An intertrochanteric fracture is a type of hip fracture located in the upper part of the thigh bone (femur), outside the hip joint capsule. It occurs between the greater and lesser trochanters, bony prominences where muscles attach. This fracture is common in older adults, often linked to osteoporosis and an increased risk of falls. Such injuries can lead to significant health complications.
Common Surgical Procedures
Surgical intervention is the primary treatment for intertrochanteric fractures, aiming to stabilize the broken bone and facilitate early patient mobilization. The choice of surgical technique depends on the fracture pattern and its stability. Unstable fractures, which may involve comminution or a thin lateral wall, often require different fixation methods compared to stable fractures.
One common surgical technique is Intramedullary Nailing (IMN), where a metal rod is inserted into the bone marrow canal of the femur. This rod helps stabilize the fracture from within the bone. IMN is frequently preferred for unstable intertrochanteric fractures, including those with a reverse oblique pattern or involving the posteromedial wall or lesser trochanter. Advantages of IMN include a decreased bending moment arm on the implant and potentially lower rates of varus collapse, a deformity where the bone angles inward. This percutaneous technique involves smaller incisions and can allow for earlier weight-bearing.
Another widely used method is the Dynamic Hip Screw (DHS), also known as a sliding hip screw. This involves inserting a large screw into the femoral head, which connects to a side plate fixed to the outer surface of the femur. The DHS allows for controlled collapse at the fracture site, promoting bone-on-bone stability and reducing the chance of the implant penetrating the joint. It is primarily used for stable and compressible intertrochanteric fractures where the lateral femoral wall is intact. The DHS promotes fracture healing by allowing dynamic compression as the patient bears weight.
The choice between IMN and DHS depends on the specific fracture characteristics and surgeon preference. IMN may offer advantages for unstable fractures, while DHS remains a standard for stable patterns.
Non-Surgical Considerations
Non-surgical management for intertrochanteric fractures, such as prolonged bed rest or traction, is generally avoided in older adults due to the significant risks involved. These approaches are associated with a higher rate of morbidity and mortality. Prolonged immobility can lead to serious complications, including pressure ulcers, pneumonia, and deep vein thrombosis.
Non-surgical treatment is considered only under specific and limited circumstances. These may include patients medically unstable for surgery due to severe comorbidities that would make an operation life-threatening. Another scenario is for non-ambulatory patients experiencing minimal pain, where surgical risks outweigh potential benefits. In such cases, the focus shifts to palliative care and managing immobility complications.
Post-Operative Care and Rehabilitation
Following surgical repair of an intertrochanteric fracture, immediate post-operative care centers on pain management, wound care, and infection prevention. Early mobilization is crucial for recovery, with physical therapy commencing soon after surgery, often within the first 24 to 48 hours. This early activity helps reduce the risks associated with prolonged bed rest.
Rehabilitation progresses through several phases. Initially, exercises focus on gentle active range-of-motion for the hip and knee, along with isometric exercises to strengthen gluteal, quadriceps, and hamstring muscles. Weight-bearing status is determined by the surgeon, with some stable fractures allowing for weight-bearing as tolerated, while unstable fractures may require partial or toe-touch weight-bearing initially.
As strength and mobility improve, progressive resistive exercises are introduced for the hip and knee. Gait training with assistive devices like walkers is initiated, gradually advancing as the patient regains balance and confidence. Rehabilitation can occur in various settings, including acute rehabilitation centers, skilled nursing facilities, or through home health services, depending on the patient’s needs and progress. The long-term goals of rehabilitation are to restore independence in daily activities, improve overall physical function, and implement strategies to prevent future falls.
Managing Unique Challenges in Elderly Patients
Treating intertrochanteric fractures in older adults presents unique challenges due to their physiological vulnerabilities and pre-existing health conditions. This demographic is particularly susceptible to a range of complications that can impede recovery and impact long-term outcomes.
Delirium, an acute state of confusion, is a common postoperative complication, affecting a significant percentage of elderly patients. Its management involves addressing underlying causes, ensuring adequate hydration, and minimizing medications that can worsen cognitive function. Pressure ulcers, also known as bedsores, are another frequent issue due to prolonged immobility; prevention strategies include regular repositioning, skin care, and nutritional support.
Older patients also face an increased risk of respiratory infections like pneumonia and urinary tract infections, often exacerbated by reduced mobility and general frailty. Pre-existing cardiovascular and renal conditions can complicate anesthetic management and increase the risk of cardiac events or kidney dysfunction during the perioperative period. Addressing underlying osteoporosis is important to prevent future fragility fractures, with treatments often including vitamin D and calcium supplementation, and potentially anti-resorptive medications. Nutritional support is also important, as adequate protein and calorie intake are necessary for wound healing and muscle recovery. Fall prevention strategies, such as home safety assessments and balance training, are implemented after recovery to reduce the risk of subsequent fractures.