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 Table of Contents  
SYMPOSIUM FRAGILITY FRACTURES
Year : 2014  |  Volume : 7  |  Issue : 2  |  Page : 108-112

Osteoporotic pertrochanteric fractures (fragility fracture)


Department of Orthopaedics, Sushrut Hospital, Research Centre and Post Graduate Institute of Orthopaedics, Nagpur, Maharashtra, India

Date of Web Publication14-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
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-7341.165214

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  Abstract 

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

How to cite this URL:
Babhulkar SS. Osteoporotic pertrochanteric fractures (fragility fracture). J Orthop Traumatol Rehabil [serial online] 2014 [cited 2019 Jun 19];7:108-12. Available from: http://www.jotr.in/text.asp?2014/7/2/108/165214


  Introduction Top


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 Top


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 Top


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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  1. Load sharing
  2. Impaction
  3. Wide buttressing
  4. Long splintage
  5. Augmentation
  6. Elastic fixation
  7. Shortening
  8. 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 Top


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.

 
  References Top

1.
Hernlund E, Svedbom A, Ivergård M, Compston J, Cooper C, Stenmark J, et al. Osteoporosis in the European Union: Medical management, epidemiology and economic burden. A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA). Arch Osteoporos 2013;8:136.  Back to cited text no. 1
    
2.
Cooper C, Campion G, Melton LJ 3 rd . Hip fractures in the elderly: A world-wide projection. Osteoporos Int 1992;2:285-9.  Back to cited text no. 2
    
3.
The Asia-Pacific Regional Audit. Epidemiology, Costs and Burden of Osteoporosis in 2013. Published by International Osteoporosis Foundation. Available from: http://www.iofbonehealth.org. [Last accessed on 2015 Sep 08].  Back to cited text no. 3
    
4.
Marshall D, Johnell O, Wedel H. Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ 1996;312:1254-9.  Back to cited text no. 4
    
5.
Miller PD, Siris ES, Barrett-Connor E, Faulkner KG, Wehren LE, Abbott TA, et al. Prediction of fracture risk in postmenopausal white women with peripheral bone densitometry: Evidence from the National Osteoporosis Risk Assessment. J Bone Miner Res 2002;17:2222-30.  Back to cited text no. 5
    
6.
Johnell O, Kanis JA, Oden A, Johansson H, De Laet C, Delmas P, et al. Predictive value of BMD for hip and other fractures. J Bone Miner Res 2005;20:1185-94.  Back to cited text no. 6
    
7.
Mithal A, Kaur P. Osteoporosis in Asia: A call to action. Curr Osteoporos Rep 2012;10:245-7.  Back to cited text no. 7
    
8.
Dhanwal DK, Siwach R, Dixit V, Mithal A, Jameson K, Cooper C. Incidence of hip fracture in Rohtak district, North India. Arch Osteoporos 2013;8:135.  Back to cited text no. 8
    
9.
Tandon N, Mithal A, Anjana RM, Pradeepa R, Deepa M, Mani K, et al. Population Prevalence of Fragility Fractures in India Based on a Nationwide Questionnaire Based Epidemiological Study. Abstract at IOF Regionals 2 nd Asia-Pacific Osteoporosis and Bone Meeting, Gold Coast, Australia; 2011.  Back to cited text no. 9
    
10.
Marwaha RK, Tandon N, Gupta Y, Bhadra K, Narang A, Mani K, et al. The prevalence of and risk factors for radiographic vertebral fractures in older Indian women and men: Delhi Vertebral Osteoporosis Study (DeVOS). Arch Osteoporos 2012;7:201-7.  Back to cited text no. 10
    
11.
Pande KC. Prevalence of low bone mass in healthy Indian population. J Indian Med Assoc 2002;100:598-600, 602.  Back to cited text no. 11
    
12.
Pande KC, Veeraji E, Pande SK. Normative reference database for bone mineral density in Indian men and women using digital X-ray radiogrammetry. J Indian Med Assoc 2006;104:288-91.  Back to cited text no. 12
    
13.
ICMR. Population based reference standards of peak bone mineral density of Indian males and females: An ICMR multi-centre task force study. New Delhi: ICMR Publication; 2010. p. 1-24.  Back to cited text no. 13
    
14.
Kadam N, Chiplonkar S, Khadilkar A, Divate U, Khadilkar V. Low bone mass in urban Indian women above 40 years of age: Prevalence and risk factors. Gynecol Endocrinol 2010;26:909-17.  Back to cited text no. 14
    
15.
Aggarwal N, Raveendran A, Khandelwal N, Sen RK, Thakur JS, Dhaliwal LK, et al. Prevalence and related risk factors of osteoporosis in peri- and postmenopausal Indian women. J Midlife Health 2011;2:81-5.  Back to cited text no. 15
    
16.
Marwaha RK, Tandon N, Garg MK, Kanwar R, Narang A, Sastry A, et al. Vitamin D status in healthy Indians aged 50 years and above. J Assoc Physicians India 2011;59:706-9.  Back to cited text no. 16
    
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Agrawal NK, Sharma B. Prevalence of osteoporosis in otherwise healthy Indian males aged 50 years and above. Arch Osteoporos 2013;8:116.  Back to cited text no. 17
    
18.
Pande KC, Pande S, Babhulkar S. Low bone mineral density in Indian patients with fragility fractures. Climacteric 2012;15:163-6.  Back to cited text no. 18
    
19.
Government of India. Ministry of Home Affairs. Office of the Registrar General and Census Commissioner, India; 2011. Available from: http://www.censusindia.gov.in. [Last accessed on 2014 Sep 24].  Back to cited text no. 19
    
20.
McKoy BE, An YH. An injectable cementing screw for fixation in osteoporotic bone. J Biomed Mater Res 2000;53:216-20.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

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