Treatment of trochanteric femoral fractures with special reference to complications

TREATMENT OF TROCHANTERIC FEMORAL FRACTURES WITH SPECIAL REFERENCE TO COMPLICATIONS MOORE MOORE, JR ., M.D. Memphis, Tennessee

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HE purpose of this article is not to advocate any one type of treatment of intertrochanteric femoral fractures but rather

ranged from a twenty-eight year old man to a ninety-seven year old woman ; sex incidence was 142 women to 37 men ; the left hip was in-

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Closed plaster method . No reduction actually, with varus and shortening . FIG . 2 . A good result was obtained by closed plaster spica in this patient . Flc . 3 . Good treatment by Jewett nailing . FIG . 4 . Good treatment by Neufcld nailing. FIG . I .

to present some of the more frequently occurring complications incident to commonly used methods of care and to offer certain general conclusions derived from the study . Also, it is to be remembered that non-union is no problem in this fracture . For our purpose, certain pertinent articles were reviewed, but every attempt was made not to bore us all with another statistical survey . The examples to be shown, both good and bad, came from 179 trochanteric fractures seen at two largely private, general hospitals in Memphis, during the years 1946 to 1950, inclusive . Patients, both private and service, were cared for by some seven or eight qualified orthopedic surgeons trained in different parts of the country ; also some three or four capable general surgeons . The age spread October, 1952

volved in about 65 per cent . Thus we have a fairly representative group from which to draw . For mortality purposes one month postoperative was arbitrarily used as a criterion . In one series (sixty-one), there were nine deaths ; in the other group (118), there were also nine deaths, or a total of to per cent mortality from all methods of treatment . Six of the first nine patients were operative cases ; the others were considered too poor risks . A similar proportion existed in the second series . Of this number one patient died thirty-three days postoperatively, one patient thirty-one and one patient twenty-eight, but they are included . One moribund, non-operated patient treated by plaster boots only also died . Causes of death were listed as : massive hematoma with second-

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5 6 Fie . 5 . Penetration of head by nail and also medial shaft migration .

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Fic . 6 . Apparently adequate nailing, but note comninution and loss of medial buttress . FIG . 9 . Varus deformity, bending of nail ; plate lifted from shaft .

ary infection ; fat embolism ; pulmonary embolus ; uremia ; uremia with cardiac decompensation ; chronic nephritis with uremia ; basilar cerebral hemorrhage ; arteriosclerotic heart disease ; chronic myocarditis ; anemia secondary to hemorrhage ; cerebral embolus ; hypertensive cardiovascular disease ; cardiac decompensation with severe cerebral arteriosclerosis ; bronchopneumonia with heart failure ; bronchopneumonia with cerebral thrombosis . Thus in only three cases was death directly connected with surgery . Too much anesthesia was the cause of a fourth death, the only patient lost on the table . As might be expected from the mortality causes these patients had the usual variety of infirmities incident to old age generally, from hemiplegia to coronary disease . These allied conditions will not be discussed except to say that competent medical help was always secured, and virtually never did they influence the type of treatment . Also, an appreciable percentage of patients had associated injuries, such as Colles' and humeral surgical neck fractures . Methods of treatment were as follows : No treatment in five patients, all died ; skin traction in four patients, all lived ; skin traction plus cast in one patient, lived ; Kirschner wire

traction in one patient, lived ; closed reduction and cast in seven patients, all lived . (Figs . i and 2 .) The remaining 162 cases were operative : one by a Smith-Petersen nail ; eleven by Neufeld nails ; one by Ncufeld nail plus graft (the only non-union), leaving 150 Jewett nailings, using SMO steel nails and screws . The trend of treatment has been and continues to he ever more strongly towards Jewett nailing . Well leg or Russell's traction, Thornton or McLaughlin plates, Blount or Austin Moore blade-plates, threaded wires or screws were not used . (Figs . 3 and 4 .) Two severe and two mild wound infections occurred . Antibiotics systemically and sulfonamides locally were given virtually routinely, plus transfusion at the time of operation . Surgical patients were gotten out of bed by at least the second postoperative day . Hospital stay was from two days (death) to 149 days (severe infection) . Ten patients were hospitalized from 35 to 149 days . Excluding these and deaths, hospital stay was from eight to twentysix days for operated patients . The average now is about ten to fourteen days . The complications noted in almost all cases were decubiti of varying degree, urinary incontinence and urinary retention . Frequently nursing notes were our prime source of such American Journal of Surgery



Moore-Trochanteric Femoral Fractures

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9

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Poor direction and placement of nail, with no engagement of head . FIGS . y and m . Progressive cutting of nail through neck and into acetabulurn . Also collapse of comminuted trochanteric area due to too early weight bearing . (Figures 8, 9 and ro are the same patient .) FIG. 8 .

information . The psychosis of senility initiated by trauma was seen in 8 per cent or more of the cases (ten) . Operation was by no means the constant exciting agent of such, as psychosis was frequently noted preoperatively and also in non-operated patients . No specific treatment gave relief for this distressing condition . The question of fewer psychoses in nailed as opposed to cast cases cannot be answered here because of so few plaster patients, but we are inclined to agree with Cleveland whose series showed that nailing reduces the incidence of psychosis . In this connection several patients were sedated much too much, both by narcotics and barbiturates . Complications (Figs . 5 to i i) peculiar to nailing were : extruded nails, from falling out of bed ; wandering of the shaft ; broken nails (two Neufeld, two Jewett) ; broken drill points ; screw heads twisted off ; protrusion of nail through the head and into acetabulum ; improperly placed nails ; battery action between nail and flange welded on ; battery action between nail and screws ; hematoma ; wound infection ; and thrombophlebitis . This latter condition occurred in six cases, far fewer than had been supposed . All patients responded promptly to lumbar sympathetic block . Pulmonary October, 1952

r . This patient walked the second postoperative day. Nailing is not everything but nail was well placed in this patient . Also note broken drill point. FIG . I

embolus (massive) and multiple fat embolism each occurred but once, and each was promptly fatal .

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The type of fracture involved was seen to exert a definite influence on the final result whether nailed or not . Those patients in whom the integrity of the medial cortex was retained all had good results, with little or no shortening, varus or protrusion of the nail. Those patients with this buttress lost were more subject to these complications as well as medial wandering of the shaft and varus . Again, all cases united save one ; this was admittedly poorly nailed . It was noted further that if the patient survived the first two weeks or so, his chance of survival by any treatment improved perceptibly . SUMMARY AND CONCLUSIONS

The more confining the treatment, the greater the mortality and morbidity . 2 . Although operative fixation and early mobilization of the patient certainly offer the best prognosis so far, this still carries a mortality rate of 1o per cent at best and no ironclad guarantee of an excellent anatomic or x-ray result . 3 . Certain complications which have plagued all generations of physicians who treat such fractures still exist abundantly ; these are chiefly decuhiti, urinary complications and psychoses ; in fact the entire lexicon of geriatric 1.

ailments . Good nursing is still the sine quo non . We must remember to treat the patient as well as the fracture . 4 . The technical aspect of nailing has certain inherent difficulties and complications which must enter into any decision as to treatment . 5 . It is believed that an appreciable number of patients have good functional results even with coxa vara and some shortening . REFERENCES

D . M . and THOMSON, F . R . Intertrochanteric fractures of the femur . J . Bone eY Joint Surg ., 29 : 1049, 1947 . 2 . EVANS, E . M. The treatment of trochanteric fractures of the femur . J. Bone &Joint Surg., 31 : 190, 1949. 3 . EVANS, F . M . Trochanteric fractures, a review of 110 cases treated by nail-plate fixation . J . Bone er Joint Surg ., 33 : 2, 192, 1961 . 4 . HARMON, P . H . The fixation of fractures of the upper femur . J . Bone C Joint Surg ., 27 : 128, 1945 . 5 . .lEwETr, E . L . One-piece angle nail for trochanteric fractures . J. Bone eY Joint Surg ., 23 : 803-810, 19416 . KEY, J . A. Internal fixation of trochanteric fractures of the femur . Surgery, 6 : 13, 1939 . 7 . TAYLOR, G . NI ., NEUEELD, A. J . and JANZEN, J . Internal fixation for intertrochanteric fractures . J. Bone C Joint Sure ., 26 : 707, 1944 . I . CLEVELAND, NI ., BosWORTH,

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