide wires and not the so-called measured wires that have rings etched around them at intervals. The nicks or etchings make it that much easier for a nail to catch the wire and cause some of the above complications. In the use of the angle fixation devices the fact that the fracture site happens to pass through the region where the guide wire or nail is placed is quite immaterial since the effectiveness of the fixation depends upon a firm grip on the head-neck complex and the shaft. It is nevertheless important that, in these completely separated fractures, the proximal fragment should be prevented from drifting down on the device so that the nail or blade penetrates the acetabulum. This may be accomplished by using either auxiliary buttressing equipment or a plate designed to prevent this deformity from occurring (Figs. 8 and 9). Much of our modern success with metal implants is due to research in physiology and metallurgy. Although the metals used are practically inert physiologically, different alloys may still develop enough potential between them so that over a long period of time destructive effects may occur. Consequently, alloys should not be mixed in the same implant. Also, in using metals, it is necessary to remember the limitations of such physical equipment. Metal is subject to fatigue and if excess stress or motion is applied it will sooner or later break. In hips, therefore, allow weight bearing in accordance with the physical characteristics of the equipment used. Do not •.try to force a plate or device into a configuration not intended for it;
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Figure 8. Extra buttress used to prevent sliding of proximal fragment down on nail. (From Boyd, H. B., and Anderson, L. D.: Burg., Gynec. & Obst. 112: 633, 1961, by permission.)
Figure 9. Model showing the "buttressing" effect which is part of the plate in one type of naIl-plate assembly.
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Figure 10. A case of failure of union probably due to distraction of the fracture site by the nail. A, Original fracture. B, Fixation 8 weeks postoperatively. C, Fourteen weeks postoperatively. Note fracture of last screw. D, Twenty-two weeks postoperatively. Note fractures of 4 of the 5 screws. E, Lateral view shows the distraction. F, Exactly 1 year later.
failure is bound to result. Use a tap drill of correct size for screws, then do not try to tighten the screws to the limit of the personal strength of the operator-snug them down comfortably tight and stop. In the case of nonpathological fracture, lack of successful bony healing is due either to failure of bone to unite or to failure of the equipment, or to both. One occasionally sees cases of nonunion or bony absorption with settling down on the nail in cases which apparently were technically well handled. Failure of bony healing in the vast majority of unsuccessful cases is due to a combination of both causes. The original nailing was not well enough fixed, or excessive stress was put on the nail too soon afterward, or the nail caused distraction. This resulted in delay in bony union which forced the equipment beyond its limit of fatigue or stress. Figure 10 shows this situation progressing step by step. Other causes for failure are pathological fractures, postoperative infections, and uncontrollable postoperative routine.
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Postoperative Care The postoperative management of these fractures is quite simple but must be fitted to the individual. On the second or third day the patient is put into a wheel chair. As soon as he is able to tolerate the discomfort, usually about the third or fourth postoperative day, he is started on active exercise in flexion and extension in this hip as well as quadriceps knee exercises. A bit of prodding and reassurance is usually needed to get this routine started. The patient is started in a walker with no weight bearing on the affected leg as soon as his general condition permits. How soon partial weight bearing is allowed is somewhat dependent upon the apparatus used. In general, weight bearing is prohibited until three months postoperatively. Then, if x-rays show satisfactory union, it is started and rapidly increased to complete weight bearing.
SUMMARY Fractures about the trochanters of the femur have a very good prognosis, supposedly because of the good circulation present. Treatment by traction is acceptable provided that the patient's age or condition warrants it, but it must be used only where constant, expert care is available. Typically, these fractures occur in an older age group than do the intracapsular variety so it is that much more important to keep the patient mobilized while healing takes place. Therefore, operation is regarded as a semi-emergency. In this age group it is also necessary to reduce the operating time to a minimum. This is done by having at hand (1) an experienced anesthesiologist, (3) adequate equipment, including x-ray facilities, and (3) experienced surgical assistance. Choice of an internal fixation device depends primarily upon strength of the device and experience and facility in its insertion. An understanding of the mechaniCs involved in each individual case is essential. Postoperative care is simple in principle but often difficult in execution. The patient should be given active exercises as soon as possible and allowed up with no weight bearing on the affected leg. Weight bearing is permitted when there is x-ray evidence of firm union.
REFERENCES Albright, F. and Reifenstein, E. C., Jr.: The Parathyroid Glands and Metabolic Bone Disease. Baltimore, Williams & Wilkins Co., 1948. Bick, E.: Source Book of Orthopaedics. Baltimore, Williams & Wilkins Co., 1948.
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Campbell's Operative Orthopaedics. 4th Ed. St. Louis, C. V. Mosby Co., 1963. Horwitz, Thomas: The posterolateral approach in the surgical management of basilar neck, intertrochanteric and subtrochanteric fractures of the femur. Surg. Gynec. & Obst. 95: 45, 1952. Howorth, M. B.: Textbook of Orthopedics. Philadelphia, W. B. Saunders Co., 1952. Hubbard, K. T.: A "contoured" device for fixation of intertrochanteric fractures. J. Bone & Joint Surg. 44A: 1170, 1962. Jones, Sir Robert and Lovett, R. W.: Orthopedic Surgery. 2nd Ed. New York, William Wood & Co., 1933. Magnuson, P. B. and Stack, J. K.: Fractures. 5th Ed. Philadelphia, J. B. Lippincott Co., 1949. Mercer, Sir Walter: Orthopaedic Surgery. 5th Ed. Baltimore, Williams & Wilkins Co., 1959. Scuderi, Carlo: Atlas of Orthopaedic Traction Procedures. St. Louis, C. V. Mosby Co., 1954. Trueta, Joseph: The normal vascular anatomy of the human femoral head during growth. J. Bone & Joint Surg. 39B: 358, 1957. Trueta, J. and Harrison, M. H. M.: The normal vascular anatomy of the femoral head in adult man. J. Bone & Joint Surg. 35B: 442, 1953. Turek, S. L.: Orthopaedics. Philadelphia, J. B. Lippincott Co., 1959. Watson-Jones, Sir Reginald: Fractures and Joint Injuries. 4th Ed. Baltimore, Williams & Wilkins Co., 1955. 715 Lake Street Oak Park, lllinois