Mechanisms of Injury
Signs and Symptoms
Imaging and Other Diagnostic Studies
Pathoanatomy and Applied Anatomy
Evolution of Treatment
Management of Expected Adverse Outcomes and Unexpected Complications
Vitamin D Deficiency
Functional Recovery and Postoperative Pain
Author’s Preferred Treatment and Future Options
Summary, Controversies, and Future Directions
Mortality = 1/1 + e– (constant + B (ASA))+ B (prefracture residence) + B (age) + B (sex) + B (type of fracture) + B (prefracture mobility) where e = 2.72 and the constant = –4.79 for 30-day mortality and –3.70 for the 120-day mortality.
From Holt G, Smith R, Duncan K, et al. Early mortality after surgical reduction of hip fractures in elderly: An analysis of data from the Scottish Hip Fracture Audit. J Bone Joint Surg Br. 2008;90:1357–1363.
A number of problems exist when determining the best option for treatment for pertrochanteric hip fractures. The classification systems do not work well enough for preoperative planning, and the reduction criteria have not been well defined. With these limitations in mind, some suggestions can be made.
First, begin with the AO/OTA classification of 31A1, A2, A3. Next, categorize the morphology of the fracture into the Dorr A, B, C groupings. Next determine the preoperative functional independence class: (1) community ambulator-self sufficient, (2) household ambulator-partially reliant, or (3) functional nonambulator-dependent for ADL. Determine if the fracture is reducible and if the bone quality is sufficient for a stable bone implant fixation; if the patient is a functional nonambulator (class 3) and the fracture is severely osteoporotic or nonreconstructable, nonoperative treatment is recommended. If the patient is a functional class 1, 2 and the fracture is not reconstructable, arthroplasty is recommended. Next obtain adequate radiographs or a CT scan to ascertain the presence or absence of a lateral wall fracture (Fig. 50-35; Table 50-10).
Table 50-11 lists the order of preference for implant for the respective fracture pattern, morphology, and activity level.
RSP, rotationally stable plate; SHS, sliding hip screw; TBP, trochanteric buttress plate; LPFP, locking proximal femoral plate with trochanteric buttress feature; SDRSN, small diameter rotationally stable cephalomedullary nail with multiple point fixation into femoral head (Nail Head D<15 mm); LDRSN, large diameter rotationally stable cephalomedullary nail with multiple point fixation into femoral head (Nail Head D>15mm); SCMN, single femoral head fixation cephalomedullary nail (Nail Head D>15 mm); cephalomedullary nails may be short or long versions; THA, total hip arthroplasty; HemiA, hemiarthroplasty; ex-fix, external fixation.