A.

BACKGROUND
Bone has many functions; including supporting the body tissue and
body organ shield, allowing the movement and mineral salt storage. Its
function, however, can be lost by fall, collision or accident that resulted in
fracture. A bone fracture is an event of continuity loss of bone tissue and/or
cartilage, which commonly caused by involuntary rupture. The injury that
causes fractures can be either direct or indirect trauma. 10
Fracture can be classified into open and closed fracture. In closed
fracture, there is no communication between bone fragments with the
environment. In open fracture, there is a communication between bone
fragments with the environment due to injury of the skin. The configuration
of fracture fragment including transverse, oblique, spiral, compression or
crush, comminuted and greenstick. 6
Fractures are more common in men than women under 45 years of age
and often associated with sports, work or injuries caused by motor vehicles.
Higher rate of mobilization in men is responsible for the high risk of
fracture. Whereas in older people, women are more likely to experience
fractures than men. It is associated with an increased in incidence of
hormone-related osteoporosis in menopause (Apley, 1995). Fracture of
intertrochanteric is one of 3 types of pelvic fractures. Intertrochanteric
fractures occur between 2 trochanters in which the greater trochanter is
attached by gluteus medius and minimus (hip extension and abduction) and
lesser trochanter is attached by iliopsoas (hip flexion) muscle. 3
The goal of rehabilitation is to return the patient function as high as
level of function prior the injury. In many cases, this is not realistic. Only
20% to 35% of patients can return according to the level of function before
the injury occurs. Approximately 15-40% of cases require constitutional
treatment more than 1 year after injury. About 50-83% of cases need tools to
help the ambulation. The aim of rehabilitation should be individualized,
with the therapist calculating comorbidity, fracture severity, and motivation
level of the patient. Successful in therapeutic goals of injuries or lesions in
 the lower extremities are restoring the range of motion of all joints,
rehabilitation of all muscle and tendon units, and unrestricted weight
bearing.2,9

B. ANATOMY OF FEMUR
Femur, the longest and heaviest bone in the body, continues the
weight from os coxae to the tibia as we stand. The head of femur propagates
toward the craniomedial and slightly to the ventral when jointed with the
acetabulum. The proximal end of the femur consists of a femoral head and 2
trochanters (greater trochanter and lesser trochanter).8

Figure 1. Anatomy of Femur

The intertrochanteric area of the femur is the distal region of the

femoral neck and proximal of the femoral shaft. This area is located between
the greater trochanter and the lesser trochanter. The head and neck of femur
form an angle (1150-1400) to the long axis of the shaft of femur; This angle
varies with age and gender. Shaft of femur curved, i.e convex towards the
anterior. The distal end of the femur, ending into 2 condylus, the medial and
the latera epicondylus curved like a thread.4,8

Figure 2. Vascularization of the femur

C. DEFINITION OF FRACTURE
Fracture is defined as a break in continuity of the bone, often followed
by soft tissue damage with varying degrees, which affects blood vessels,
muscles, and nerves.3
The definition of intertrochanteric fracture of the femur is the break of
bone continuity in the area between the greater and lesser trochanter
extracapsullary.1
D. CLASSIFICATION OF FEMUR FRACTURE
The are two types of femur fractures:
1. Intracapsular fracture
Occurs in joint, hip, and capsule
Through the femoral head
Just below the femoral head
Through the neck of femur
2. Extracapsular fracture
Occurs outside the joints and capsules, through the greater or lesser
trochanter of the femur or in the intertrochanteric region.
Occurs distal to the neck of the femur but no more than 2 inches
below the lesser trochanter7

While the classification for intertrochanteric is based on the stability

of the fracture pattern, i.e stable fracture (standard oblique fracture pattern)
and unstable fracture (reverse oblique fracture pattern). 3

Figure 3. Classification of hip fracture

Intertrochanteric fracture

In this fracture, the transverse fracture line is formed from the

greater trochanter to the lesser trochanter. Unlike intracapsular
fractures, this type of extracapsular fracture can integrate better.
The risk for non-union complications and avascular necrosis is
very small compared to the risk of intracapsular fracture

Fracture may result from direct trauma to the greater

trochanter or indirect trauma causing twisting of that area.
 Based on Kyle's classification (1994), intertrochanteric
fractures can be divided into 4 types according to the stability of
the bone fragments. Fracture is termed to be unstable if:

- The connection between bone fragments is not good.

- There is a continuous force that causes displaced bones to
become more severe.
- Fracture is accompanied or caused by the presence of
osteoporosis.

Figure. Kyles Classification for intertrochanteric fracture1

Figure. Evans classification for intertrochanteric fracture10

E. ETIOLOGY OF FRACTURE
1. Injury
Most fractures are caused by sudden and excessive muscle force,
due to beating, destruction, bending, twisting, or pulling force. When
exposed to direct force, the bone may be broken at the affected site; Soft
tissue is also undoubtedly damaged. When exposed to indirect forces, the
bone may fracture away from the affected site; Soft tissue damage at the
site of fracture may not exist.1
2. Compression
Cracks can occur in bone, just as in metals and other objects, due
to repeated pressures. This condition is most commonly found in tibia or
fibula or metatarsal, especially in athletes, dancers, and military
personnel who have gruelling exercise programmes 1
3. Pathological Fracture
Fractures may occur even with normal pressure if the bone has
been weakened (eg. by a tumor) or if the bone is very fragile (eg. in
Paget's disease).
F. DIAGNOSIS
To establish the diagnosis of fractures, history taking, physical
examination, and additional investigation are required, as follows:
1. History Taking
In general, there is a history of injury (mechanism of injury),
followed by the inability to use an injured limb. After falling down,
patient unable to stand, the affected leg is shorter and rotated compared
to the neck fracture of femur (because the fracture is extracapsular) and
the patient is unable to lift his leg.1
2. Physical examinaton
Localized sign in fracture may be found as follows:
- Look
Swelling, bruising, deformity may be obvious, but the important
thing is whether the skin is intact or not.1
- Feel
There is local tenderness, but it is also necessary to check the distal
part of the fracture to feel the pulse and test the sensation 1
- Movement
Crepitations and abnormalities can be found, but it is more important
to ask patient to move the joints in the distal part of the injury.1
3. Additional Investigation
Radiological examination of the hip joint including x-ray of pelvic
in anteroposterior (AP) view and injured areas, as well as lateral view of
hip. In some cases, CT scan may be required..4

Figure 4. Radiological appearance of the intertrochanteric fracture

of the femur

G. FRACTURE HEALING
 The healing process of the fracture begins since the fracture occurs as a
body effort to repair the damage. The healing of the fracture is affected by
several local and systemic factors, as for local factors:
1. Fracture site
2. Type of the affected bone
3. Stability of anatomical repositioning and immobilization
4. The presence of contacts between fragments
5. The presence or absence of infection
6. Severity of fracture

Systemic factors:
1. General condition of the patient
2. Age
3. Malnutrition
4. Systemic disease

The fracture healing process consists of several phases, as follows:

1. Reactive Phase
a. Haematoma formation and inflammation
b. Granulation tissue formation
2. Reperative Phase
a. Callus formation
b. Lamellar bone
3. Remodelling Phase
a. Remodelling in to the original bone form

In classical histological term, fracture healing has been divided in to

primary and secondary fractures healing.

1. Primary fracture healing

 This healing process occurs through internal remodeling which
includes direct efforts by the cortex to rebuild itself when continuity is
impaired. In order for the fracture to become fused, the bone on one side
of the cortex must coalesce with the bone on the other side (direct
contact) to establish the mechanical continuity.
There is no relation with callus formation. Internal remodeling of the
Haversian system occurs and fracture fragments are united.

2. Secondary fracture healing

Secondary healing includes responses of periostium and external
soft tissues. The healing process of this fracture is broadly divided into 5
phases, i.e haematoma formation phase (inflammation), proliferation
phase, callus phase, ossification, and remodelling.
i. Inflammatory Phase
The inflammatory phase lasts for several days and disappears with
alleviating of swelling and pain.

ii. Proliferation phase

In approximately 5 days, the haematoma will undergo
organization, forming fibrin threadss in the blood, forming tissues
for revascularization, and invasion of fibroblasts and osteoblasts.

iii. Callus Formation Phase

This phase occurs after haematoma and proliferation phases
begin to form bone tissue as a network of bone chondrocytes that
begin to grow or generally referred as cartilage tissue.

iv. Stage of Consolidation

 By continuous osteoclast and osteoblast activity, the
immature bone (woven bone) is transformed into mature one
(lamellar bone).

v. Stage of Remodelling.
The fracture has been connected with a strong bone sheath
which is different from the normal bone. Within months and even
years there is a continuous process of formation and absorption of
bone, thick lamella will be formed at the side with high pressure. 1,3,7

H. COMPLICATION OF FRACTURES
Local complications of fractures can be divided in to early and later
complication
b. Early complication of fracture
i. Bone : infection
ii. Soft tissue
Blister and laceration due to casting
Ruptured muscle and tendon
Vascular injury (including compartment syndrome)
Nerve injury
Visceral injury
iii. Joint
Hemarthrosis and infection
Ligament injury
Algodystrophy
c. Late Complication of Fracture
i. Bone
Avascular necrosis
Delayed-and non-union
Mal-union
 ii. Soft Tissue
Decubitus ulcer
Myositis ossificans
Tendinitis and tendon rupture
Nerve pressure and entrapment
Volkmanns Contracture
iii. Joint
Instability
Stiffness
Algodystrophy

Patients with femoral intertrochanteric fractures are at risk of

developing thromboembolic disease and death as in patient with fracture of
femoral neck. In addition, the risk of osteonecrosis and non-union is minimal,
because of the good blood supply in the femoral region. 9

I. MANAGEMENT OF FRACTURE5
a. Surgery
Open Reduction Internal Fixation (ORIF)
b. Medical Rehabilitation
Medical rehabilitation for intertrochanteric fracture includes:

Duration Treatment
Prevention Measure
Avoid the passive ROM

First day 1
Range of Motion (ROM)
week
Active ROM on hip and knee with flexion, extension,
abduction, and adduction
 Muscle Strength
Isometric exercises at m.gluteus and m.quadriceps

Fungsional Activity
Transfer to stand-pivot for non-weight bearing. For weight
bearing, the affected limb is used during transfer
Use supportive tool for ambulation
Weight bearing
Weight bearing fits the tolerance for a stable fracture. Toe-
touch to partial weight bearing or non-weight bearing for
unstable fracture.

Prevention measure
Avoid standing on an injured leg without help.
Avoid passive ROM.

Range of Motion
Active ROM at hip and knee. Hip is flexed over 900.

Muscle Strength
Isometric exercises for glutei, quadriceps and hamstrings.
2 Weeks

Functional Activity
Depending on the weight bearing, the patient performs a stand-
pivot transfer or uses the affected extremity during transfer. For
ambulation, use a supportive tool.

Weight bearing
Depending on the procedure, weight bearing is tolerated. Non-
weight bearing to partial weight bearing, toe-touch for unstable
fracture.
 Prevention measure
Avoid twisting or rotation at the fracture side.

Range of Motion
Active, active-assistive ROM at hip and knee.

Muscle Strenght
Isometric exercises for glutei, quadriceps and hamstrings.
Active resistive exercise for quadriceps, glutei, and hamstrings,
if joint movement is well-tolerated
4 6 weeks
Functional Activity
Depending on the weight bearing, stand-pivot or weight
bearing as tolerated to the affected limb during the transfer.
Perform ambulation with supportive tools.

Weight bearing
Weight bearing fits the tolerance for a stable fracture. Partial
weight bearing, non-weight bearing to toe-touch for unstable
fracture.

Prevention Measure
None

Range of Motion
8 12 weeks
Continue active, active-asisstive ROM. Start passive ROM and
warming the hip and knee up

Muscle Strenght
 Progressive resistive exercises at hip and knee.

Functional Activity
Patients use extremities including full weight bearing under
tolerance or weight bearing during transfer and ambulation.
Stop using the supportive tool.

Weight bearing
Full weight bearing
12 16 weeks No change