Date: Fri, 27 Sep 2002 21:44:24 EDT

Subject: Intertrochanteric Hip Fx - Malrotation

What is the appropriate closed reduction technique for a displaced intertrochanteric hip fracture?

Mike Messieh

Reply at: Orthopaedic Trauma Association forum

Date: Sat, 28 Sep 2002 11:30:10 -0500

From: Andrew H. Schmidt

What is the appropriate closed reduction technique for a displaced intertrochanteric hip fracture?

Traction, slight abduction, correction of the posterior sag, and whatever degree of rotation works - in my experience it is not uncommon to find that some external rotation of the distal leg is necessary.

How much internal rotation should be applied to the leg?

It depends - slight IR helps in stable fractures, but in unstable fractures IR is often counterproductive.

Does excessive IR of the leg lead to a higher failure rate?

I don't know of any work that addresses this; how can you measure rotation on follow-up x-rays? However, unless the fracture line is perfectly transverse, rotation will also affect the neck shaft angle. Therefore, excessive rotation in either direction should result in a malreduction, which we know is a bad thing.

Are there any pearls for assessing the reduction on the lateral xray?

Watch the posterior sag.

How do most correct posterior sag?

You can get a special attachment to some fracture tables that is designed precisely to correct this problem. We don't have one, so I use a Cobb elevator placed beneath the fracture and held there by an assistant. Sometimes a crutch works beneath the buttocks.

What is the groups experience with pinning the hip with the leg in external or neutral rotation in traction?

These maneuvers can work fine - do whatever it takes to get the best reduction.

Andy Schmidt
Hennepin County Medical Center

Date: Mon, 30 Sep 2002 09:49:45 -0400

From: James Carr

For a displaced 4 part, I find closed reduction can restore the neck shaft angle, but rarely restores true bone-on-bone contact. To do this, you must pull the shaft laterally (a vector the fracture table does not provide) and lever the anterior neck with a blunt elevator until it lines up with the intact anterior cortex of the distal piece. The reduction should look like a hairline crack, and the lag screw is rarely over 130 degrees if inserted parallel to the neck. You know if you have bone on bone contact when the compression screw reaches a firm endpoint soon after tightening. The leg rotation is typically neutral for this to work. I once had a leg needing to be derotated for postop "intoeing" due to too much internal rotation. Everybody worries about the posteromedial comminution, but restoring anterior bone-on-bone contact is where it's at.