What Makes an Intertrochanteric Fracture Unstable in 2015? Does the Lateral Wall Play a Role in the Decision Matrix?

Abstract

Intertrochanteric (IT) fractures pose a tremendous burden to the healthcare system. Although consistently good results are obtained while treating stable IT fractures, treatment failure rates with unstable fractures are much higher, and hence, it is imperative to identify unstable patterns. Presently, the conventionally classified unstable configurations (fracture with posteromedial comminution, reverse oblique, IT with subtrochanteric extension) and the recently added fracture patterns (IT fractures with avulsed greater trochanter and lateral wall breach) qualify as unstable IT fractures; however, the list is certainly not exhaustive. Disruption of lateral wall converts an IT fracture into a reverse oblique fracture equivalent and should be given a strong consideration in the decision matrix.

Which Fixation Device is Preferred for Surgical Treatment of Intertrochanteric Hip Fractures in the United States? A Survey of Orthopaedic Surgeons

“…Multiple clinical trials and meta-analyses have directly compared the two techniques for treatment of these fractures [3, 18-20, 27, 28, 30, 34]. Particular fracture patterns, such as those with reverse obliquity, subtrochanteric extension, fracture extension into the lateral wall, or greater trochanteric avulsion [23,26,33], have lower rates of failure and reoperation when treated with a cephalomedullary nail than a sliding hip screw. However, to our knowledge, no study has found one construct to be clearly superior in the treatment of commonly encountered conventional obliquity fracture patterns, and controversy over the optimal treatment strategy persists [3,5,25,27,28,30,32].…”

New classification focusing on the relationship between the attachment of the iliofemoral ligament and the course of the fracture line for intertrochanteric fractures

“…Type I is defined as a type of intertrochanteric fracture but the pathology is similar to that of pertrochanteric fractures associated with a lateral wall fracture. Since bony factors supporting the proximal bone fragment are lost, this type may induce rotation instability and/or excessive telescoping [2]. Therefore, either SHS with a trochanteric buttress support should be used to stabilize the proximal primary fragment or SFN which also acts as "a lateral prosthetic wall" [2] may be used.…”

“…Since bony factors supporting the proximal bone fragment are lost, this type may induce rotation instability and/or excessive telescoping [2]. Therefore, either SHS with a trochanteric buttress support should be used to stabilize the proximal primary fragment or SFN which also acts as "a lateral prosthetic wall" [2] may be used. Type I sometimes looks like Reverse Oblique Pattern (Type III) depending on the course of the LFL.…”

“…However, in terms of the main location of the displacement, the treatment strategies were totally different from that for another unstable pertrochanteric fracture, such as AO/OTA 31-A2 (hereinafter referred to A2) (cases associated with a lesser trochanter fracture, those associated with avulsion fractures of the greater trochanter, and those where the LFL extended to the subtrochanteric area [2]). The basic treatment strategy of A2 is to reduce the shortening between the primary bone fragments (correction of varus deformity) and subsequently to perform an extramedullary reduction of the anteromedial cortices of the proximal main fragment against the distal main fragment for stabilization [12,13] (Fig.…”

“…An intertrochanteric fracture is defined as when "The lateral fracture line (LFL) reaches the lateral cortices distal to the vastus ridge of the greater trochanter, which connects to the medial cortices", and is considered as an unstable pertrochanteric fracture of the hip [1,2]. As first defined by Wright et al in 1947, a "typical intertrochanteric fracture has reverse oblique intertrochanteric fractures" [3].…”