What is the most common extracapsular fracture in the elderly?

Intertrochanteric Fractures Are the Most Common Extracapsular Fractures in the Elderly

Intertrochanteric fractures are the most common type of extracapsular hip fractures in the elderly population, accounting for approximately half of all hip fractures. 1

Classification of Extracapsular Hip Fractures

Extracapsular hip fractures include:

1. Intertrochanteric fractures (most common)

   • Can be divided into stable (AO/OTA 31-A1 and A2) and unstable (AO/OTA 31-A3) types
   • Occur between the greater and lesser trochanters

2. Subtrochanteric fractures (less common)

   • Occur below the lesser trochanter

Clinical Significance of Extracapsular Fractures

Extracapsular fractures have important clinical characteristics that differentiate them from intracapsular fractures:

• Greater blood loss: Blood loss from cancellous bone can exceed one liter, especially with greater comminution and larger bone fragments 1
• More painful: Greater periosteal disruption causes extracapsular fractures to be considerably more painful than intracapsular fractures 1
• Higher morbidity and mortality: When treated conservatively with traction and bed rest, these fractures are associated with increased morbidity and mortality 1

Management Approach

Surgical Management

Surgical fixation is the standard of care for extracapsular fractures in the elderly:

• Intertrochanteric fractures:

  • Stable intertrochanteric fractures (31-A1/A2): Sliding hip screw is favored 1
  • Unstable intertrochanteric fractures (31-A3): Antegrade cephalomedullary nail is recommended 1, 2

• Subtrochanteric or reverse oblique fractures:

  • Strong evidence supports using cephalomedullary devices 1

Surgical Considerations

• Implant selection: While sliding hip screws and intramedullary nails show similar outcomes for stable pertrochanteric fractures, intramedullary nails are clearly superior for unstable (AO/OTA 31-A3) fractures 2
• Risk factors for complications: Cut-out risk is significantly higher in basicervical fractures regardless of nail design 3
• Timing: Early surgical intervention is associated with better outcomes and reduced mortality 1

Postoperative Care

Comprehensive postoperative care is essential and should include:

• Appropriate pain management
• Antibiotic prophylaxis
• Correction of postoperative anemia
• Regular assessment of cognitive function
• Assessment for pressure sores
• Monitoring of nutritional status and renal function
• Early mobilization 1

Rehabilitation

An appropriate rehabilitation program should include:

• Early postfracture introduction of physical training
• Muscle strengthening
• Long-term continuation of balance training
• Multidimensional fall prevention 1

Pitfalls and Caveats

• Conservative management (traction and bed rest) should be avoided as it significantly increases morbidity, mortality, and reduces the chance of the patient returning home 1
• Inappropriate implant selection for unstable fractures can lead to fixation failure
• Inadequate reduction and poor implant positioning in the femoral head can lead to cut-out and operation failure 2
• Despite some centers trending toward intramedullary devices for all intertrochanteric fractures, evidence does not support this practice for stable fractures (31-A1/A2) and it carries excess cost 4

Understanding the prevalence and management of intertrochanteric fractures is crucial as they represent the most common extracapsular fracture pattern in the elderly and require specific treatment approaches to optimize outcomes and reduce mortality.