14:30,18,Mar,2011 | (330/0/0) | Original

the intertrochanteric fracture


About intertrochanteric fracture disease refers to the level of the femoral neck between the base to the lesser trochanter fractures, more common in elderly men than women, about 1.5:1,
Intertrochanteric fracture is outside the joint capsule fracture. As part of the blood supply to the femoral rich, rare nonunion or avascular necrosis. Non-surgical therapy to therapy. All over the serious hip injury, the more unstable fracture, on the contrary, the original hip varus over the light with or without those, fractures become increasingly stable. Therefore, the stability of fracture and fracture to appear independent of the direction. Femur including the femoral head, femoral neck and the size of the tuberosity. From the neck to the base beyond the level of lesser trochanter fractures occurred more parts, called the intertrochanteric fracture, more common in people over the age of 60. Intertrochanteric part of the bone is spongy bone, old age, this part of the bone is brittle and loose, so prone to fracture. As this part of the attachment of many muscles, so the wealth of the local blood supply, to fracture the contact area, therefore, generally after fracture healing is not a problem connecting. The main problem is the trend of turning intramedullary occur, the formation of abnormal connections, resulting in a limp, and because of changes in load-bearing lines may be in the post-traumatic arthritis caused by limb. Clinical manifestations of post-traumatic localized pain, swelling, tenderness and dysfunction than obvious, and sometimes subcutaneous bleeding visible lateral hip spot, at the extreme outer segment distal fracture
Intertrochanteric fractures rotated position seriously, up to 90 ° external rotation. Mostly elderly patients, hip pain after injury, can not stand or walk. Leg shortening and external rotation deformity was no shift of the fracture or displacement of intercalation less stable fractures, the symptoms were relatively small. Examination shows increased ipsilateral tuberosity, local visible swelling and bruising, local tenderness evident. Percussion affected area often cause severe heel pain. Often subject to X-ray examination before they can confirm the diagnosis, and according to X-ray films were classified. Diagnosis of disease diagnosis is based on (1) history of trauma
Intertrochanteric fractures (2) The clinical symptoms and signs: tenderness, pain, external rotation deformity (3) X-ray shows fracture of the differential diagnosis of femoral neck fractures and intertrochanteric fractures of the injured position, similar clinical manifestations, the two are easy to confuse, should pay attention to differential diagnosis, in general, intertrochanteric fractures due to local rich blood supply, swelling, ecchymosis obvious than severe pain, severe than the femoral neck fracture; former tender points more in greater trochanter Department, the latter point more in the groin tenderness to the outer ligament below the
midpoint. X-ray can help identify. Treatment of patients, mostly senior citizens, first of all pay attention to the body, the prevention of bed-ridden after fracture caused by the life-threatening complications, such as lung
Intertrochanteric fracture of inflammation, bedsores and urinary tract infections. Purpose is to prevent the occurrence of fracture of hip varus, specific treatment should be based on fracture type, displacement situation, age and general condition of patients, respectively, to take a different approach. Traction therapy to adapt to all types of intertrochanteric fractures. In particular, the stability of nondisplaced fractures and a severe visceral disease not suitable for surgery. Traction has the advantage of controlling limb external rotation of I, II-type fracture stability, traction for 8 weeks, and joint activities, with Shui Shimoji, but subject to 12-week weight-bearing limb fracture healing in a solid before it can to prevent hip inversion occurred. Unstable fracture of the traction requirements are: a. traction weight, weight about 1 / 7; b. Once the correction of varus deformity, the need to maintain the total weight of 1 / 7 1 / 10 of the traction weight to prevent hip recurrence of varus deformity; c. traction should be maintained in sufficient time, the general should be more than 8 to 12 weeks, fracture healing after the initial solid to traction. Closed by multiple Steinmann pin from the internal fixation of tibial tubercle traction first, reset, line systemic examination within 3 ~ 7d after injury, fractures of the stage surgery. 3.5mm in diameter with four femoral neck fracture Steinmann pin with multiple Steinmann pin fixation. Fixation screw-plate type is applicable to all types of adult fractures, internal fixation are commonly used in DHS (dynamic hip screw), and Charnley sliding compression screw and so on.
Ender nailing of intertrochanteric fracture fixation on the nails from the femoral condyle at the perforated 2cm, the observed X-Ender-pin TV screen through the articular surface of femoral head fracture directly under the Ministry of around 0.5cm. The number of fan-shaped root screw terminal or harpoon-like spread, fixed proximal bone. Applied after skin traction or anti-external rotation shoes. Gamma nail the early 90s, some countries use Gamma nail, that is, an interlocking intramedullary nail, cut through a thick screws through the femoral head and neck, due to nail through the canal, from the bio-mechanical analysis, power line from the stock center near the bone, therefore, Gamma nail femur is subjected to high stress, can achieve the purpose of early weight bearing ambulation. Classification of Diseases, also known as intertrochanteric fracture of intertrochanteric fractures, fractures are common in the elderly. As society ages, the extension of life expectancy, bone
Gamma nail loose the increasing number of elderly intertrochanteric fracture occurs the probability of an upward trend. Careful study of intertrochanteric fractures of the fracture type is conducive to making more accurate assessment of the extent to select a more appropriate treatment and prognosis. Intertrochanteric fracture of the classification to be reviewed. Intertrochanteric fractures by indirect and direct violence and injury by violence. Elderly patients with intertrochanteric fractures, mostly caused by direct external forces such as falls. Often accompanied by varying degrees of osteoporosis, it is easy to cause a serious fracture. Intertrochanteric fractures of the type a lot, now recognized and can be applied in the following ten: Evans classification (1949), Boyd? Griffin classification (1949), Ramadier classification (1956), DecoulxLavarde classification (1969) , Ender classification (1970), Tronzo classification (1973), Jensen classification (1975), Deburge classification (1976), Briot classification (1980), AO classification (1981). All type can be grouped into two categories: a) anatomical descriptions (Evans; Ramadier; Decoulx? Lavarde); b) the prognosis (Tronzo; Ender; Jensen modified Evans classification). Must be applied to any type of simple fractures, and can guide treatment, and prognosis can be clinically significant. For intertrochanteric fracture type, being able to reset the fracture stability and fixed after a fracture site to judge whether the tolerance to physiological stress is particularly important. AO classification, Evans classification, Jensen type and Boyd? Griffin is well-known type and can be widely applied. Are presented below. AO AO classification of fractures of the intertrochanteric fracture in their overall classification system classified as type A fracture. A1-type: simple fracture by the rotor (two parts), medial cortical bone is still good support, lateral cortex intact. 1, along the intertrochanteric line; 2, through the greater trochanter; 3, through the small rotor. A2 type: comminuted fracture through the rotor, the medial and posterior cortical bone broken in a few planes, but the lateral cortex intact. 1, there is a medial fracture fragment; 2, a few blocks of the medial fracture fragment; 3, under the small rotor extends beyond 1cm. A3 type: reverse obliquity fractures, lateral cortical bone has broken. 1, oblique; 2, transverse; 3 pieces. AO classification facilitate statistical analysis. Both for the intertrochanteric fracture with morphological descriptions, but also to judge the prognosis. At the same time, including the choice of fixtures can also make recommendations. Evans Evans type the direction of the fracture line is divided into two main types. â…  type, the fracture line up outside the small trochanter extension; â…¡ type, the fracture line is anti-diagonal form. 1 degree of type â…  and type â…  is stable 2 degrees accounted for 72%, â…  type 3 degrees, â…  and â…¡ type 4 degrees, 28% are unstable. Evans observed that stability is the key to reset the zone repair the medial femoral cortex continuity, simple and practical, and helps to understand the characteristics of the stability of reset, accurate predictions of intertrochanteric fractures anatomic reduction and secondary fractures after nailing the possibility of displacement. Jensen Jensen type classification for Evans has been improved, based on the size of the tuberosity fractures are involved and the stability of reset is classified into five types. â… : 2 fracture fragments, fracture without displacement. â…¡: 2 fracture fragments, with displaced fractures. â…¢: 3 fracture fragment displacement of the greater trochanter because of the lack of fragments after the lateral. â…£: 3 fracture fragments, the lesser trochanter or the lack of medial calcar fractures. Type â…¤: 3 fracture fragments, the lack of support inside and outside, as type â…¢ and â…£ combination. Jensen found â… , â…¡ fracture stability after 94% reduction; â…¢ fracture after reduction of 33%
Stability of intertrochanteric fractures; â…£ 21% reduction after fracture stabilization; â…¤ 8% reduction after fracture stability. Jensen pointed out that the size of the trochanter after crushing the degree of reduction is inversely proportional to the stability of the fracture. Jensen et al Evans improved on the basis of classification, more widely, research has shown, Jensen and other modified Evans classification to determine the stability of reset and shift the risk of another fracture providing the most reliable forecast. Boyd? Griffin Boyd and the 1949 classification of intertrochanteric fractures of Griffin will be divided into four types, including the joint capsule from the neck to other parts of 5cm below the lesser trochanter of all fractures. â… : with the greater trochanter to lesser trochanter intertrochanteric line along the fracture occurred, stability, no shift, no grinding, a simple reset (21%). â…¡: fractures in the intertrochanteric line, accompanied by multiple fractures of cortical bone, the fracture, associated with displacement, reduction more difficult to obtain stable when reset. There is a special fractures - intertrochanteric line before and after the fracture, the fracture line can only be seen on lateral radiographs (36%). â…¢: basically subtrochanteric fractures, at least one fracture line crossing the lesser trochanter or the proximal femoral lesser trochanter area beyond, there is a large posteromedial comminuted region, and unstable, difficult to reset, operative , recovery, more complications (28%). â…£: proximal femoral intertrochanteric region and at least two planes of fracture, femoral shaft mostly oblique or spiral butterfly fractures, subtrochanteric fractures, including parts and unstable. The choice of which type, before surgery to judge the stability of the fracture is very important. Stability of intertrochanteric fracture depends on two factors: a) the integrity of the medial arch (small trochanter is involved); b) the degree of comminuted posterior cortex (greater trochanter crushing degree). In addition, the reverse is very unstable intertrochanteric fractures. Lesser trochanter fracture of the medial arch of cortical bone defects and loss of mechanical support, resulting in varus. Greater trochanter fractures are further aggravated the sagittal plane instability, which resulted in the femoral head backward. Inverse fracture intertrochanteric fractures often occur distal to the medial shift, such as the reduction will result in poor fixation in the femoral head in the cutting. Unstable fractures is fixation failure (bending, breaking, cutting) is one of the factors. Palm, etc. In summary, the currently available types of intertrochanteric fractures in, AO classification of intertrochanteric fractures in guiding the diagnosis, treatment and prognosis better than the other type, but its reliability is still deposit disputes, and better typing methods need to be further study of the majority of orthopedic surgeons. Expert Tips fracture, is common in the elderly, fracture in the thigh, where muscles rich, very easy to shift, with manual reduction, local and external fixation, bound to fail. Such fractures, orthopedic doctor should go to the hospital to find timely diagnosis and treatment. Traction therapy or surgery. Otherwise it will affect the function of malunion, or long-term bed rest, causing complications such as bedsores. The scope of a drug. Most patients, symptomatic treatment may be, such as analgesics, early Taohongsiwutang, post eight treasures soup. Can be served calcium: calcium gluconate, vitamin A + D, Tang Chinese Medicine and Washing Shujin help functional recovery. 2. Surgical patients with antibiotics prevent infection, postoperative wound infection can be three days without stopping. Some patients to blood transfusion. Nursing measures (1) The patients are mostly elderly, so the general condition of the patient should be observed to prevent the long-term complications occurred in bed, such as pneumonia, urinary tract infections, and varus deformity. (2) The intertrochanteric fractures occur in the elderly, it is generally higher mortality rate. Conservative treatment currently used in the activity exercise, could achieve better therapeutic effect and reduce mortality, thus enhancing the efficacy of nursing plays a vital role. Since most patients with intertrochanteric fractures is Rosso's traction, very few surgical repair. Therefore, the focus of such fractures in elderly patients traction nursing care. Intertrochanteric fractures (3) during the traction, to observe patients with and without foot drop, and to note whether the pressure on the outside of the knee. Prevention of pneumonia, bed sores, urinary system
Intertrochanteric fractures of infectious complications. Poor blood circulation, the elderly, less active, prone to bed sores, especially when the patient to use the potty, if the body is lifted high enough, potty out in the buttocks, is pushed, it may break the skin rub can be further developed into a bedsore. Therefore, the patient should explain the reason the family should be patiently in order to obtain the patient's cooperation. Patients with the pull method is to use both hands pulling the handle rack, while using the contralateral leg kicking the bed surface, the whole upper body and hips to lift, so that patients can promote the body other than the activities of inter limb exercise, improve blood circulation and respiration. And because of body position from the supine to sit, is conducive to the discharge of urine sediment. Prone to pressure sores on patients, massage pressure areas should be strengthened. For the frail elderly, should be in their hip pads balloon or pad foam pad. Encourage patients to cough, try cough up sputum. Get up every morning and evening before going to sleep instruct patient to sit up, take a deep breath, and beat back. Encourage patients to drink more water or drink, to flush urinary tract and prevent urinary tract infections. Bedridden elderly patients often lack of energy, lazy activity, coupled with the activity afraid of the pain, afraid of plenty of water, urine, sitting potty trouble, so family members need to encourage and assist patients in activities. Taken during the semi-supine lower limb traction, can relax the psoas muscle, which will help fracture of the bit. Note that a small pillow or lumbar pad after the pad to maintain physiological lordosis and prevent back pain. Encourage patients to have planned for the functional exercise, such as the ankle, toe, quadriceps exercise. (4) removal of traction and external fixation after discharge, the care should note the following: Such fractures usually require more than 8 weeks -12 weeks of traction, external fixation lifted, usually in bed joint activities, exercise quadriceps 1 week -2 weeks to leave the bed. Shimoji, often elderly and frail and do not use the street, slow to learn, patience to help the Church of patients with crutches, without weight-bearing limb. Be sure to pay attention to safety, to prevent patient falls. Except fixed to the patient's supine position can be arbitrary, but to pay attention to preventing the occurrence of muscle adduction deformity, so patients do not in the contralateral side. Supine, in the folder a pillow between the two legs to control the limb adduction. Treatment PFNA cases of intertrochanteric fractures in the application of summary PFNA Objective PFNa treatment of intertrochanteric fractures of clinical efficacy. Methods August 2005 ~ September 2006, 10 cases of intertrochanteric fractures to
PFNA with PFNA internal fixation, fracture type according to Evans. Results All the patients were followed up for 8 to 54 weeks. All fractures healed, the healing time is 8 to 22 weeks, an average of 14 weeks, no infections, fat embolism, deep venous thrombosis, fracture nonunion, varus deformity and other complications and rotation. Conclusion PFNa treatment of intertrochanteric fractures is simple, less invasive, in line with the principles of biological fixation, fracture fixation, fewer complications and patients can be out of bed early weight bearing, etc., especially for elderly patients. Keywords intertrochanteric fracture fixation of intertrochanteric fractures of fracture is common, frequently-occurring disease, more common in the elderly, the treatment of multiple tends to fixation. PFNa in recent years for the treatment of trochanteric fractures with intramedullary fixation system is designed. August 2005 ~ September 2006 PFNA fixation with 10 cases in patients with intertrochanteric fractures and achieved good results. Surgical surgical patients admitted to hospital after row tibial tubercle skin traction or traction, traction improved during the examination, active treatment medical complications, underwent surgery in stable condition. 8 cases with continuous epidural anesthesia, lumbar epidural anesthesia in 1 case, 1 case of anesthesia. Orthopedic traction bed placed in surgical patients, closed reduction and traction, C-arm X-ray machine reset after the success of perspective, take the top of the greater trochanter 3-5cm incision, the rotor tip with three pyramid arrogant direction of the medial femoral canal to the opening perspective, see the three pyramids and direction of a good entry point, insert the guide pin, drill with the flexibility to expand the rotor entrance will be installed on the handle in the sight of proximal femoral nail into the medullary cavity, after the adjustment of the depth of the right angle before, by sight within the proximal femoral neck screw into the keyhole to the guide wire 1, anteroposterior perspective in the guide pin in the femoral neck 1 / 3, lateral fluoroscopy guide pin is located in the middle of the femoral neck, hollow drill along the guide pin drilling, drilling only through the lateral cortex, the direction along the guide pin into the spiral blade, under the guidance of the locator into the distal two nail to remove the locator, because of small incision, damage, generally do not place the drainage tube. After 1-3 days of postoperative antibiotics, prophylactic use of anticoagulants 1 week after anesthesia can sit up line after 2 days of motion muscles can practice walking with crutches come down to earth, according to fracture type and decide not reset the injured limb or part of the load weight. Referral 1 month after discharge from hospital X ray film callus grew well, the fracture line can be judged as fuzzy fracture healing. Postoperative results of intertrochanteric femur fractures is one of the most common fractures, occurs in the elderly, easy, and medical disorders associated with osteoporosis, though mostly due to low-energy injury, but if not timely and effective manner treatment, and easy to stay hip varus, limb shortening or other consequences, to strengthen the perioperative treatment of patients before surgery should be comprehensive and systematic examination of the coexistence of disease and to find appropriate treatment. Prone to prolonged bed rest lung infection, urinary tract infections, bed sores and other serious complications. Now more advocate early surgical treatment in patients with conditions to obtain a stable reduction and firm fixation, so that an early recovery of patients. PFNa is a new internal fixation system, which is characterized by spiral screw blade diameter, the lateral incision through the anti-rotation lock automatically, just open the outer cortex, do not remove the bone, even in very severe cases of osteoporosis , you can still feel the spiral blade firmly anchor force, spiral blades can be smoothly rotated, when the blade does not spiral into the femoral head and femoral neck and femoral head and neck rotation separation, partial nail with a 6-givers angle to facilitate insertion from the top of the greater trochanter; remote to select a lock hole static or dynamic locking; as long as possible and groove edge design to facilitate insertion and avoid PFNA the local stress concentration; for Long PFNA, also two dynamic. PFNA features: are intramedullary fixation, which maintained a strong fixed idea of AO, biomechanical stability of a strong, early walk with. Also embodies the essence of BO and minimally invasive surgery, the incision is only 3 ~ 5cm, shorter operation time, average 60min, less blood loss, average 72.2ml, without blood transfusion. Screw diameter of 11 mm of the spiral blade, just a guide pin, and head and neck do not need to drill holes, nail 6 givers angle, can be inserted from the top of the greater trochanter, simplifying the surgical procedure and shorten the operation time, reducing the number of perspective. PFNA with a variety of models, adapted to the Evans classification of various types of fracture, for subtrochanteric fractures and femoral shaft fractures in patients on the option lengthened. Should note the following specific points: intertrochanteric fractures (1) read the piece carefully before operation, understanding fracture type, canal size, decided to nail length, thickness; (2) reset must not be too slight, too slight to have been stable fracture becomes unstable, insert the nail easier to shift when the fracture; (3), 6-givers for PFNA proximal angle, into the medial tip of the greater trochanter nail 0.5cm from penetrating, easily lead to partial foreign greater trochanter fracture, partial access to the from the pyriform can cause fracture dislocation; (4) into the guide pin, the guide pin should be noted that the position of the phase axis, positioning accuracy and then open the outer cortex, into the nail Once again into the nail changes, due to the stability of femoral neck bone destruction is greatly reduced; (5) To ensure smooth insertion PFNA tail rotor Department and should be expanded from small to large, should not leapfrog reamed and the use of violence, rotor to prevent splitting; (6) PFNA to intramedullary fixation system, less prone to loss of medial coxa vara, so small rotor displacement do not advocate a separate fixation, significantly increased due to reduction and fixation to trauma. In summary, the application PFNA treatment of intertrochanteric fractures with a fixed Indeed, trauma, get out of bed early, fracture healing, fewer complications, the treatment of intertrochanteric fractures of the ideal equipment.
the intertrochanteric fracture

【Secondary References CJFD ago 10 1 Lu Ying; Luo positive;; 203 cases of intertrochanteric fracture analysis [J]; of Bone and Joint Surgery; 1991 01 2 Ji Fang, Pu Runxiu, Tsai Chung Dong-young , Huang Changming, Jia Jinpeng, Shao Haijun; prosthesis replacement in the treatment of Senile unstable intertrochanteric fractures [J]; of Bone and Joint Surgery; 2002 03 3 Cheng Liming, Li Jian; hip over the age of 80 fractures (clinical analysis of 85 cases) [J]; of Bone and Joint Surgery; 2002 05 4 Bihai Yong, Zhang Shudong, Liu valuable, Zhao Zhongyuan; artificial joint replacement in the treatment of intertrochanteric femoral fractures [J] ; Practical Orthopedics; 2003 04 5 Lee First, QIU Gui-xing, Weng Xi-sheng, Zhang Bao, gold today, Lin Jin, Zhao Hong, Wang Peng; elderly intertrochanteric fractures with dynamic hip screw surgery [J]; Journal of Traumatic Orthopaedics; 2004 05 6 An Weijun, Xiao-Ming Ma, Chen Jun, rice accounted for Hu, Teh; intertrochanteric fractures of the surgical treatment [J]; Journal of Traumatic Orthopaedics; 2004 05 7 Fu Jie Zhong Hongbin, Xu ball, Chenfu Wen, Zhang Zhijie, Wang Yueqing, Liu Zhigang, Wang Jianping, thorough, Wang Bin; dynamic hip screw in treatment of intertrochanteric fractures [J]; Traumatology; 2004 01 8 Paul, the Liu Changgui, Luo is, INTEGRATED, Li Yadong; interlocking intramedullary nailing for femoral shaft fractures with ipsilateral femoral neck and intertrochanteric or subtrochanteric fracture comminuted fracture [J]; Spine; 2000 03 9 Huang Gongyi, Wen-liang yuan; intertrochanteric fractures [J ]; Spine; 2003 10 10 Jiang Zhiqiang, Zhou Liangan, Chen Kuan Lin; application of interlocking intramedullary nailing in the treatment of proximal femoral intertrochanteric fractures [J]; China Orthopedic Surgery; 2003 14
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