Inter Trochanter Fracture Management: A Review Article

Bone fracture often occurs in trauma patients. Bone fractures
can be open or closed. Although closed, fractures should...


Introduction
Bone fracture often occurs in trauma patients. Bone fractures can be open or closed. Although closed, fractures should still be treated as soon as possible because closed fractures in several places can cause a severe occult bleeding that threatens the patient's life. In adults, fractures can occur in many places, one of which should be considered is the hip (intertrochanter fr. Femur, fr. Femoral neck, disloc and fr. Of hip), pelvis (fr. Pelvis) .1 If the internal rotation is full of pelvis widened but flexed back. This may be a pathological sign of the anterosuperior femoral head, possibly avascular necrosis. However, in young people, pain on internal rotation with hip flexion can be a sign of tearing of the acetabular labrum [1]. Pain in the hip joint is felt in the groin, descending forward toward the thigh, and some to the knee, sometimes knee pain is the only symptom. Pelvic back pain rarely comes from the joints, often the pain originates from the lumbar spine. Impaired walking (asymmetry) is the next symptom that often occurs. It may occur due to compensatory mechanisms of pain or from changes in leg length, weakness of the hip abductor muscles, joint instability and the presence of bone fractures. Patients may complain of disturbances in walking long distances, and some patients begin to use assistive devices to walk [2]. An inter trochanter fracture is one of 3 types of hip fracture. The site of this fracture is in the proximal to the femur. The proximal area of the femur consists of the head of the femur, neck of the femur and the inter trochanter region.
Usually an intertrochanter fracture occurs between the major trochanters where the gluteus medius and minimus (hip extensor and abductor) muscles are attached with the minor trochanter to which the ilipsoas (hip flexor) is attached [2]. Aims of this article is to review management of inter trochanter fracture.

Discussion
Inter trochanter fractures of the femur also account for ½ of hip fractures caused by low energy mechanisms such as falling from a standing position. This fracture often occurs in people who have risk factors, including: getting older, women, there is osteoporosis, a history of falls, and abnormalities in walking. Surgery is the recommended therapy because of the high morbidity and mortality rates in non-operated patients. Usually there are also comorbidities that accompany, thus affecting the outcome of therapy [3]. The inter trochanter area of the femur is distal to the neck of the femur and proximal to the femoral shaft. This area is where the two trochanters of the femur are located. Major and minor Trochanters.
There is a femoral artery and nerve anteriorly and a sciatic nerve posteriorly. The majority of the bones in this area are cancellous, extracapsular, and have high vascularization which allows a strong healing environment to be created. The femoral calcar is a solid component of the posteromedial bone that supports the transfer of pressure from the neck to the femoral shaft. 6 The stability of the inter trochanter fracture depends on the amount of contact between the proximal and distal major fragments. A fracture consisting of 2 parts is very stable because when the two halves are reduced, they are attached to each other so that they are stable for the implant [4] (Figure 1).
In a three-part fracture, the stability of the fracture depends on the size of the fragment of the minor tochanter. Instability occurs when more than 50% of the calcar femoral is affected, causing the proximal fragment to fall into the varus position and shorten. Therefore, the fracture is said to be unstable if there is a large minor trochanter fragment or if the major and minor trochanters are separated by fracture fragments (4-part fracture) [5]. Another indicator of fracture stability is the degree of intimacy of the lateral wall of the trochanter, one part of the greater trochanter that extends to form the vastus ridge (attachment of vastus lateralis) to the tip of the greater trochanter. If the wall is fractured, the fixation may collapse at an undesirable position, or the implant will fall off [6].
The more unstable the fracture is, the more difficult it is to reduce and the more indications that implants, such as a cephalomedullary nail, will be needed to stabilize the fracture and prevent collapse.

Management of Inter Trochanter Fracture
Therapy for patients with inter trochanter fractures is of above also indicate fracture stability or instability, the need for fracture reduction, and whether further manipulation is required to make the reduction stable enough for healing before implant fixation is lost [9]. history, and results of laboratory and radiological screening. Any medical disorder needs to be treated promptly and as best as possible before operative intervention is carried out to ensure that complications do not occur due to delays in initiating treatment.
Precise measurements are needed to reduce the likelihood of developing DVT and secondary pulmonary embolism (usually considered preoperative protocol) [6,9].

Postoperative Handling
After the intertrochanter fracture has been repaired, other nonorthopedic conditions in the patient can be further treated. The DVT prevention protocol is followed by a combination or appropriate choice of antiembolic and anticoagulant stockings. Anticoagulants include aspirin, heparin or heparin derivatives, and warfarin or warfarin derivatives. Anticoagulants require proper monitoring to ensure adequate doses and to prevent over-medication and bleeding. With each treatment or protocol, the dose of therapy given is different, the length of therapy is different, and the combination of medication and anticoagulant use varies [12]. Physical therapy is needed to help the patient walk with the help of a therapist or nurse. The equipment required includes walkers, crutches, fourpost canes, and other assistive devices as recommended by the therapist and surgeon. The therapist directs the therapy program and the use of walking aids based on the surgeon's instructions.
The surgeon indicated a difference between no weightbearing, toe touching, partial weightbearing, and full weightbearing therapy and the proper technique of using a walking aid. Elderly patients may find it difficult to administer full weight-bearing therapy [10].

Complications
Intertrochanter hip fractures have a significant complication rate: 20-30% in the first year, including 5% incidence of non-union, Loss of positioning before healing can also occur if the fixator fails to work due to improper insertion [12].

Conclusion
Patients with intertrochanter fractures can undergo surgery after the medical evaluation or trauma has been performed and the medical condition has stabilized. Surgery is contraindicated when the patient has uncontrolled or uncorrected blood disorders or other metabolic disorders that cannot be corrected with possible death.