1. Extracapsular Fractures

2. Intertrochanteric Fractures
Common in elderly, osteoporotic women.
They unite easily, rarely cause Osteonecroses.
Mechanism of injury:
Fall on the greater trochanter.
Indirect twisting injury.
Pathological fractures.

3. The line of the fracture runs from the greater to the lesser trochanter.

4. Clinical Features Old female, after fall she is unable to stand.
The leg is short and externally rotated.
Examine for concomitant medical diseases and possible cause of pathological fracture.

5. Plain X-ray Kyle classification: Type I: Undisplaced, uncomminuted.
Type II: Displaced with comminution of lesser trochanter.
Type III: Displaced with comminution of lesser and greater trochanter.
Type IV: Sever comminution with subtrochanteric extension.

6. Treatment Always surgery:
1. Early mobilization of the patient to avoid the general fracture complications (local and systemic).
2. To get the best position in AP and Lateral planes because malunion is very common.

7. General (DVT, PE, pneumonia, bed sores).
Surgical Treatment
Closed reduction under x-ray control and internal fixation by (dynamic hip screw, proximal femoral nail or angled blade and plate).
Complications:
General (DVT, PE, pneumonia, bed sores).
Failed fixation.
Malunion (Varus).
Non union.

8. Fracture Shaft Femur
Strong muscles make displacement severe and reduction difficult.
Mechanism of injury:
Its fracture of young adult results from high energy trauma,
Elderly shaft fractures may be pathological,
Children's may be victims of child abuse.
Spiral fracture (indirect injury) FFH.
Transverse and oblique
(anulatory or direct force) RTA.

9. Displacement: Comminuted (combined forces).
Proximal and mid shaft fractures: proximal shaft flexes and abduct (iliopsoas, gluteus medius).
Distal fractures: proximal shaft adduct, distal fragment flex by gastrocnemius.
1-2 liters of blood may be loosed
( periostium, perforators).

10. Clinical Features Swelling ,deformity and echymoses.
General examination (shock, other injuries).
Examine the neurovascular system, hip and pelvis.
X-ray: two views& two joints (site, type, comminution, displacement,…..).

11. Treatment Emergency treatments: Shock.
Immobilization (Thomas splint, tie to other leg), in hospital skeletal traction}.

12. Definitive Treatment Traction: used only for children below 10 years
( neonate gallows traction) for 2 weeks followed by hip spica cast for 4 weeks.

13. Acceptable angulations
Neonates(60ْ -80ْ ).
Infants(30ْ ).
Between 2-10 years(20ْ and 2cm shortening).
Teenagers(15ْ ).

14. Open reduction and plating:
Fractures at either ends with intra articular or trochanteric extensions.
Fractures with vascular injury.
Fracture shaft in a growing child.
Locked Intramedullary nailing: the standard method for most fractures.
Flexible Intramedullary Nail (teenagers).

15. 5. External fixation: (compound fracture, multiple fractures, bone loss to perform bone transport, adolescent fracture femur).
6. Pathological fractures best treated by intramedullary nailing and bone cementing.

16. Complications Early: a- Shock (hypovolemic, neurogenic).
b- Fat embolism and ARDS.
c- Thromboembolism.
d- Infection.
Late:
Delay union and non union(100days).
Malunion(>15 ْangulations, shortening> 2cm).
Joint stiffness.
Refracture and implant failure.