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Type-IV Intertrochanteric Fractures


- See: Unstable Intertrochanteric Fractures

- Discussion:
    - consist of an intertrochanteric frx w/ a subtroch component;
    - constitutes 15% of intertroch frx;

- Treatment Options:
    - sliding hip-screw or 2nd-generation locking nail may be used in rx of intertroch-subtroch frx that have femoral shaft extension;
    - second-generation locking nail is an excellent form of fixation if piriformis fossa is intact;
    - when piriformis fossa is not intact, rx w/ hip-screw w/ long side-plate, combined w/ limited interfragmentary fixation & bone-grafting;
    - in subtroch frx that extend quite distally into shaft & that are combined w/ intertroch frx & involvement of piriformis fossa, reconstration IM nail may be only option;
           - however, surgeon should anticipate difficulty in its use because starting point has been destroyed;
    - in the report by Barquet A, et al, the authors identified 52 closed intertroch-
           subtrochanteric fracture which underwent internal fixation with an IM nail;
           - at one year, 7 patients died and 2 were lost to follow up;
           - 83% of patients were restored to their preinjury status and rate of union was 100%;
           - technical points: the tip of the greater troch is used as a starting point, but in cases of intertroch frx, the starting point goes directly through the fracture site;
           -Intertrochanteric-subtrochanteric fractures: treatment with the long Gamma nail.

- Case Example:
    - 30-year-old infantry man who sustained an intertroch/subtroch fracture during a parachute jump;
    - at 8 months postop he was wt bearing as tolerated and asymptomatic, despite evidence of delayed healing of the subtrochanteric component; (bone grafting was not used in this case)