Reverse obliquity and transverse fractures of the trochanteric region of the femur; a review of 101 cases
Introduction
Most trochanteric femoral fractures have a fracture running obliquely from proximally at the greater trochanter to distally at the lesser trochanter. If such a fracture is fixed with a sliding hip screw (SHS), the fracture is at right angles to the lag screw and sliding of the device enables controlled collapse of the fracture. This is not the case for reverse obliquity and transverse fractures at the level of the lesser trochanter. These fracture lines run either distally from a medial to lateral position or transversely. Such fracture patterns are biomechanically less stable due to their tendency towards femoral medialisation. The pull of the iliopsoas muscle on the lesser trochanter attached to the distal part of the fracture displaces the femur medially (Fig. 1). This medial displacement of the femur reduces the area of bone-to-bone contact, delays fracture healing and increases the risk of fixation failure.9
The early classification system of Evans3 in 1949 made specific mention of the reverse obliquity fractures with a separate sub-classification as type II, compared to pertrochanteric fractures, which were type I. All type II fractures were considered to be unstable. Haidukewych et al.5 reported that two percent of all hip fractures had a reversed fracture pattern, with a 32% incidence of fracture healing complications. This highlights the difficulties with managing these fractures. The purposes of this further study was to add to the information and understanding of this problematic fracture pattern by determining their frequency, and analyse the results of treatment with various different types of fixation.
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Materials and methods
Between May 1989 and April 2001, information on 3336 consecutive patients admitted with a hip fracture was prospectively collected. At the time of admission all fractures were classified using the Orthopaedic Trauma Association scheme.7 One thousand four hundred and forty-two fractures were classified as extracapsular; and of these, 101 were of the reverse obliquity and transverse facture pattern (types 31A3.1, 31A3.2 and 31A3.3) (Fig. 2). Demographic data for these patients was recorded on
Results
One hundred and one reverse obliquity and transverse fractures were identified. This accounted for 3% of all hip fractures and 7% of all extracapsular fractures. One patient was treated conservatively and the remainder operatively. The reason for conservative treatment was severe chest disease. This fracture was treated with traction and the patient discharged back home after a hospital stay of 170 days. At 1 year from injury, the fracture had healed, the patient reported constant pain with
Discussion
There are few previously published reports of reverse obliquity and transverse fractures and this study comprises the largest published series to date. Reverse obliquity fractures of the proximal femur have been noted as biomechanically unstable since the classifications proposed by Evans3 in 1949. Wright13 described three cases of reverse obliquity fracture in 1947 (all treated successfully conservatively) and noted the potential instability of such fractures. Haidukewych et al.5 reported a
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