Answer

Intertrochanteric fracture of the hip

Hip fracture classification

1. Femoral head fractures

2. Femoral neck fractures (Fig. 3.40)

3. Intertrochanteric fractures

4. Trochanteric fractures

5. Subtrochanteric fractures

The anatomical site of a fracture has a significant impact on healing. Femoral head and femoral neck fractures are both intracapsular, whereas intertrochanteric, trochanteric and subtrochanteric fractures are extracapsular. Intracapsular fractures are more prone to complications of healing such as avascular necrosis.

This is consequence of the critical blood supply to the region. Blood supply is derived from three main sources which include

■ perforating branches of medial and lateral circumflex artery,

■ inferior and superior gluteal arteries, 160 ■ obturator artery (posterior branch).

Fig. 3.40 Femoral neck fracture.

In the majority of people the foveal artery which runs with the ligamentum teres to reach the femoral head is insufficient to supply the entire femoral head.

Femoral neck fractures especially if displaced frequently lead to avascular necrosis of the femoral head due to disruption of the interosseus and capsular vessels (which run with the periosteum of the femoral neck).

Mortality and morbidity associated with hip fractures is considerable. Mortality is greatest in the elderly, is highest in the first few months but remains high for up to 1 year afterwards. The immediate mortality after repair of fractured neck of femur is less when spinal anaesthesia is used rather than a general anaesthetic, probably because of a reduction in thromboembolic complications. However, at 1 month there is no difference in outcome between the two techniques. Morbidity due to surgery and anaesthesia:

■ DVT and pulmonary embolism

■ Muscle wasting

The problems following fractured neck of femur are closely linked to immobilisation. In the months following hip fracture reduced ambulation and mobility leads to a loss of independence, reduced quality of life and often depression in the elderly.

Reference

1. Advanced Trauma Life Program for Doctors, 6th edn. American College of Surgeons, Chicago, 1997.

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