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| SYMPOSIUM — FRAGILITY FRACTURES |
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| Year : 2014 | Volume
: 7
| Issue : 2 | Page : 108-112 |
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Osteoporotic pertrochanteric fractures (fragility fracture)
Sudhir S Babhulkar
Department of Orthopaedics, Sushrut Hospital, Research Centre and Post Graduate Institute of Orthopaedics, Nagpur, Maharashtra, India
| Date of Web Publication | 14-Sep-2015 |
Correspondence Address:
Prof. Sudhir S Babhulkar
Sushrut Hospital, Research Centre and Post Graduate Institute of Orthopaedics, Central Bazar Road, Ramdaspeth, Nagpur - 440 010, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0975-7341.165214
The management of osteoporotic pertrochanteric fracture femur is 2-fold. 1. Management and care of acute fractures and 2. simultaneous treatment of underlying disease. There is hardly any role of conservative treatment, however, patients with co-morbid conditions temporary treatment with traction till patient are fit for surgery may be performed. Surgical treatment of pertrochanteric fracture should be undertaken as early as possible. Following principles of "Internal Fixation in Osteoporotic Fractures" must be carried out depending upon the type of fracture. 1. Loadsharing 2. Impaction 3. Widebuttressing 4. Longsplintage 5. Augmentation 6. Elasticfixation 7. Shortening 8. Bonesubstitution-prosthesis. Timely surgery in these patients prevents not only morbidity but mortality also. Keywords: Fragility fracture, osteoporosis, pertrochanteric fractures
How to cite this article:
Babhulkar SS. Osteoporotic pertrochanteric fractures (fragility fracture). J Orthop Traumatol Rehabil 2014;7:108-12 |
| Introduction | |  |
Osteoporosis is defined as a disease characterized by low bone mass and micro architectural deterioration of bone, leading to enhance bone fragility and a consequent increase in fracture risk. Fractures secondary to normal physiological stress on abnormal underlying bone are called as insufficiency fractures. Osteoporosis is generally accepted as being the most common underlying disease.
Osteoporosis is now recognized as a major problem of health care worldwide. Fractures are the hallmark of osteoporosis commonly affecting the distal radius, vertebral bodies, and the hips. Fractures at various other sites are also more frequent in osteoporosis than patient in good health. These can lead to considerable morbidity and are also associated with excess mortality. There are multiple socioeconomic consequences associated with these fragility fractures. [1] It is estimated that by 2050, the largest increase in the rate of hip fractures will be in Asia. [2] In 2013, it was estimated that 50 million people in India have either osteoporosis or osteopenia (International Osteoporosis Foundation 2013). [3]
One of the most important reasons for examining skeletal status in osteoporosis is to identify individuals at risk of sustaining a fracture. Bone mineral density (BMD) is widely recognized as one of the main factors predictive of fragility fractures. [4],[5],[6] The BMD studies indicate that measuring any skeletal site can predict future fracture with relative risk of around 1.5-2/standard deviation decrease in BMD.
It is clear from the available data that hip fractures are common in India and occur about 10 years earlier than in the West. [7],[8] The incidence of fragility fractures of the hip, vertebrae, and wrist assessed by a questionnaire survey was 34.3/100,000/year. [9] The incidence of radiologic vertebral fracture in Indian subjects over 50 years is similar to the Western population. [10]
Both healthy Indian men and women have lower bone density than Western counterparts. [11],[12],[13],[14],[15],[16],[17] Indian subject with fragility fractures has lower BMD. [8],[18] It is estimated that the population of those over 50 years of age is expected to grow an average of 144% by the year 2050 in Asia, with India showing the greatest total increase of 416%. There will be an estimated 620 million people over 50 years of age in India in 2050. [19] The life expectancy in India in 2013 was 67 years, which is expected to increase to 77 years by 2050. [19]
Osteoporosis remains a greatly under-diagnosed and under-treated disease, even in the case of high-risk patients who have already fractured. Fractures, particularly of the hip and spine, are associated with high morbidity and increased mortality.
A patient who has a hip fracture is at a greater risk of a second osteoporosis-related fracture, including a fracture of the contralateral hip, acetabulum, sacrum, distal radius, and proximal humerus.
| Management of Osteoporotic Pertrochanteric Fracture Femur | | |
The management of these fractures is 2-fold. Management and care of acute fractures and simultaneous treatment of underlying disease. There is hardly any role of conservative treatment, however, patients with co-morbid conditions temporary treatment with traction till patient are fit for surgery may be performed. Surgical treatment of pertrochanteric fracture should be undertaken as early as possible [Figure 1]. The detailed principle of surgical treatment will outline in detail below. | Figure 1: (a and b) X-ray of pelvis showing fragility fracture neck femur left side and trans-trochanteric fracture on right side
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Simultaneously patient must be treated for the osteoporosis, in terms of reduction of risk factors, nutritional support by plenty of Vitamin D and calcium. Pharmacological treatment of osteoporosis must be carried out depending upon the status of BMD. Commonly, estrogens, selective estrogen receptor modulators, bisphosphonates, calcitonin parathyroid hormones, and fluorides and teriparatide in consultation with physician and endocrinologist are prescribed [Figure 1].
| Surgical Treatment | | |
Several factors need considerations for planning the surgical treatment. Due consideration should be given to the functional demand of the patients and his general condition to withstand the procedure. One must give proper consideration to the increased brittleness and poor holding capacity for implants because of fragility fractures and poor co-operation for postoperative rehabilitation. One must follow strict principles of internal fixation in osteoporotic fractures; otherwise implant failure is commonly seen following poor fixation of osteoporotic fractures [Figure 2]. | Figure 2: (a) X-ray showing cut out of dynamic hip screw implant in an osteoporotic comminuted trochanteric fracture. (b) Showing cut out of screws following dynamic condylar screw fixation for subtrochanteric fractures
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Following principles of "Internal Fixation in Osteoporotic Fractures" must be carried out depending upon the type of fracture [Figure 3]: | Figure 3: The principles of internal fixation in osteoporotic fractures. (a) Load sharing fixation by nailing interlocking (b) Fixation by impaction (c) Wide buttress fixation (d) Long plate fixation (e) Bone augmentation (f) Shortening in comminuted fractures (g) Joint replacement
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- Load sharing
- Impaction
- Wide buttressing
- Long splintage
- Augmentation
- Elastic fixation
- Shortening
- Bone substitution-prosthesis
Load sharing - nailing interlocking
As far as possible, pertrochanteric fracture should be treated preferably by reconstruction nailing, proximal femoral nail (PFN), gamma nailing, etc., [Figure 4], [Figure 5], [Figure 6]. | Figure 4: (a and b) X-ray pelvis showing fragility fracture subtrochanteric treated by long proximal femoral nail
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 | Figure 5: (a-c) Comminuted intertrochanteric fracture treated by standard proximal femoral nail
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 | Figure 6: (a and b) Subtrochanteric fracture treated by long proximal femoral nail antirotation II
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Long splintage
In long comminuted fractures, subtrochanteric or shaft fixation may be done by long splintage by plating and buttressing [Figure 7]a or by intramedullary fixation [Figure 7]b. Long plates, preferably be an locking compression plates (LCP), should be used in fixation of osteoporotic bones. | Figure 7: (a) Comminuted subtrochanteric fracture treated by long plate fixation. (b) Comminuted shaft fracture treated by nailing interlocking
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Prosthetic replacement
In elderly patients with marked osteoporosis and unstable four part intertrochanteric fractures, due consideration should be given for primary prosthetic replacement. It is commonly performed as primary surgical treatment for comminuted unstable intertrochanteric fracture around the age of 70 years or above [Figure 8]. | Figure 8: (a and b) Comminuted unstable four part osteoporotic fracture in 70-year-old lady treated by primary bipolar hip replacement
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Augmentation
Fracture fixation in comminuted pertrochanteric or subtrochanteric fracture can be augmented by the use of bone grafts, bone substitutes, or bone cement. The use of bone grafts, autogenous, or allografts is commonly practiced. However, to avoid host disability, one may use bone substitutes. To enhance the internal fixation, one can use bone cement. There are multiple methods for using bone cement-polymethylmethacrylate [Figure 9] and [Figure 10]. | Figure 9: (a and b) The use of cement through the holes in specially prepared screws
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 | Figure 10: X-ray showing unstable comminuted intertrochanteric — subtrochanteric fracture treated by dynamic hip screw with augmentation by the use of cement through the fracture site
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Make drill holes and place the cement followed by insertion of screws before the cement hardens, final tightening may be done after hardening of cement. Alternatively, let the cement harden and then drill, tap, and insert the screws. Another alternative is the use of cementing screws with holes at the sides [Figure 9]. [20]
Bone grafts may be procured from the same person, cancellous, cortical, or fibular grafts. Since autogenous grafts cause disability at the donor site, one may use allografts or bone substitutes. Absorbable bone substitute, Norian SRS & HA granules are available for the use to augment the fixation [Figure 10].
| Summary and Conclusion | | |
It is necessary to identify the fragility fractures and osteoporosis in all pertrochanteric fractures. In addition to the treatment of acute fractures on the principles described above, the diagnosis of osteoporosis should be confirmed by dual-energy x-ray absorptiometry and Vitamin D3 levels to prevent another fracture. Treat the fracture surgically and medically with suitable drugs. While surgically fixing the fracture consider the principles of stabilization in osteoporotic fractures, preferably by load sharing - nailing interlocking, Long LCP or consider primary replacement arthroplasty.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
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