Subtrochanteric femoral fracture
| Classification according to ICD-10 | |
|---|---|
| S72 | Fracture of the femur |
| S72.2 | Subtrochanteric fracture |
| ICD-10 online (WHO version 2019) | |
Subtrochanteric femur fracture is the medical term for a fracture of the thighbone below the so-called linea intertrochanterica , i.e. a line between the two rolling hills ( trochanter major and trochanter minor ).
Occurrence
Similar to the other fractures on the proximal (near the trunk) thigh, it usually occurs in older people when they fall onto the corresponding hip. In high-energy trauma (e.g. traffic accidents or falls during winter sports or from a great height), the fracture also occurs in younger people; in children it is rare.
From an anatomical point of view, it is a femoral shaft fracture, but functionally it can be assigned to the so-called “femoral fractures near the hip joint”. Mostly there are lump or comminuted fractures, which not infrequently reach far down into the shaft. It is not uncommon for there to be combined injuries from a pertrochanteric fracture with additional subtrochanteric parts, which in clinical usage is often referred to as per- / subtrochanteric fracture.
treatment
Before the development of osteosynthesis procedures in the second half of the 20th century, thigh fractures were treated in a stretching device . The extremely long bed-rest associated with this, however, resulted in considerable hospital mortality, especially in elderly patients, due to hypostatic pneumonia , deep vein thrombosis with subsequent pulmonary embolism and extensive, difficult-to-treat ulcers . Patients who survived the extension treatment required a very lengthy rehabilitation due to the regularly occurring pronounced muscular inactivity atrophy (muscle wasting) and inactivity osteoporosis (bone wasting ), in addition there were joint contractures with loss of mobility in the knee and hip joint. Therefore, with the development of appropriate procedures, surgical treatment of subtrochanteric fractures has quickly gained acceptance. The aim today is primarily a load-stable osteosynthetic supply that allows immediate mobilization and physiotherapy exercise treatment.
Initially, intramedullary procedures such as the intramedullary nail developed by Gerhard Küntscher and the bundle nailing according to J. Ender were used. However, the complicated leverage at the femoral neck and proximal femoral shaft often led to material breakouts and secondary loss of correction (“slipping”) of the fracture. These procedures were therefore not load-stable and therefore almost only successful in patients with good compliance .
After the establishment of the AO , fractures near the hip joint were increasingly treated using external fixation, i.e. plate fixation and procedures derived from them such as the angle plate . The latter offered better stabilization of the femoral neck to the shaft, but proved to be technically very demanding; The "cutting out" of the blade caused problems here when the fracture gradually slipped together while shortening the femoral neck.
This problem could be largely solved by means of the dynamic hip screw (DHS) developed by the AO from the "Pohlschen tab screw" : here a powerful screw inserted into the femoral neck slides in a sleeve integrated into the plate, which causes the screw to migrate into the hip joint Rule prevented. Due to standardization and special instruments, this method was technically far less complex than the angle plate and produced more reliable results. This method is still used successfully for simple transverse or short oblique fractures without a comminuted zone.
The next advance in the treatment of these fractures was achieved with the development of intramedullary locking nails with a femoral neck component. The pioneer was the gamma nail , further developments for example the sliding nail and the proximal femoral nail. These nails are inserted from the greater trochanter without exposing the fracture area ("closed reduction"), a locking bolt inserted in the lower area across the shaft prevents the fracture from shortening even if the fragment zone is extensive, the angularly inserted femoral neck component consists of a sleeve and a support screw and therefore works similarly to the DHS mentioned above. These nails can therefore not only be used for per- and subtrochanteric fractures, but also as restorations to preserve the femoral head for femoral neck fractures. The inherently stable system usually allows the fracture to be fully loaded very early on.
If there is no malalignment, conservative treatment can in rare cases be considered in children. Common surgical procedures in children and adolescents are ESIN nailing or - rarely - angle plate osteosynthesis.
Complications
The loss of blood in the area of the bone fracture can lead to a lack of blood , so that blood transfers may become necessary. Other possible complications are wound healing disorders, thromboses, pneumonia and others. Osteonecrosis and pseudarthroses rarely occur due to the good blood supply to the bone pieces, in contrast to femoral neck fractures .
Individual evidence
- ↑ a b F. Hefti: Pediatric orthopedics in practice . Springer, 1998, ISBN 3-540-61480-X .
- ^ A. Greenspan: Orthopedic Radiology. A practical approach. 3. Edition. Lippincott Williams & Wilkins, 2000, ISBN 0-7817-1589-X , pp. 220 ff.
