M.E.Müller: Atlas: Fracture 31-A1

Femur, Proximal, extra-articular fracture, trochanteric area, intertrochanteric 3,56% of the total
5,89% of the femur
8,42% of the segment

415 fractures
21,5% group
35%M, 65%F

453 fractures
23,4% group
38%M, 62%F

1066 fractures
55,1% group
33%M, 67%F

Simple, oblique Simple, transverse Multifragmentary +Q

These are oblique reverse intertrochanteric fractures, with the fracture line occurring through the lateral cortex and extending proximally above the level of the lesser trochanter, which remains intact. Ref. Manual of Internal Fixation :
262 - 265. 272 - 275. 530 - 533.
Surgeon. JG, JG, MS.

The reduction must be anatomic, reconstructing the medial cortex support. In this situation the ideal implant is the 95º condylar plate, which allows axial compression, either with the tension device or through the DCP plate holes, combined with interfragmentary compression lag screws to the calcar and diaphysis.

The 120º angled blade plate allows some valguization and interfragmentary compression, through its double bend, when the plate screws are tightened.The DHS, too often used indiscriminately in proximal femoral fractures, has no biomechanical sense as a sliding tutor in this fracture subgroup, although it can be effective.

preoperative + 4 months

preoperative + 4 months

preoperative + 2 years

These are transverse intertrochanteric fractures either immediately proximal or distal to the lesser trochanter, which remains intact, so the cortical contact is restored once the fracture is reduced. Ref. Manual of Internal Fixation:
262 - 265. 530 - 533.
Surgeon. RO, RO.

For anatomic reductions, the ideal implant is the 95º condylar plate, which after the blade is inserted, allows reduction of the diaphysis to the plate and axial compression combined with interfragmentary compression by a lag screw through the calcar.

Two surgical steps are essential. The exact placement of the blade determines the reduction. The drill for the calcar screw may slide and break. To avoid this accident, one must use sharp drills and slowly push through the arched hard cortex of the calcar. Either a cortical screw or the stronger cancellous screw can be used for the lag screw fixation.

preoperative + 4 months

preoperative + 1 year

preoperative preoperative

0 moths 0 moths

+ 8 moths + 8 moths

These are multifragmentary intertrochanteric fractures which always have a detached medial fragment, with the fracture line usually reversed, extending distally to the diaphysis and frequently associated with an ascending fracture line towards the greater trochanter, visible or not in the X-ray. The subgroup is caracterized by the lesser trochanter detachment, resulting in the loss of continuity of the postero-medial cortex. Ref. Manual of Internal Fixation:
262 - 265. 280 - 281. 528 - 531.
Surgeon. RO, MV, CS.

As with all of the fractures of the group, the indicated implant is the 95º condylar plate, which allows one to combine axial and interfragmentary compression effects. In this subgroup, reduction and fixation of the lesser trochanter with a lag screw, whenever possible, must be considered.

The use of the DCS implant for these fractures is only justified by the easier placement of the cannulated screw in the center of the femoral head, guided by a threaded pin. The remaining characteristics of the implant are considered by us disadvantageous with respect to the 95º condylar plate. The DCS usually determines varus reductions. It is an excessively rigid and bulky implant. Its corner can cause trochanteric bursitis. Its use has no biomechanical justification. We have been able to verify how, when there is no medial cortex contact, its thick plate suffers fatigue breakage like any other implant.

The case below is a fracture belonging to this group treated by DHS, which is not a proper indication for this kind of implant. Once the dynamic screw had been placed, the external cortex prolonguing the greater trochanter broke when applying the plate and trying to reduce the fracture. This led to a valgus angulation of the proximal fragment with biomechanical advantages. A cortical screw has purchase in the femoral calcar. The fracture collapsed when loaded, following the axes of the screws, which were therefore ejected. Thus, the fracture stabilises and heals. This case has been selected as a typical example of a dynamic intenal fixation, and to demonstrate that Nature, sometimes, helps out both the patient and the surgeon.

preoperative + 4 months

preoperative + 6 months

preoperative postoperative + 1 year




						Femur, Proximal, extra-articular fracture, trochanteric area, intertrochanteric	3,56% of the total 5,89% of the femur 8,42% of the segment






These are oblique reverse intertrochanteric fractures, with the fracture line occurring through the lateral cortex and extending proximally above the level of the lesser trochanter, which remains intact.		Ref. Manual of Internal Fixation : 262 - 265. 272 - 275. 530 - 533. Surgeon. JG, JG, MS.

The reduction must be anatomic, reconstructing the medial cortex support. In this situation the ideal implant is the 95º condylar plate, which allows axial compression, either with the tension device or through the DCP plate holes, combined with interfragmentary compression lag screws to the calcar and diaphysis.	The 120º angled blade plate allows some valguization and interfragmentary compression, through its double bend, when the plate screws are tightened.The DHS, too often used indiscriminately in proximal femoral fractures, has no biomechanical sense as a sliding tutor in this fracture subgroup, although it can be effective.






These are transverse intertrochanteric fractures either immediately proximal or distal to the lesser trochanter, which remains intact, so the cortical contact is restored once the fracture is reduced.		Ref. Manual of Internal Fixation: 262 - 265. 530 - 533. Surgeon. RO, RO.

For anatomic reductions, the ideal implant is the 95º condylar plate, which after the blade is inserted, allows reduction of the diaphysis to the plate and axial compression combined with interfragmentary compression by a lag screw through the calcar.	Two surgical steps are essential. The exact placement of the blade determines the reduction. The drill for the calcar screw may slide and break. To avoid this accident, one must use sharp drills and slowly push through the arched hard cortex of the calcar. Either a cortical screw or the stronger cancellous screw can be used for the lag screw fixation.






These are multifragmentary intertrochanteric fractures which always have a detached medial fragment, with the fracture line usually reversed, extending distally to the diaphysis and frequently associated with an ascending fracture line towards the greater trochanter, visible or not in the X-ray. The subgroup is caracterized by the lesser trochanter detachment, resulting in the loss of continuity of the postero-medial cortex.		Ref. Manual of Internal Fixation: 262 - 265. 280 - 281. 528 - 531. Surgeon. RO, MV, CS.

As with all of the fractures of the group, the indicated implant is the 95º condylar plate, which allows one to combine axial and interfragmentary compression effects. In this subgroup, reduction and fixation of the lesser trochanter with a lag screw, whenever possible, must be considered. The use of the DCS implant for these fractures is only justified by the easier placement of the cannulated screw in the center of the femoral head, guided by a threaded pin. The remaining characteristics of the implant are considered by us disadvantageous with respect to the 95º condylar plate. The DCS usually determines varus reductions. It is an excessively rigid and bulky implant. Its corner can cause trochanteric bursitis. Its use has no biomechanical justification. We have been able to verify how, when there is no medial cortex contact, its thick plate suffers fatigue breakage like any other implant.	The case below is a fracture belonging to this group treated by DHS, which is not a proper indication for this kind of implant. Once the dynamic screw had been placed, the external cortex prolonguing the greater trochanter broke when applying the plate and trying to reduce the fracture. This led to a valgus angulation of the proximal fragment with biomechanical advantages. A cortical screw has purchase in the femoral calcar. The fracture collapsed when loaded, following the axes of the screws, which were therefore ejected. Thus, the fracture stabilises and heals. This case has been selected as a typical example of a dynamic intenal fixation, and to demonstrate that Nature, sometimes, helps out both the patient and the surgeon.