hip fracture and surgery - Learning issue Hip fractures...

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Learning issue: Hip fractures: surgery types, when, other treatment, life expectancy Name: Michael Holmes At our institution, Boyd and Griffin (1949) classified fractures in the peritrochanteric area of the femur into four types. Their classification, which included fractures from the extracapsular part of the neck to a point 5 cm distal to the lesser trochanter, follows ( Fig. 52-2 ): Type 1: Fractures that extend along the intertrochan-teric line from the greater to the lesser trochanter. Reduction usually is simple and is maintained with little difficulty. Results generally are satisfactory. Type 2: Comminuted fractures, the main fracture being along the intertrochanteric line, but with multiple fractures in the cortex. Reduction of these fractures is more difficult because the comminution can vary from slight to extreme. A particularly deceptive form is the fracture in which an anteroposterior linear intertrochanteric fracture occurs, as in type 1, but with an additional fracture in the coronal plane, which can be seen on the lateral radiograph. Type 3: Fractures that are basically subtrochanteric with at least one fracture passing across the proximal end of the shaft just distal to or at the lesser trochanter. Varying degrees of comminution are associated. These fractures usually are more difficult to reduce and result in more complications at operation and during convalescence. Type 4: Fractures of the trochanteric region and the proximal shaft, with fracture in at least two planes, one of which usually is the sagittal plane and may be difficult to see on routine anteroposterior radiographs. If open reduction and internal fixation are used, two- plane fixation is required because of the spiral, oblique, or butterfly fracture of the shaft. The most difficult types to manage, types 3 and 4, accounted for only about one third of the trochanteric fractures in Boyd and Griffin's series. Evans devised a widely used classification system based on the division of fractures into stable and unstable groups ( Fig. 52-3 ). He divided unstable fractures further into those in which stability could be restored by anatomical or near-anatomical reduction and those in which anatomical reduction would not create stability. In an Evans type I fracture, the fracture line extends upward and outward from the lesser trochanter. In type II, reverse obliquity fracture, the major fracture line extends outward and downward from the lesser trochanter. Type II fractures have a tendency toward medial displacement of the femoral shaft because of the pull of the adductor muscles.
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Nonoperative Treatment
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