CLASSIFICATION AND TREATMENT OF TROCHANTERIC

FRACTURES
HAROLD B. BOYD, M.D.
MEMPHIS, TENN.
AND

LAWRENCE L. GRIFFIN, M.D.

AUSTIN, TEXAS

THE
the study of 300 trochanteric
data obtained from
fractures of the femur treated by the
staff of the Campbell Clinic. The results obtained by internal fixation
are compared with those following nonoperative methods. A classifi-
cation is given based on prognosis and the difficulty of securing and
maintaining reduction. The number of cases was arbitrarily limited to
300 to facilitate calculation of data. These were as nearly consecutive
as possible, consistent with the availability of roentgenograms and com-

pleteness of records. All were private patients and most were treated
at the Campbell Clinic, since a complete series of roentgenograms was
not always preserved at other hospitals. Avulsion fractures of the
greater or lesser trochanter were excluded.
A number of classifications of trochanteric fractures are recorded in
the literature. These have generally been based on the anatomic site
of the fractures. Stuck1 (using Boehler's classification), Moore,2
Briggs and Keats 3 and others classified trochanteric fractures primarily
from an anatomic standpoint. Key's 4 and Myron Henry's 5 classifica¬
tions were devised as guides to the use of various types of internal
fixation.
Read at the Fifty-Sixth Annual Meeting of the Western Surgical Association,
St. Louis, Dec. 4, 1948.
From the Campbell Clinic and the Department of Surgery, University of
Tennessee, Memphis, Tenn.
1. StW.
uck, G.: The Treatment of Intertrochanteric Fractures of the Femur,
Surgery 15:276 (Feb.) 1944.
2. Moore, J. R.: Fractures of the Upper End of the Femur Including Fracture
Dislocation at the Hip Joint, Am. J. Surg. 44:117 (April) 1939.
3. Briggs, H., and Keats, S.: Management of Intertrochanteric Fractures of
the Femur by Skeletal Traction with the Beaded Kirschner Wire, Am. J. Surg.
71:788 (June) 1946.
4. Key, J. A.: Internal Fixation of Trochanteric Fractures of the Femur,
Surgery 6:13 (July) 1939.
5. Henry, M. O.: Intertrochanteric Fractures, Minnesota Med. 26:690 (Aug.)
1943.
 In the study of this series, the cases were grouped according to
the relative ease or difficulty of securing and maintaining reduction ;
this, we feel, provides information of value in planning the treatment
and estimating prognosis. Four types were designated.
the
I
Type designates fractures showing a more or less linear break
extending along the general direction of the intertrochanteric line from
greater to lesser trochanter (fig. 1). In this group reduction is usually
simple and maintained with the least difficulty.

Fig. 1.—Types of trochanteric fracture.

Type II designates fractures which are comminuted, with the main

line of fracture being along the intertrochanteric line but with multiple
breaks occurring in the cortex (fig. 1). Here reduction is more difficult.
In this type degrees of comminution vary from slight to the extreme.
One deceptive form of type II fracture is that which on an anteroposterior
roentgenogram appears to be a linear intertrochanteric fracture, or
type I, but in the lateral view of the femoral neck and trochanter
reveals an additional fracture in the coronal plane.
 Type III designates fractures which are essentially subtrochanteric,
with at least one fracture line passing across the upper end of the
shaft just below or in the region of the lesser trochanter (fig. 1).
Various degrees of comminution may be associated with this type.
The features seen in either type I or type II may be present in addition
to the subtrochanteric fracture. Type III fractures are generally much
more difficult to reduce and to maintain in reduction than either of
the first two types.
Type IV designates comminuted fractures which extend through
the trochanteric region and usually on into the shaft, with fracture

Takle 1.—Trochanteric Fractures of the Femur

Type Number of Cases Percentage
1. 88 29.3
II. Ill 37.0
III. 80 26.7
IV. 21 7.0
Total. :m 100.0

Table 2.—Mortality of Trochanteric Fractures of the Femur

Number of
Age Cases Number Percentage
Under 59. 62 0 0
60 to 69. 48 4 S.33
70 to 79. IIS 1!) 16.1
80 to 89. 60 23 38.3
90 to 96. 9 77.8
Exact age unknown. 1 33.3
Total. 300 54 18.0

lines in at least two planes. In the event open reduction and internal
fixation are employed, these fractures require two plane fixation.
The frequency of the four types is noted in table 1. Fortunately the
most difficult fractures to manage, types III and IV, constituted only
33.7 per cent of the entire series.
Ninety and seven-tenths per cent of the patients were over 50
years of age, with the average age for the series being 69.7 years. The
mean age (representing 39.7 per cent of all the patients) was 70 to 79
years of age. A marked sex difference was seen; 226, or 75.8 per cent,
of the patients were females and 74, or 24.2 per cent, were males. None
of the patients had more than one trochanteric fracture, but patients
were included in the series who had a fracture of the femoral neck on
one side and a trochanteric fracture on the other, not simultaneously.
Additional fractures were seen in 25, or 8.3 per cent, of the patients ;
sixteen of these were Colles' fractures and nine were other fractures.
The mortality rate was 18 per cent, 54 deaths in 300 cases. The
mortality rate by decades is shown in table 2. As shown, no deaths
occurred in patients under 60 years of age. The mortality rate increased
with each decade to 77.8 per cent in the tenth decade. A breakdown
of mortality following the four main types of treatment used is shown
in table 3. It is of interest to note that although a greater proportion
of patients die after internal fixation during the first month, 13.3 per cent

Table 3.—Mortality in Types of Treatment of Trochanteric Fractures of the Hip

Type of Number of Under Under After
Treatment Cases 1 Mo. 3 Mo. 3 Mo. Percentage
None. S 4 0 0 50
Traction. 6 0 10 16.7
Casts. 77 7 6 1 18.2
Internal fixation. 209 28 6 1 16.7

Total. 300 39 13 2 18.0

Table 4.—Types of Treatment for Trochanteric Fractures of the Hip

Treatment Number Percentage
None. S 2.8
Traction. 6 2.0
Casts. 77 25.7

Nonoperative. 91 30.5
Neuf eld nail. 164 54.5
Jewett nail. 28 9.3
Other types of internal fixation. 17 5.7

Operative. 209 69.5

Total. 300 100.0

as compared with 9 per cent of those treated by casts, the total mortality
rate,including deaths known to have occurred at least in the first three
months after injury, showed a lower rate, 16.7 per cent in the. operative
group as compared with 18.2 per cent of those treated by casts.
The types of treatment used in these cases are shown in table 4.
These data do not represent the present policy toward the treatment of
trochanteric fractures. The nonoperative group, 30.5 per cent, largely
represents the patients treated in the earlier years included in this
study. At the present time the vast majority of patients are treated
by operative methods. Since the Jewett nail has been used only
during the past two and a half years, it is now being used in a larger
percentage of patients than indicated in the table.
 In the patients listed as having no treatment a Thomas splint with
adhesive traction was applied to the involved leg, but no further
measures were taken, generally because the patient's condition was
too poor to warrant more aggressive treatment. Four of these patients
died shortly after admission to the hospital, and 2 were carried home,
with no follow-up information available. In 1 patient union occurred in
three months, but with coxa vara deformity. The eighth patient, who
had fallen on the hip of an amputated limb, was treated in bed for a
month and then allowed up on crutches without wearing his prosthesis ;
the fracture united without deformity.
Six patients were treated by traction, 2 with skeletal traction and
4 with adhesive traction on Hodgen's splints. One died after three
months in traction, 1 was "taken home to die" after seventy-six days,
without follow-up, and in 4 the fracture united, with coxa vara in 2.
This method was not favored because of the immobility of the patient in
bed and the long period of hospitalization required.
Seventy-seven patients were treated in plaster of paris casts.
Sixty-six of these were placed in body casts in which a Hoke well leg
traction was incorporated, i. e., adhesive traction, beneath the cast on
the affected leg, attached to a ratchet to maintain the traction. This
method was considered the most satisfactory of the nonoperative pro¬
cedures, as the patient could be turned over in bed. Also, if the
patient's general condition permitted, hospital care would be shortened
to a few weeks, provided proper nursing and medical care were avail¬
able at home.
In the group treated by casts as a whole 14 died—a mortality rate
of 18.2 per cent—which compares favorably with Key's report 4 of a
38 per cent mortality in 214 intertrochanteric fractures treated con¬
servatively. Morris 6 reported a 44 per cent mortality rate in 16 con¬
secutive cases of trochanteric fractures treated by nonoperative means.
Harmon 7 reported a 39 per cent mortality in 164 cases, and Taylor
and others 8 reported a 25.4 per cent mortality in 114 cases of fractures
treated without operation. All the patients in this series were private
patients, which had some bearing on the relatively low death rate, as
adequate means were available for the proper care of a patient in a body
cast. An incidence of coxa vara of 10 degrees or more was noted in
25, or 31.4 per cent, of this group. This developed in spite of closed
reduction under anesthesia and after good position was demonstrated
by postoperative roentgenograms made through the casts. Nonunion
6. Morris, H. D.: Trochanteric Fractures, South. M. J. 34:571 (June) 1941.
7. Harmon, P. H.: The Fixation of Fractures of the Upper Femur and Hip
with Threaded, Hexagon-Headed, Stainless-Steel Screws of Fixed Length, J. Bone
& Joint Surg. 27:128 (Jan.) 1945.
8. Taylor, G. M.; Neufeld, A. J., and Janzen, J.: Internal Fixation for Inter-
trochanteric Fractures, J. Bone & Joint Surg. 26:707 (Oct.) 1944.
 Fig. 2.—A, a comminuted type II fracture which was converted to a type III
fracture at the time of operation. B, roentgenogram taken in the operating room
after the operation. Note that the end of the nail comes within a centimeter of
the articular surface. A shorter nail would have been preferable. C, result follow¬
ing medial migration of the distal fragments, with penetration of the acetabulum
by the Neufeld nail. D, result seven months after the operation; the Neufeld nail
has been removed. There is bony union, with a good functioning hip.
occurred in 1 patient treated by Hoke well leg traction. Here reduction
was demonstrated to be adequate by postoperative roentgenograms

except for moderate angulation in the lateral view. At the end of two
and a half months there was no sign of union, and the cast was removed
and the patient kept in bed. Six months after the first reduction a bone

Fig. 3.—A, comminuted type III trochanteric fracture. B, position of the frag¬
ments and the internal fixation following the use of a Neufeld nail and additional
plate to pcevent medial migration of the distal fragment. C and D, appearance of
the fracture and the internal fixation six months after the operation. The fracture
has united in satisfactory position.

graft was done, and union obtained. Another nonunion developed

was
which required subsequent bone graft, but this was not necessarily due
a
to the method of treatment, as the patient, a wilful 27 year old man,
took his cast off without permission and started full weight bearing at
five and a half weeks.
 Internal fixation was carried out in 209 patients, or 69.7 per cent,
of the series. The Neufeld nail was used in 164 patients and other
forms of internal fixation in the remaining 45.
In 4 cases of this series, type I fracture in 1 case and type II in 3
cases, the fractures were converted to type III at the time of operation.
The lateral cortex was shattered either by drilling the hole for the nail
or at the time the nail was inserted, which
produced a subtrochanteric
fracture.
In subtrochanteric (type III) fractures medial migration of the distal
fragment may occur because of the pull of the adductor muscles. This
is especially true if the angle of the Neufeld or Jewett nail is at the
same level as the subtrochanteric fracture. Since the plate element of
these nails is attached to the shaft of the femur, any medial migration
of the shaft fragment forces the proximal portion of the nail deeper into

Table 5.—Loss of Position in Fractures Treated by Internal Fixation

Type
Coxa Medial Converted Non-
Type Number Vara Migration to III union
1. 62 4 .. 1 1
II. 76 7 13..
Ill. 54 9 9 3
IV. 17 2 ..

Total. 209 22 10 4 4

the head of the femur. The nail may be forced through the articular
surface of the head of the femur and into the hip joint and in some
cases through the floor of the acetabulum into the pelvis (fig. 2). To
prevent this medial migration we have used additional internal fixation
of several types. None has been completely successful. At the sug¬
gestion of Dr. Thomas A. Richardson, one of the fellowship men at the
Clinic, a "T" or "Y" type of nail has been used. This is accomplished
by superimposing a second plate over the vertical portion of the Neufeld
nail which extends upward along the lateral surface of the trochanter
(fig. 3). This prevents medial migration of the shaft fragment but does
not prevent bending of the Neufeld nail and angulation at the fracture
site. The Neufeld nail is ideal for type I and II fractures, but it should
be made stronger for type III fractures.
Type III fractures are the most difficult to treat. A study of
table 5 shows that coxa vara is more common in subtrochanteric fractures
than in any other type. Medial migration of the distal fragment was
seen in only one type II fracture and in no fractures of types I and IV,
while this complication was seen in nine type III fractures. Nonunion
is rare in trochanteric fractures. When it does occur it is usually
seen in type III fractures. In the 209 patients who were treated by
operation, nonunion occurred in three type III fractures and in one
I
type fracture.
Eight Neufeld nails bent, and three broke. This weakness is one of
the disadvantages of the Neufeld nail. On the other hand, its slight
flexibility is an advantage in securing accurate apposition between the
plate portion of the nail and the shaft of the femur. In 3 muscular
persons in whom it was feared the nail would bend, two Neufeld nails
were superimposed. No bending occurred in these patients.
In type IV fractures in which two plane fixation was necessary,
reduction was accomplished and stainless steel screws were placed
across the fracture line or lines from cortex to cortex before the blade
plate was applied. In this series, supplementary internal fixation was
used eleven times in addition to Neufeld nails.
Jewett nails were used in 28 cases. These have given satisfactory
results, with no instances of breakage of the nail. In these cases, coxa

Fig. 4.—A, comminuted type II trochanteric fracture. and C, result six

months after insertion of the
Jewett nail.
vara occurred in only3.6 per cent of the cases, as compared with 9.7
per cent of cases in which Neufeld nailing was used. The Jewett
nail is more difficult to insert, as the guide wire must be in the proper
position while the Neufeld nail may be allowed to drift slightly from
the guide wire in order to insure proper apposition of the plate to
the side of the femoral shaft.
The Moore-Blount blade plate was used in 6 cases. Surprisingly,
despite the apparent great strength of the nail, one broke at its angle.
One patient in this series had a complete posterior dislocation of
the head of the femur with an associated trochanteric fracture. This
patient was treated by open reduction of the dislocation and fixation of
the fracture with Knowles pins followed by skeletal traction for·
sixty-four days. No loss of position occurred.
An analysis was made of the 209 cases in which internal fixation was
used and of the results obtained in the different types. As might be
predicted, type III fractures proved to offer the greatest incidence of
loss of position postoperatively. In all, there were 9 cases of medial
migration of the distal fragment, 9 cases of coxa vara and 17 cases of
protrusion of the nail through the head. All three conditions tended to
occur simultaneously. Most of these occurred in type III fractures.
These factors suggested the need for supplementary internal fixation in
some type III fractures. All type III fractures do not require additional
internal fixation. Some are stabilized by jagged or serrated fracture
lines that prevent migration after accurate reduction. In others a solid
bridge of bone between the portion of the nail in the head and neck of
the femur and the subtrochanteric fracture will prevent medial migra¬
tion of the distal fragment. Also, the type II fractures offer some
difficulty in maintenance of reduction. In this group there were 7 cases
of coxa vara and 1 of medial migration of the distal fragment.
In the series, some of the nails obviously were too long when first
inserted, but it is believed that "overdrive," as described by Cleveland
and others,9 depends also on the type of fracture involved. Type III
fractures offered the best opportunity for medial migration of the shaft
and nail, permitting protrusion of the nail through the head. A low
incidence of postoperative loss of position in the difficult type IV frac¬
tures was due to adequate fixation of the fragments at the time of
operation.
COMMENT

In a comparison of the results in the patients treated by internal

fixation with those in patients treated by nonoperative measures, the
mortality was no higher in the operative series. In hospitals where the
nursing problem makes it difficult to give patients in body casts adequate
care, the mortality would be much less in the patients treated by opera¬
tion than in those treated by casts or in traction.
The patients treated by internal fixation are more comfortable.
Adequate medical care, especially to prevent decubitus ulcers and post¬
operative pneumonia, is facilitated. The time in the hospital is reduced,
which is a saving in hospital beds and lightens the financial strain on the
patient and his family. Cleveland and others 9 have shown that senile
psychosis is far more frequent in patients treated in body casts than in
the patients treated by operation. At the present time, it is our policy
to treat all patients that are not moribund by open reduction and internal
fixation as soon as they can be hydrated and their general medical con¬
dition evaluated. In our experience the general condition of the patient
can rarely be improved by delaying surgical treatment more than twelve
.to twenty-four hours. The patients' general condition usually improves
after the operation, as they can be moved often and with little pain.
9. Cleveland, M.: Bosworth, D. M., and Thompson, F. R.: Intertro-
chanteric Fractures of the Femur: A Survey of Treatment in Traction and
by Internal Fixation, J. Bone & Joint Surg. 29:1049 (Oct.) 1947.
 Trochanteric fractures usually unite ; consequently, they have not
been given the consideration in medical literature that has been devoted
to fractures of the neck of the femur. Avascular necrosis of the head of
the femur, seen so often after fractures of the neck of the femur, is not
seen after trochanteric fractures. The only exception to this rule was
in 1 case of fracture of the base of the neck of the femur associated with
a comminuted trochanteric fracture. In other respects, trochanteric
fractures are more serious than neck fractures. In our series 10 the
average patient with a trochanteric fracture was older than the patients
with fractures of the neck of the femur and the mortality has been about
double. The operation required for internal fixation of a trochanteric
fracture is more extensive than that for a fracture of the neck of the
femur. We routinely give 500 cc. of whole blood at the time of opera¬
tion. This is not necessary with fractures of the neck of the femur
unless the general condition of the patient requires it.
The prognosis in type III subtrochanteric fractures is poorer than
in the other three types. Coxa vara is more apt to occur. Nonunion,
rare in trochanteric fractures, is most apt to be seen in this type. If the

type III fractures are not well stabilized at the time of operation, medial
migration of the distal fragment may occur. If this complication is
likely, additional internal fixation is indicated.
summary
1. Thiee hundred of trochanteric fractures are reviewed.
cases

2. There was a gross mortality rate of 18 per cent.

3. The fractures have been classified into four types and the prog¬
nosis given for each group.
4. The difficulties encountered in the subtrochanteric (type III)
fractures are emphasized and a method to prevent medial migration of
the distal fragment suggested.
5. Various forms of treatment are evaluated, with the conclusion that
operative treatment and internal fixation is the treatment of choice.
DISCUSSION
Dr. Don H. O'Donoghue, Oklahoma City: This is a pertinent subject for
some of us "bone setters." As you are all well aware, in the last few years there
has been a drastic change in treatment of a fracture of the neck of the femur to
the point where I think it is completely accepted that if a fracture of the neck of
the femur will not survive surgical repair it will not survive so-called conservative
treatment.
I believe the treatment should not be called conservative or operative but
should be called nonsurgical or surgical, because in the great majority of instances
the surgical treatment is the conservative treatment.
10. Boyd, H. B., and George, I. L.: Fractures of Hip: Results Following
Treatment, J. A. M. A. 137:1196-1199 (July 31) 1948.
 I have heard Dr. Boyd talk on this subject before, and I know he was handi¬
capped somewhat this morning from the standpoint of time. I think we should
enlarge a little not on the technical factors, because they are not particularly impor¬
tant, but on the problem as a whole. What are the alternatives in the treatment
of an intertrochanteric fracture? As a rule the intertrochanteric fracture occurs
in slightly older age
a group than does a fracture of the neck of the femur. These
persons are extremely poor risks, no matter what you do.
The so-called conservative or, as I prefer to call it, the nonsurgical method
entails one of two or three things : First, do nothing to the leg. Second, put it in a
cast with various forms of fixed traction. Third, put it in so-called movable traction
with Kirschner wires and weights. Any of those methods entails a long period
in bed. That time in bed may range anywhere from twelve to twenty-four weeks.
If you put a person in that age bracket to bed for that length of time you will
make an invalid of him.
Dr. Boyd's figures on mortality are entirely misleading if you consider a
patient's useful life rather than the fact that he is alive and breathing. Old persons
put to bed for many weeks, or kept in the hospital for many weeks, become
disoriented and mentally unbalanced ; they have a great deal of difficulty in ever
regaining that spark which keeps them alive and in active health.
I would like to second Dr. Boyd's comment that if the patient is not moribund
on admission surgical treatment should be strongly considered. Almost uniformly
we regret later not operating on patients because they are bad risks. If they are

going to be operated on they should be operated on soon. That does not mean
particularly as an emergency. You can take twelve, twenty-four or thirty-six
hours to prepare them, if you wish. After that length of time you will lose ground
unless there is some specific problem you can remedy.
Too often the medical consultant will say : "Let me build him up and get him
in better shape." The result is that the patient gets in worse shape. I think that
in another five or ten years the surgical treatment for intertrochanteric fractures
will be just as much accepted as is the surgical treatment now for fractured neck
of the femur.
Dr. James J. Callahan, Oak Park, 111. : About seven years ago we collected
100 cases of intertrochanteric fracture picked at random. Most of those cases
were of two to ten years' duration. We were surprised at the end results.
Naturally, in a county institution one cannot get the response of outpatients that
one would like to have. We had an adequate response. In this number of cases
we found that on return examination every patient had from \ to 2 inches (1.27
to 5.08 cm.) of shortening. When they left the hospital their legs were of equal
length. We had 1 case of nonunion.
The peculiar complaint of all those patients was not pain in the hip but pain
in the back because of the shortening and the fact that the back could not accom¬
modate this. The arthritic changes were present in the back.
These patients were all treated conservatively, or nonsurgically if you wish.
It is our belief that patients with intertrochanteric fractures which are not
comminuted, or, as in Dr. Boyd's classification, with type I fractures, should be
operated on. We do not operate on comminuted fractures. I realize that this is
a departure, but when you try to operate on these patients you have an eggshell
to put your plate on, or screws or whatever type of internal fixation you wish
to use, and frequently you will find that after putting in this internal fixation, if
it is not protected adequately, it will break through or break off.
 Dr. Kellogg Speed, Chicago : I am a great admirer of Dr. Boyd, his clear
thinking and the excellent way in which he expresses his thoughts. Also, as you
all know, he works with Speed.
In the matter of the care of these fractures, in 1921 I reported a series of 120
cases without operative correction. Since then I have practically never used
operative fixation for this type of fracture, for some of the reasons which Dr.
Callahan has already stated or which have entered into the discussion. These
persons are old, and their bones are soft, and the trauma of the injury, which
does not so seriously affect the young active person, leads to serious fracture.
(Slide) The mechanism of the injury is a fall on the side and not a preliminary
fracture or trip, as in fractures of the neck of the femur. There is a
massive force applied on the thigh, with the body weight acting as the other factor
to separate the intertrochanteric part of the femur.
(Slide) This opens up a large part of the femur, composed of porous or cancel¬
lous bone which has perhaps the best blood supply of any part of the whole
femur; so you may expect, as already has been said, that a bony union will
develop.
(Slide) The different types (and these are illustrated by me in 1921) shown are
the same as those that Dr. Boyd has mentioned to you, without any attempt
at too rigid classification. I do not believe you can put them all in closely bound
bundles, but the slide shows the different types as then described.
(Slide) The worst types are these comminuted ones or the impacted ones, in
which the sharp angle of the head fragment is shoved down into the cancellous
bone of the trochanteric fragment.
(Slide) The most difficult ones are those in which there is gross overriding or
shortening, generally in the neglected type.
For nonoperative treatment we use the Russell traction. This will pull down
most of the fractures within twenty-four hours, especially if you put a box under
the foot on the well side, a padded box such as a starch box, so that the patient
can use his good leg for counterpressure. The Russell traction inevitably pulls
down and abducts, and in most cases within twenty-four hours there is a reduction.
Eight weeks is all that any patient requires in bed, regardless of age. I disagree
with Dr. O'Donoghue that some need twelve or twenty weeks. Eight weeks is
all they need, and then they can be put in a chair and their progress stimulated
in the ordinary \vay.
It seems to that with the thinness of the outer wall of the femur and the
me

dangers of operation, not in the hands of Dr. Boyd or of the men in the Campbell
Clinic or of other surgeons present here but in the hands of the average physician,
the implanting of complicated angle irons is far too great for them to attempt.
Dr. F. Walter Carruthers, Little Rock, Ark. : I have had many opportunities
in the past to see and observe intertrochanteric fractures. I feel that it is timely
to emphasize, particularly to the patient, the difference between intertrochanteric
fractures and capital fractures of the neck of the femur. No doubt many of you
have the same experience as I with the referral of such a case. The attending
physician many times says : "I am sending you a patient with fracture of the hip."
They use this term when in reality it is an intertrochanteric fracture.
In my personal interviews with my patients who happened to be the victims
of intertrochanteric fractures—usually seen in elderly women and occasionally in
men—I refer to the intertrochanteric fracture as a fortunate fracture, in spite
of the high mortality, as demonstrated by Dr. Boyd. It occurs in the older person.
The patients themselves are interested in only one question : "Will my fracture
unite, and will I be able to walk again?" In my answer, based on statistics, I
assume full confidence of a union. This, I think, is a good answer psychologically.
Obviously, if the patient dies as a result of the particular type of fracture, nothing
can be done. On the other hand, the assurance of the patient who survives that
he can expect a union and be able to walk is a paramount conclusion in the case
after all.
At this time I can recall nonunion in only one intertrochanteric fracture and
that was a fracture involving pathologic changes in the bone. One should bear
in mind from the beginning that one is dealing with an intertrochanteric fracture
which is in reality a fracture of the shaft of the femur involving the trochanteric
region. This certainly places it in a specific anatomic category, in direct contrast
to a capital fracture only about 1 inch (2.5 cm.) away.
There are, obviously, many types. The subtrochanteric types are the ones that
really give us trouble, particularly with reference to postangulation.
Dr. R. C. Webb, Minneapolis : It has been suggested that weight bearing
might be started in some cases of intertrochanteric fractures of the femur after
eight weeks. In this connection I should like to mention an experience with a
45 year old man who had an average type of intertrochanteric fracture of the left
femur in good position except for marked coxa vara. The fracture was seven weeks
old when I first saw him, and I applied 50 pounds (22.7 Kg.) of skeletal traction
through the lower end of the femur for forty-eight hours. Although I nearly
dislocated the hip downward, I found that the callus was still soft enough to
permit restoration of the normal angulation to overcome the coxa vara.
Dr. James Jackson, Madison, Wis. : It gives me great pleasure to be here
and to see that there are many orthopedic surgeons who have been converted to
the method of open reduction and internal splinting of fractures.
Thirty-six years ago, in 1912, I did my first open reduction at a time when
this type of procedure was openly criticized by most surgeons. In fact, I appeared
before a meeting of the Railway Surgeons in Chicago a few years ago, where I
showed slides from some 200 cases of open reduction of fractures of the long
bones. In a discussion of my paper a prominent Chicago surgeon said he did
not believe a single word the author said.
Today, when men are doing such brilliant work with open reduction and
internal splinting of fractures, I feel justified in having once been a bone surgeon.
Dr. Harold B. Boyd, Memphis, Tenn. : The discussion has been interesting and
instructive. I wish to thank all the discussers. Some of the points discussed are
included in the written paper which time did not permit reading.
Dr. Speed, whom I admire very much, has brought to our attention the treat¬
ment of these patients by traction. There is no question that good end results
can be obtained in trochanteric fractures by conservative treatment. The principal
reasons for operating on these patients are medical and not surgical. Every
surgeon cannot treat trochanteric fractures the same, but we feel that in the
majority of patients open reduction and internal fixation is a good method. The
patients are more comfortable ; they are in the hospital on an average of two
to three weeks, which is an economic saving to the family and also makes more
hospital beds available. In hospitals with adequate nursing care the mortality is
about the same in the nonoperative group as in the operative group. In hospitals
without adequate nursing care for patients in body casts or in traction, the mortality
is much less in the patients treated with internal fixation.
Surgical thinking should not be kept in logic-tight compartments. Patients
should be treated in the manner which is best suited to the individual patient,
the surgeon and the equipment with which he must.work. We do not think that
all trochanteric fractures should be treated with internal fixation in all circum¬
stances and by all surgeons. But for our patients we feel that internal fixation
in the vast majority is the method of choice.