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REVERSE OBLIQUITY INTERTROCHANTERIC FRACTURES

INTRODUCTION
The reverse obliquity intertrochanteric fracture is a distinct type of fracture
pattern that is mechanically different from most intertrochanteric fractures. This
fracture pattern has been classified under the Orthopaedic Trauma Association
classification system as AO/OTA 31-A3 in which the fracture line extends through the
lateral femoral cortex distal to the vastus ridge of the greater trochanter. The fracture
configuration is opposite to standard intertrochanteric fractures, extending from distallateral to proximal medial. Various methods of fixation have been used for this
fracture pattern from fixed angled plates and screw-plates to the sliding hip screws
and intramedullary fixation devices. Some are biomechanically inappropriate while
others are unsuitable for certain fracture configuration. This case write-up will discuss
the various fixation devices and the optimum implant in managing these difficult and
controversial fractures.
CASE REPORT
Madam LBC is a 92 year old, elderly, Chinese, female, who presented to the
Casualty Department, HUKM after a fall at home onto her right hip. She complained
of right hip pain and was unable to stand up after the fall. Her gait had always been
unsteady after a right sided cerebral vascular accident that had occurred 8 years
before. Premorbidly, she was able to walk without any walking aids albeit very slow
and unsteady. She was otherwise independent in her activities of daily living. She has
no history of hypertension, diabetes, renal or cardiac problems.
On clinical examination, Madam LBC was alert and well oriented. She was
pink and her blood pressure and pulse rate was normal. Her right lower limb was
externally rotated and shortened and there was tenderness and swelling over the right
greater trochanteric region. She had no foot drop, sensory was intact and her distal
pulses were normal. Radiographs of the right hip revealed a reverse obliquity

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intertrochanteric fracture with comminution and extension to the greater trochanter as

well as involvement of the lesser trochanter. She was admitted to the orthopaedic
female ward and skin traction with 3 kg was applied. She was also initiated on IM
Miacalcic 100 iu daily and IM Tramal 50 mg tds for pain relief.
The following day the patient underwent an elective Dynamic Condylar Screw
fixation of the right hip under spinal anaesthesia. The patient was placed on a traction
table an reduction of the fracture was performed under image intensifier guidance. IV
Zinacef 1.5 gm prophylactic antibiotics were given and the skin was cleaned and
draped in the usual manner. A longitudinal incision was made centered over the
greater trochanter and the fracture site was exposed. K-wires were used initially to
stabilize the fracture fragments. The surgeon initially wanted to attempt fixation with
a dynamic hip screw but this was abandoned as the insertion site for the lag screw was
centred over the fracture site on the lateral cortex of the proximal femur. A DCS guide
pin was then inserted under image intensifier guidance and measurement of the length
of the lag screw and reaming was performed. The DCS lag screw was then inserted
and a 95 degrees 8 hole DCS plate was placed into position and the fracture was
reduced again. The plate with then fixed with 5 cortical screws. The wound was then
washed and closure of the wound in the usual manner was done.
The immediate post-operative period was uneventful and check radiographs
were acceptable. She was only allowed ambulation on a wheelchair as the fracture
was comminuted and unstable. On post-operative day 5, Madam LBC was discharged
well. Unfortunately, at her first orthopaedic clinic follow-up visit at 2 weeks post-op,
the patient complained of right leg swelling over the past 2 days. The wound was
clean and there was no calf tenderness. Madam LBC was readmitted to the ward for
further investigation. Doppler ultrasound confirmed the diagnosis of right femoral
vein thrombosis. She was immediately started on S/C Clexane 60mg 12 hourly which
was given for a total of 5 days and Tab Warfarin with doses adjusted to maintain an
optimum INR therapeutic range of 2.1 to 4.8. She was still only allowed mobilization
with a wheelchair.

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DISCUSSION
The reverse obliquity fracture of the proximal femur is a distinct fracture
pattern that is mechanically different from most intertrochanteric fractures. The
fracture line in

most intertrochanteric fractures runs obliquely from the greater

trochanter proximally to the lesser trochanter. The reverse obliquity fracture of the
proximal part of the femur has the opposite configuration, with the major fracture line
running from distal-lateral to proximal-medial. [1]
Evans in 1949 and subsequently, Jensen and Michaelson classified
intertrochanteric fractures based on the likelihood of achieving and maintaining
anatomic reduction. This classification stresses the importance of an intact
posteromedial cortex for maintaining a stable reduction. Unstable fractures are those
with comminution of the posteromedial cortex, subtrochanteric extension, and reverse
obliquity patterns. The Evans classification has poor reproducibility, thus most
surgeons find it more useful and simpler to classify the fracture patterns into stable
and unstable fractures. [5]
The Orthopaedic Trauma Association has classified fractures about the
trochanter as AO/OTA 31-A, delineating them as extracapsular fractures of the hip.
These fractures are further subdivided into groups A1, A2, and A3 fractures. A1
fractures are simple, 2-part fractures. A2 have multiple fragments. A3 fractures
include reverse oblique and transverse fracture patterns. The distinctive characteristic
of A3 fractures is the fracture line extends through the lateral femoral cortex distal to
the vastus ridge of the greater trochanter. A3 fractures have been classified differently
by different authors. A3 fractures have been called in some studies as unstable
intertrochanteric fractures. Other studies describe these fractures as a combination of
intertrochanteric and subtrochanteric fractures. [4] Some authors have even classified
this fracture as a Type II-A subtrochanteric fracture using the Russell-Taylor
Classification as this fracture pattern behaves more like a subtrochanteric fracture
than an intertorchanteric fracture with regards to fracture forces and instability
patterns. [7]

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Reverse obliquity intertrochanteric fractures of the femur are uncommon but

not rare fractures. This fracture pattern accounts to between 5% to 16.6% of all
intertrochanteric

and

subtrochanteric

fractures.[1,6]

The

reverse

obliquity

intertrochanteric fractures of the femur are recognized as biomechanically different

from standard intertrochanteric fractures. They behave more like subtrochanteric
fractures than intertrochanteric fractures with regards to fracture forces and instability
patterns. The tendency for medialization of the femoral shaft in relation to the head
and neck components of the fracture places significant deforming forces on the
internal fixation. [7]
The fracture pattern of standard intertrochanteric fractures can be effectively
treated with sliding-screw devices that allow compression and collapse of the fracture
into a stable configuration. The key to the success of these devices is controlled
postoperative impaction of the fracture to a stable configuration. This concept requires
that the direction of compression be perpendicular to the major fracture line. The
application of this concept to reverse obliquity fractures is unfavorable because
sliding of the proximal fragment and medialization of the distal fragment can lead to
fracture distraction. There is no medial buttress and the implant acts as a load-bearing
device. [1]
Haidukewych et al. retrospectively studied 2472 patients with hip fractures
between 1988 and 1998 of which 1035 were classified as intertrochanteric or
subtrochanteric. Fifty-five of these were reverse obliquity intertrochanteric fractures.
Forty-nine were followed up until the fracture united or revision operation was
performed. Thirty-two (68%) of 47 hips treated with internal fixation healed without
an additional operation. Fifteen of 47 failed to heal or had failure of fixation. The
failure rate was 9 of 16 (56%) for sliding hip screws, 3 of 10 (30%) for dynamic
condylar screws, 2 of 15 (13%0 for blade plates, 1 of 3 (33%) for cephalomedullary
nails, and 0 of 3 (0%) for intramedullary hip screws. Use of the fixed angle devices
(the blade plate and the dynamic condylar screw) resulted in fewer failures than did
use of the sliding hip screw. (p=0.023). The authors concluded that 95 fixed-angle
internal fixation devices performed significantly better than did sliding hip screws.

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Results were worse for fractures with poor reduction and those with a poorly placed
implant. [1]
In a letter to the editor, Stocks concurred with Haidukewych et al. that there is
little in the literature to guide treatment of these difficult fractures and that a sliding
hip screw has a relatively high failure rate. He observed that despite this, the sliding
hip screw is often used for reverse obliquity fractures. This may be because firstly,
emergency department radiographs may fail to demonstrate the reverse obliquity
pattern. Thus, no plan was made preoperatively to use an implant other than a sliding
hip screw. Second, the surgeon may be unfamiliar with the reverse obliquity pattern
and how it differs biomechanically from a standard intertrochanteric hip fracture. He
also suggested that all intertrochanteric fractures should be referred by their OTA
classification before choosing the method of fixation to minimize suboptimal
treatment choices. Stocks also concurred that 95 fixed-angle devices perform better
than sliding hip screws as the former allows more fixation in the proximal fragment
and provides a better buttress on the lateral cortex of the proximal fragment to prevent
varus collapse. A relatively good success with intramedullary fixation has been
observed as well. [6]
In contrast, Zickel, also in a letter to the editor, commented that Haidukewych
et al. lacked

perspective on the treatment of reverse obliquity intertrochanteric

fractures. He suggested that Haidukewych refer to an article An Intramedullary

Fixation Device for the Proximal Part of the Femur . Nine YearsExperience.
(1976;58:866-72) in which a follow-up analysis of 84 nonpathological fractures
treated with the Zickel nail device. This article had reported 64 oblique pattern
fractures treated with the Zickel nail device that had healed uneventfully without the
necessity for either reoperation or bone grafting. He commented that it is poorly
understood that when a screw-plate or nail-plate device is used to fix this
subtrochanteric fracture, the stresses are on the plate and the compression screw is
merely anchoring that plate to the proximal part of the femur. Zickel also expressed
his surprise thatu Haidukewych et al. failed to realize that intramedullary fixation of

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this fracture is not only the safest method of fixation but also one that has been used
for a long time. [9]
Watson et al. compared the Medoff sliding plate with a standard compression
hip screw in a randomized, prospective study for the fixation of 160 stable and
unstable intertrochanteric fractures. Stable fracture pattern (46 hips) united without
complication in both treatment groups. Unstable fractures (114 hips) which included 8
reverse obliquity fractures (4 treated with sliding hip screw and 4 with Medoff plate)
had a overall failure rate of 9.6%. The failure rate with the use of a compression hip
screw was 14% (9 patients), significantly greater than 3% (2 patients) with the Medoff
plate. However the operating time and estimated blood losses were greater with the
use of the Medoff plate. [8]
Kummer et al. in a biomechanical study using sawbone composite femurs
showed that significantly more shaft medialization occurred with reverse obliquity
fracture patterns when the Medoff plate was fully dynamized. Approximately 80% of
this translation occurred within the first 100 loading cycles. When the lag screw was
locked and only the femoral plate permitted to slide, minimal translation (<2 mm) was
observed compared to 5 mm when the Medoff plate was fully dynamized. The authors
recommended the lag screw be locked and that the plate be dynamized in the clinical
treatment of reverse obliquity fractures. [2]
In a prospective, randomized study of 39 patients with AO/OTA 31-A3
fractures, i.e. reverse oblique or transverse intertrochanteric fractures, Sadowski et al.
compared the results of intramedullary fixation using a Proximal Femoral Nail (PFN)
in 20 patients against the 95 fixed-angle screw-plate (Dynamic Condylar Screw,
DCS) in 19 patients. The authors reported that patients treated with an intramedullary
nail had shorter operative times, fewer blood transfusions, and shorter hospital stays.
Implant failure and/or nonunion was noted in 7 of the 19 patients who had been
treated with the 95 fixed-angle screw-plate. Only 1 of 20 fractures treated with an
intramedullary nail did not heal. The authors concluded that the results of their study
support the use of an intramedullary nail rather than a 95 fixed-angle screw-plate for

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the fixation of reverse oblique or transverse intertrochanteric fractures in elderly

patients. [4] Intramedullary devices or cephalomedullary nails, which allow fixation
into the femoral head with lag type screws, are the devices of choice for these
fractures. [7]
Although locked intramedullary nails are preferable to plate devices because
of their load-sharing capacity and immediate stability, these implants do not provide
stable fixation if fracture comminution involves the greater trochanter such as seen in
this patient. Under these conditions, plate and screw osteosynthesis remains the
treatment of choice for reverse obliquity or subtrochanteric fractures. There are
increased complications with intramedullary nails when the fracture extends into the
greater trochanter or piriformis fossa. The 95 blade plate serves as a lateral tension
band for fracture stabilization. This implant allows for multiple screw fixation of the
proximal fragment and thus possesses clear advantages over either 135 or 150
compression hip screws. The Dynamic Condylar Screw or DCS, a 95 fixed-angle
screw-plate, is a modified version of the 95 blade plate by the AO group. This
implant is much easier to apply because it is essentially a cannulated screw. In order
to achieve optimal results using the DCS, strict adherence to the postoperative regime
of delayed weight bearing is of utmost importance. This is to prevent excessive stress
on the plate and screw device with subsequent implant failure. [3]
CONCLUSION.
Reverse obliquity intertrochanteric fractures are unstable fractures which have
opposite configuration compared to the standard intertrochanteric fractures. As such,
sliding hip screws are not suitable for these fracture patterns because sliding of the
proximal fragment and medialization of the distal fragment can lead to fracture
distraction resulting in a higher incidence of implant failure. Fixed-angle devices such
as the 95 angle blade-plates and the Dynamic Condylar Screw have been proven
effective in treating these difficult fractures. Nevertheless, intramedullary fixation
devices are regarded by various surgeons as the implant of choice. However, usage of

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this method of fixation is inappropriate when the fracture extends to the greater
trochanter/piriformis fossa making fixed-angle devices more suitable.
REFERENCE
1.

Haidukewych GJ, Israel TA, Berry DJ. Reverse Obliquity Fractures of the
Intertrochanteric Region of the Femur. J Bone Joint Surg 2001; 83-A(5): 64350.

2.

Kummer, FJ, Pearlman CA, Koval KJ, Ceder L. Use of the Medoff Sliding
Plate for Subtrochanteric Hip Fractures. J Orthop Trauma 1997; 11(3): 180-2.

3.

Pai CH. Dynamic Condylar Screw for Subtrochanteric Femur Fractures with
Greater Trochanteric Extension. J Orthop Trauma 1996; 10(5): 317-22.

4.

Sadowski C, Lbbeke A, Saudan M et al. Treatment of Reverse Oblique

and Transverse Intertrochanteric Fractures with Use of an Intramedullary Nail
or 95 Screw-Plate. J Bone Joint Surg 2002; 84-A(3): 372-81.

5.

Schrank P, Koval KJ. Fractures of the Femoral Neck and Intertrochanteric

Region. In Brinker MR, ed. Review of Orthopaedic Trauma. Philadelphia:
W.B. Saunders Company, 2001; pp. 53.

6.

Stocks GW. Treatment of Reverse Obliquity Fractures of the Intertrochanteric

Region of the Femur. J Bone Joint Surg 2002; 84-A(5): 869-70.

7.

Tornetta P. Case Controversy: Subtrochanteric Femur Fracture. J Orthop

Trauma 2002; 16(4): 280-3.

8.

Watson JT, Moed BR, Cramer KE, Karges DE. Comparison of the
Compression Hip Screw with the Medoff Sliding Plate for Intertrochanteric
Fractures. Clin Orthop 1998; 348: 79-86.

9.

Zickel RE. Fixation of Reverse Obliquity Fractures of the Subtrochanteric and

Intertrochanteric Regions of the Femur. J Bone Joint Surg 2002; 84-A(3): 494.