Trochanteric fractures are the most common hip fractures in older and older adults. Women suffer these fractures 3-5 times more often than men. Moreover, trochanteric fractures are more common in older people, and cervical fractures are more common in older people. The high incidence of trochanteric fractures in old people, according to A.V. Kaplan, depends on the sharp manifestation at this age of osteoporosis of the trochanters, in the spongy substance of which large “voids” are formed. And the cortical layer of the trochanters becomes very thin and becomes weak and fragile.
The mechanism of trochanteric fractures in elderly and old people is the same as the mechanism of medial femoral neck fractures, and is usually associated with a fall on the greater trochanter area or with a mild injury to this area.
Clinical symptoms of trochanteric fractures:
- sharp pain in the hip joint and upper third of the thigh;
- significant swelling and deformation of the proximal part of the femur in the area of the greater trochanter;
- significant external rotation of the leg, the outer edge of the foot is adjacent to the bed;
- relative shortening of the leg by 2-4-6 cm depending on the degree of displacement of the distal fragment, there is no anatomical shortening;
- positive symptom of “stuck heel”. The diagnosis is confirmed and the type of trochanteric fracture is determined by an x-ray of the hip joint and the upper third of the femur in the anteroposterior projection.
Principles of treatment of trochanteric fractures
Trochanteric fractures have a high mortality rate in elderly and elderly people. Prolonged forced positioning of elderly and old patients on their backs can lead to severe pulmonary and cardiovascular complications. If a patient who has received a trochanteric fracture suffers from senile insanity, severe disorders of the cardiovascular and respiratory systems, or did not get out of bed even before receiving the fracture, then early mobilization is used, as with cervical fractures, to save life.
Why is the risk of fractures higher in older people?
The first and main factor is bone fragility, caused by a slowdown in metabolic processes in the body, a lack of calcium and a decrease in regenerative function - the ability to naturally repair damage. Every fifth man and every third woman after fifty years suffer from osteoporosis - a reduction in bone density. Any careless movement with such a disease can provoke a fracture.
Frequent falls are another serious cause of limb fractures in old age. Decreased visual and hearing acuity, dizziness, weakness, convulsions, sudden surges in pressure - all this leads to the fact that older people easily lose their balance and fall even out of the blue. At the same time, the nature of the fall changes with age: if young people fall forward or backward, then older people fall on their side, supporting themselves on their arms and hands. In this regard, cases of fractures of the femoral neck, shoulder, vertebrae, and wrist are becoming more frequent among the latter.
Add to this chronic diseases that drag on for years and significantly undermine the body’s ability to quickly recover.
Surgical treatment of trochanteric fractures
For many elderly and especially old patients, conservative treatment with skeletal traction is impossible, since they cannot stand a long forced position in bed. The high mortality rate with conservative treatment of trochanteric fractures served as the basis for the use of surgical treatment, since surgery allows patients to be quickly mobilized and prevents complications.
Surgical treatment of trochanteric fractures consists of low-traumatic osteosynthesis of the fracture using modern metal fixators.
Diaphyseal femoral fractures
Diaphyseal fractures of the femur account for about 25% of all fractures of the femur and belong to severe injuries, since they are often accompanied by significant (up to 1.5 l) hemorrhage into the tissue. They arise as a result of direct and indirect trauma and can be localized at various levels of the diaphysis. There are fractures of the upper, middle and lower thirds of the femoral diaphysis. Fractures in the middle third of the thigh are more common. Depending on the mechanogenesis, there are different types of fractures of the femoral diaphysis (transverse, comminuted, double, oblique, spiral, with and without displacement of fragments, etc.).
The displacement of fragments is caused by a reflex contraction of the thigh muscles, which have different attachment sites and directions of traction, as well as the mass of the peripheral segment. Thus, in case of fractures in the upper third of the diaphysis of the femur, the central fragment is retracted by the gluteal muscles, and by the iliopsoas muscle, attached to the lesser trochanter, bent and slightly rotated outward. The higher the fracture, the greater the retraction and bending of the fragments.
The peripheral fragment is driven by the adductor muscles, pulled upward by the long muscles of the thigh, and under the mass of the peripheral segment it is shifted back and somewhat rotated outward. With fractures in the middle third, such flexion and abduction of the central fragment does not occur, because the gluteal muscles are opposed by the adductor muscles.
If there is a fracture of the lower third of the femur, the central fragment is held in place by the balanced traction of the antagonist muscles, and the peripheral fragment is displaced back under the influence of contraction of the strong calf muscle. And the shorter the peripheral fragment is, the more it bends back. If this displacement is not corrected in a timely manner, it is fraught with circulatory disorders due to pinching of the popliteal vessels.
Diagnosis of fractures of the femoral diaphysis is not difficult (the fragments are displaced). Upon examination, swelling and a classic deformity of the hip are visible - breeches, forced position of the limb and its shortening. On palpation, sharp pain and pathological mobility are determined; it is possible to cause, although this is not desirable, crepitation of fragments. Active movements are impossible. X-rays in two projections clarify the nature of the fracture.
Treatment . For fractures of the femur, it is very important to provide the patient with high-quality first aid in order to prevent a deterioration in his general condition. To do this, 2 ml of a 1% solution of promedol is injected intravenously (for an immediate analgesic effect), and 40-60 ml of a 1% solution of novocaine is injected into the fracture site. The limb is fixed with a Dieterichs splint or some other available means with mandatory immobilization of two adjacent joints. If there is shock, a drip infusion of anti-shock fluids is established through a catheter connected to a vein.
In a hospital setting, the doctor assesses the general condition of the patient and, if necessary, continues anti-shock therapy, which includes the application of a skeletal traction system on a Beler splint. Skeletal extraction is applied behind the distal metaepiphysis for fractures of the upper and middle thirds of the femur, behind the tibial tuberosity for fractures of the lower third. Despite the nature of the fracture and the degree of displacement of the fragments, the wire is performed under local anesthesia with a 1% novocaine solution.
In children with subperiosteal fractures, the bone axis is aligned under anesthesia. To achieve reposition of fragments in a fracture of the femur, you should relax the muscles as much as possible, that is, balance the tension of the antagonist muscles and observe the basic principle of reposition - to compare the axes of the peripheral fragment and the central one. Therefore, in case of fractures of the upper third of the femur, the limb is abducted and flexed at the hip joint as much as possible.
The standard Böhler splint, designed for the average physiological position of the limb (angle 135°), is suitable for the treatment of patients with fractures of the middle third of the femur. For treatment of fractures of the upper and lower thirds, special splints made of telescopic tubes have been proposed, by adjusting which you can achieve the required flexion angles in the joints of the limb. But since functional controlled splints (Bogdanova, Chaklina, Shulutko, Solman, etc.) are not yet produced by the medical industry, to reduce fractures of the upper third of the femur, a system of Balkan frames is used, respectively, they are covered with a Beler splint or pillows are used to create the necessary angle of flexion in the hip joint according to Sitenko.
This also applies to the treatment of patients with fractures of the femur in the lower third : the lower leg is lowered in the Beler splint and foot pads are not used in order to relax the calf muscle more. The lower the fracture of the femur, the lower the tibia is lowered, sometimes to an angle of 90°. If the fragment cannot be removed by flexing the tibia, it is advisable to use a double skeletal extraction: the main one - for the tibial tuberosity, the reduction one - for the peripheral fragment. The method of repositioning low fractures of the femur by skeletal extraction in the prone position is too difficult for the patient, and therefore it is not used.
The load to eliminate longitudinal displacement of fragments, that is, for extraction along the axis of the femur, is dosed individually, starting from the minimum, depending on the mass of the segment and muscle strength. A cuff extraction with a load of 3-4 kg with derotational support is placed on the lower leg. Displacement at an angle and in width is eliminated by lateral corrective rods using hinges. The degree of reposition of fragments is determined visually, by palpation and by comparative measurement of the length of the segment. X-ray control is carried out only when it is considered that the fracture has been reduced based on clinical signs. Excessive exposure of the patient is unacceptable.
As a rule, reposition and stabilization of fragments is achieved in the first 2-4 days, i.e. at the stage of small cell infiltration. Any correction of fragments at the stage of cell differentiation and later leads to disruption of reparative osteogenesis and delayed fusion.
known method for simultaneous reposition of transverse fractures of the femur by skeletal extraction using large loads at once . Without leaving the patient, the fragments are compared and the load is immediately reduced to a minimum. However, this method is difficult for the patient, very responsible for the doctor, not always effective, and therefore is not used. From the first days of the patient’s stay, exercise therapy is carried out, movements in the ankle joint, toes, and patella are recommended. Functional treatment has a beneficial effect on reparative processes and rapid restoration of movements in the joints. The period of stay for extraction is individual, on average 1.5-2 months. After the formation of callus, which is determined clinically and radiologically, a massage of the thigh muscles is performed. If the patient is able to lift the leg freed from the load, the skeletal extraction is stopped and the cuff is replaced with a disciplinary traction (2-3 kg).
After 2.5-3 months, you are allowed to walk on crutches, loading your leg in doses. Performance is restored 5-7 months after injury. If x-rays reveal an insufficiently pronounced callus, after skeletal traction a plaster bandage is applied for 1-1.5 months to prevent possible secondary angular displacement (breeches). After removing the bandage, restorative therapy is carried out.
In addition to the generally accepted indications for surgical treatment for all fractures, transverse and oblique fractures of the femur with a small joining area are considered, in which the fragments are difficult to reduce and tend to be displaced. Metal osteosynthesis for closed fractures of the femur is carried out routinely after the patient has been recovered from a serious condition. For this purpose, different types of fixators are used depending on the level of the fracture. For fractures of the middle third of the femur, the most stable fixation is achieved using a CITO or Kincher rod of the appropriate diameter, the upper third using a Sivash corkscrew fixator, compression with a Krupko nail screw, and a Fishkin fixator.
For fractures in the lower third of the femur due to the gradual expansion of the bone marrow cavity, Bogdanov rods or CITO rods are used. More durable fixation is achieved by using various types of bone plates, including those with compression devices (Klimova, Vorontsova, "AO") or the Rublenik locking rod. The operation is performed under general anesthesia or epidural anesthesia. An incision along the outer surface of the thigh with muscle separation exposes the fragments. A rod is driven retrogradely into the medullary cavity of the central fragment, which, when the femur is bent and adducted, extends into the supra-acetabular area.
At the site where the rod exits, the skin is cut (2-3 cm) and the nail is driven in until its end is equal to the fracture line. The peripheral fragment is reduced, and the nail protruding into the supra-acetabular area is driven into the medullary cavity of the peripheral fragment. In case of oblique and screw fractures, sometimes the fragments are additionally fixed with a cercelial wire suture or screws. The wounds are sutured, and the limb is placed on a Beler splint in the mid-physiological position. After the stitches are removed, the patient is allowed to walk on crutches without putting any weight on his legs for 3-4 weeks. In transverse fractures, the load promotes callus formation. Full weight bearing on the leg is allowed if the callus is determined by x-ray.
In case of unstable osteosynthesis (due to tactical and technical errors), a compression-distraction device (Ilizarov, Kalnberza) consisting of two rings should be applied after the operation, since a coxite plaster cast leads to extension contracture of the knee joint. This sometimes limits performance and even requires repeated reconstructive surgery - arthrolysis, mobilization of the rectus femoris muscle.