Open lower extremity fractures in the geriatric population.

INTRODUCTION: Open fractures in the elderly are distinct compared to younger populations. The purpose of this study is to follow a series of open fractures of the lower extremity in the geriatric population to better prognosticate outcomes. METHODS: We performed a retrospective chart review of patients over the age of 65 years old who were treated for an open, lower extremity fracture across two level I trauma medical systems. Patients were included if they had documented wound healing problems in the postoperative period, or 6 months of follow-up, or if they had a definitive radiographic outcome. Sixty-four patients were included of an average age of 76.23, of whom 73.4% were female. RESULTS: The fracture types were midshaft femur in 3, distal femur in 9, patella in 2, proximal tibia in 3, proximal fibula in 1, midshaft tibia in 14, distil tibia in 8, ankle in 23, and talar neck/calcaneus in 1. Forty-two fractures were the result of low energy mechanism and 22 fractures were from high energy mechanism. Fourteen fractures were type 1, 32 were type 2, 11 were type 3A, 6 were type 3B, and 1 was type 3C. At final follow-up, 13 wounds were well healed, 39 wounds were healed following a delay of more than 6 weeks to achieve healing, 3 were infected, 3 had been treated with amputation, 2 had chronic ulceration, 2 with active draining, and 2 had draining sinuses. DISCUSSION: Open lower extremity fractures are serious injuries with high rates of morbidity. Such risks are even higher in the geriatric population, particularly with regard to wound healing. This study provides important prognostic information in counseling geriatric patient with an open lower extremity fracture, as well as informs treatment in terms of wound surveillance and care in the postoperative period.

Open Ankle Fractures: What Predicts Infection? A Multicenter Study.

OBJECTIVE: To identify the patient, injury, and treatment factors associated with an acute infection during the treatment of open ankle fractures in a large multicenter retrospective review. To evaluate the effect of infectious complications on the rates of nonunion, malunion, and loss of reduction. DESIGN: Multicenter retrospective review. SETTING: Sixteen trauma centers. PATIENTS: One thousand and 3 consecutive skeletally mature patients (514 men and 489 women) with open ankle fractures. MAIN OUTCOME MEASURES: Fracture-related infection (FRI) in open ankle fractures. RESULTS: The charts of 1003 consecutive patients were reviewed, and 712 patients (357 women and 355 men) had at least 12 weeks of clinical follow-up. Their average age was 50 years (range 16-96), and average BMI was 31; they sustained OTA/AO types 44A (12%), 44B (58%), and 44C (30%) open ankle fractures. The rate FRI rate was 15%. A multivariable regression analysis identified male sex, diabetes, smoking, immunosuppressant use, time to wound closure, and wound location as independent risk factors for infection. There were 77 cases of malunion, nonunion, loss of reduction, and/or implant failure; FRI was associated with higher rates of these complications (P = 0.01). CONCLUSIONS: Several patient, injury, and surgical factors were associated with FRI in the treatment of open ankle fractures. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Henry Versus Thompson Approach for Fixation of Proximal Third Radial Shaft Fractures: A Multicenter Study.

OBJECTIVE: To compare the volar Henry and dorsal Thompson approaches with respect to outcomes and complications for proximal third radial shaft fractures. DESIGN: Multicenter retrospective cohort study. PATIENTS/PARTICIPANTS: Patients with proximal third radial shaft fractures ± associated ulna fractures (OTA/AO 2R1 ± 2U1) treated operatively at 11 trauma centers were included. INTERVENTION: Patient demographics and injury, fracture, and surgical data were recorded. Final range of motion and complications of infection, neurologic injury, compartment syndrome, and malunion/nonunion were compared for volar versus dorsal approaches. MAIN OUTCOME: The main outcome was difference in complications between patients treated with volar versus dorsal approach. RESULTS: At an average follow-up of 292 days, 202 patients (range, 18-84 years) with proximal third radial shaft fractures were followed through union or nonunion. One hundred fifty-five patients were fixed via volar and 47 via dorsal approach. Patients treated via dorsal approach had fractures that were on average 16 mm more proximal than those approached volarly, which did not translate to more screw fixation proximal to the fracture. Complications occurred in 11% of volar and 21% of dorsal approaches with no statistical difference. CONCLUSIONS: There was no statistical difference in complication rates between volar and dorsal approaches. Specifically, fixation to the level of the tuberosity is safely accomplished via the volar approach. This series demonstrates the safety of the volar Henry approach for proximal third radial shaft fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Complications Associated With Minimally Invasive Anterior to the Psoas (ATP) Fusion of the Lumbosacral Spine.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To analyze complications associated with minimally invasive anterolateral retroperitoneal antepsoas lumbosacral fusion (MIS-ATP). SUMMARY OF BACKGROUND DATA: MIS-ATP provides anterolateral access to the lumbar spine allowing for safe anterior lumbar interbody fusions between T12-S1. Anecdotally, many surgeons believe that ATP approach is not feasible at L5-S1 level, predisposing to catastrophic vascular injuries. This approach may help overcome limitations associated with conventional straight anterior lumbar interbody fusions, MIS lateral lumbar interbody fusion, and oblique lateral interbody fusion. METHODS: A detailed retrospective chart review of patients who had underwent MIS-ATP approach for lumbar fusion between T12-S1 was performed. Available electronic data from surgeries performed between January 2008 and March 2017 was carefully screened for surgical patients treated for spondylolisthesis, spondylosis, stenosis, sagittal, and/or coronal deformity. Detailed review of electronic medical records including operative notes, progress notes, discharge summaries, laboratory results, imaging reports, and clinic visit notes performed by a single independent reviewer not involved in patient care for documented complications. A complication is defined as any adverse event related to the index spine procedure for which patient required specific intervention or treatment. RESULTS: Nine hundred forty patients with a total of 2429 interbody fusion levels performed via MIS-ATP were identified during the study period. Sixty-seven patients (7.2%) sustained one or more complications during the perioperative period, of which 25.5% were surgical and 74.5% were medical. Overall, 78 (8.2%) surgical complications pertaining to the index procedure were noted during a postoperative period of 1 year from the date of surgery. No major vascular or direct visceral injuries were encountered. CONCLUSIONS: MIS-ATP approach provides a safe access to anterolateral interbody fusions between T12-S1. The ATP approach is performed by the spine surgeon, does not require neuromonitoring, and warrants minimal to no psoas muscle retraction resulting in significantly reduced postoperative thigh pain and rare neurologic injuries. Additionally, the direct and clear visualization of the retroperitoneal vasculature provided by the ATP approach minimizes the risk of inadvertent vascular injury. LEVEL OF EVIDENCE: 4.

Minimally Invasive Plate Osteosynthesis for Periprosthetic and Interprosthetic Fractures Associated with Knee Arthroplasty: Surgical Technique and Review of Current Literature.

With the increasing number of total knee arthroplasties (TKAs) being performed, the incidence of periprosthetic fractures adjacent to a TKA is rising. Minimally invasive plate osteosynthesis (MIPO) has proven to be successful for the biological fixation of many fractures. Advances in surgical instrumentation and techniques made MIPO possible for more complex fractures. Periprosthetic fractures are always complicated by problems of soft tissue incisions, scarring, and, of course, the arthroplasty components. MIPO techniques may be particularly suited to these injuries and may make the surgical repair of these fractures safer and more reliable. In this review, case examples are used to define the indications, preoperative planning, implant selection, complications, limitations, and challenges of MIPO for the treatment of periprosthetic fractures about the knee. When considering MIPO for any fracture, we recommend prioritizing an acceptable reduction with biological fixation and resorting to mini-open or open approach when necessary to achieve it. Awareness of the learning curve of the surgical technique, advances in implant designs, the tips and tricks involved, and the limitations of the MIPO is of paramount importance from the orthopaedic surgeon's perspective.

How Often Are Protocols Followed at Level I Trauma Centers?

This study analyzes adherence to an evidence-based protocol established at two level I trauma centers to determine its effect on clinical decision making. The centers' trauma databases were retrospectively studied and 51 patients with long bone fractures were identified who required revascularization and orthopaedic intervention and survived long enough to receive an index intervention. An arterial shunt was the protocol's first step; the preprotocol rate of shunting was 9.5%, while the postprotocol rate of shunting was 3.3%. The protocol's next step was external fixation; among the cases managed without a shunt, external fixation was the index intervention in 63.2% of the preprotocol cases and 31.0% of the postprotocol cases. Definitive vascular surgery was routinely performed before external fixation in 28.6% of the preprotocol cases and 56.7% of the postprotocol cases. This study demonstrates that this evidence-based protocol had no effect on the management of patients with combined orthopaedic and vascular injuries. Protocols should never supersede clinical judgment, but poor protocol adherence may represent a need for trauma centers to routinely review their protocols' compliance and efficacy. (Journal of Surgical Orthopaedic Advances 27(2):109-112, 2018).

Is "Early Total Care" a Safe and Effective Alternative to "Staged Protocol" for the Treatment of Schatzker IV-VI Tibial Plateau Fractures in Patients Older Than 50 Years?

OBJECTIVES: To compare "Early Total Care" (ETC) with "Staged Protocol" (SP) for the treatment of Schatzker IV-VI tibial plateau fractures in patients older than 50 years regarding safety and effectiveness. DESIGN: Retrospective cohort study. SETTING: An academic level 1 US trauma center. PATIENTS/PARTICIPANTS: Eighty-one patients older than 50 years with Schatzker grade IV-VI tibial plateau fractures were included. INTERVENTION: Fifty-three patients were treated under SP with immediate external fixation followed by definitive internal fixation. Twenty-eight patients were treated under ETC with immediate internal fixation. MAIN OUTCOME MEASUREMENTS: Comparison of perioperative findings, time to bony and clinical union, soft-tissue and bony complications, radiological outcome, and secondary procedures. RESULTS: The 2 groups were comparable without significant difference regarding age, sex, side of involvement, body mass index, smoking status, American Society of Anesthesiologist classification, associated injuries, comorbidities, follow-up duration, and fracture classification. No statistically significant difference was found regarding the perioperative complications, quality of reduction, time to union, Rasmussen score at union or at the final follow-up, soft-tissue/bony complications, and the rate of the secondary procedures. CONCLUSION: ETC seems to be a safe, efficacious, and effective alternative to the SP for the treatment of some Schatzker IV-VI fractures in patients older than 50 years. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Medial Malleoli Fractures: Clinical Comparison Between Newly Designed Sled Device and Conventional Screws.

BACKGROUND: The Trimed Medial Malleolar Sled is a newer device designed to treat medial malleolus fracture. The purpose of this study was to compare the outcome of medial malleolar fractures treated with the sled and conventional malleolar screws. METHODS: After obtaining an institutional review board approval, we conducted a retrospective study to identify all skeletally mature patients who sustained an ankle fracture with medial malleolar involvement treated with the sled and we identified a matched cohort treated with conventional malleolar screws. The patients were divided into 2 groups: group A included patients treated with malleolar screws and group B included patients treated with the sled device. The outcomes measured included rate of union, implant removal, and pain over the implant site. RESULTS: Eighty-five medial malleolar ankle fractures were divided into 2 groups: group A included patients (n = 64) treated with malleolar screws and group B included patients (n = 21) treated with the sled device. In group A (n = 64), 62 patients (96.8%) achieved radiological union with a mean union rate of 11 weeks and 10 (15%) patients underwent repeat surgery for implant removal of which 3 patients (4.6%) had pain specifically over the medial implant. In group B (n = 21), all of the patients (100%) achieved radiological union with a mean union rate of 10.8 weeks and 3 patients (14.2%) underwent repeat surgery of which 1 (4.7%) was related to the medial pain. There is no significant difference between the groups for the outcomes measured, including rate of union ( P = .93), visual analog scale score for pain ( P = .07), implant removal ( P = .41), and pain over the implant site ( P = .88). CONCLUSION: Based on the data from our study, we conclude that there are no major differences between the sled devices and conventional screws relating to union rate and complications. LEVELS OF EVIDENCE: Level III: Observational study.

External validation of the clinical indications of computed tomography (CT) of the head in patients with low-energy geriatric hip fractures.

INTRODUCTION: On evaluation of the clinical indications of computed tomography (CT) scan of head in the patients with low-energy geriatric hip fractures, Maniar et al. identified physical evidence of head injury, new onset confusion, and Glasgow Coma Scale (GCS)<15 as predictive risk factors for acute findings on CT scan. The goal of the present study was to validate these three criteria as predictive risk factors for a larger population in a wider geographical distribution. PATIENTS AND METHODS: Patients ≥65 years of age with low-energy hip fractures from 6 trauma centers in a wide geographical distribution in the United States were included in this study. In addition to the relevant patient demographic findings, the above mentioned three criteria and acute findings on head CT scan were gathered as categorical variables. RESULTS: In total 799 patients from 6 centers were included in the study. There were 67 patients (8.3%) with positive acute findings on head CT scan. All of these patients (100%) had at least one criteria positive. There were 732 patients who had negative acute findings on head CT scan with 376 patients (51%) having at least one criteria positive and 356 patients (49%) having no criteria positive. Sensitivity of 100% and negative predictive value of 100% was observed to predict negative acute findings on head CT scan when all the three criteria were negative. CONCLUSION: With the observed 100% sensitivity and 100% negative predictive value, physical evidence of acute head injury, acute retrograde amnesia, and GCS<15 can be recommended as a clinical decision guide for the selective use of head CT scans in geriatric patients with low energy hip fractures. All the patients with positive acute head CT findings can be predicted in the presence of at least one positive criterion. In addition, if these criteria are used as a pre-requisite to order the head CT, around 50% of the unnecessary head CT scans can be avoided.

Obesity Is Associated With High Perioperative Complications Among Surgically Treated Intertrochanteric Fracture of the Femur.

OBJECTIVES: To document the complications among obese patients who underwent surgical fixation for intertrochanteric femur (IT) fractures and to compare with nonobese patients. DESIGN: Retrospective cohort study. SETTING: Four level I trauma centers. PATIENTS: 1078 IT fracture patients. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Patient and fracture characteristics, surgical duration, surgical delay intraoperative and postoperative complications, inpatient mortality, and length of stay. METHOD: A retrospective review at 4 academic level I trauma centers was conducted to identify skeletally mature patients who underwent surgical fixation of intertrochanteric fractures between June 2008 and December 2014. Descriptive data, injury characteristics, OTA fracture classification, and associated medical comorbidities were documented. The outcomes measured included in-hospital complications, length of stay, rate of blood transfusion, change in hemoglobin levels, operative time, and wound infection. RESULTS: Of 1078 unique patients who were treated for an IT fracture, 257 patients had a Body mass index (BMI) of 30 or greater. Patients with a high BMI (≥30) had a significantly lower mean age (73 vs. 77 years, P < 0.0001), higher percentage of high-energy injuries (18% vs. 9%, P = 0.0004), greater mean duration of surgery (96 vs. 86 minutes, P = 0.02), and higher mean length of stay (6.5 vs. 5.9 days, P = 0.004). The high-BMI group (n = 257) had significantly higher percentages of patients with complications overall (43% vs. 28%, P < 0.0001), respiratory complications (11% vs. 3%, P < 0.0001), electrolyte abnormalities (4% vs. 2%, P = 0.01), and sepsis (4% vs. 1%, P = 0.002). Patients with BMI ≥ 40 had a much higher rate of respiratory complications (18%) and wound complications (5%) than obese (BMI: 30-39.9) and nonobese patients (BMI < 30). CONCLUSION: Intertrochanteric hip fracture patients with a BMI of >30 kg/m are much more likely to sustain systemic complications including respiratory complications, electrolyte abnormalities, and sepsis. In addition, morbidly obese patients are more likely to sustain respiratory complications and wound infections than obese (BMI: 30-39.9 kg/m) and nonobese patients (BMI: < 30 kg/m). The findings from this study can help direct surgeons in the counseling to obese patients and their family, and perhaps increase hospital reimbursement for this group of patients. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Role of Radiographs and Office Visits in the Follow-Up of Healed Intertrochanteric Hip Fractures: An Economic Analysis.

OBJECTIVES: The purpose of this study was to evaluate the role and the necessity of radiographs and office visits obtained during follow-up of intertrochanteric hip injuries. DESIGN: Retrospective study. SETTING: Two level I trauma centers. PATIENTS: Four hundred sixty-five elderly patients who were surgically treated for an intertrochanteric fracture of the femur at 2 level I trauma centers between January 2009 and August 2014 were retrospectively identified from orthopaedic trauma databases. INTERVENTION: Analysis of all healed intertrochanteric hip fractures, including demographic characteristics, quality of reduction, time of healing, number of office visits, number of radiographs obtained, and each radiograph for fracture alignment, implant position or any pathological changes. RESULTS: The surgical fixation of 465 fractures included 155 short nails (33%), 232 long nails (50%), 69 sliding hip screw devices (15%), 7 trochanteric stabilizing plates (1.5%), and 2 proximal femur locking plates (0.5%). The average fracture healing time was 12.8 weeks and the average follow-up was 81.2 weeks. Radiographs of any patient obtained after the fracture had healed did not reveal any changes, including fracture alignment or implant position and hardware failure. In 9 patients, pathological changes, including arthritis (3), avascular necrosis (3), and ectopic ossification (3) were noted. The average number of elective office visits and radiographs obtained after the fracture had healed were 2.8 (range: 1-8) and 2.6 (range: 1-8), respectively. According to Medicare payments to the institution, these radiographs and office visits account for a direct cost of $360.81 and $192, respectively, per patient. CONCLUSION: The current study strongly suggests that there is a negligible role for radiographs and office visits during the follow-up of a well-healed hip fracture when there is documented evidence of radiographic and clinical healing with acceptable fracture alignment and implant position. Implementation of this simple measure will help in reducing the cost of care and inconvenience to elderly patients. LEVEL OF EVIDENCE: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Improvement in osteoporosis detection in a fracture liaison service with integration of a geriatric hip fracture care program.

INTRODUCTION: Care gaps have been identified in the treatment of osteoporosis after the occurrence of a fragility hip fracture. HiROC (High Risk Osteoporosis Clinic) is a fracture liaison service implemented at our institution. In ProvenCare geriatric hip fracture care program at our institution pre-set orders for the inpatient HiROC consults were prescribed. We hypothesized that there will be a significant increase in the rate of enrollment of patients in the HiROC program after the integration of the pre-set orders. PATIENTS AND METHODS: The trauma database at a level-I trauma center was reviewed retrospectively for the charts of patients >50 years of age with fragility intertrochanteric fractures. Patients not treated under the geriatric hip fracture care program and patients treated under the geriatric hip fracture care program were identified and reviewed for the enrollment in HiROC and subsequent follow up. RESULTS: Out of 589 patients treated before the implementation of ProvenCare, 443 patients (75%) were enrolled in HiROC at the index consult. In comparison, out of 153 patients treated after the implementation of ProvenCare, 131 patients (85.6%) were enrolled in HiROC at the index consult. The difference between the two groups was statistically significant (p=0.008). CONCLUSION: Our experience shows that the occurrence of a fragility intertrochanteric fracture can be effectively utilized for the detection and initiation of treatment of osteoporosis. With the implementation of pre-set orders in the geriatric hip fracture care program significantly better enrollment can be achieved.

Osteoarticular allograft reconstruction of post-traumatic defect of distal femur in a pediatric patient: A case report and literature review.

Successful results of osteoarticular allografts in reconstruction of periarticular bone defect after tumor resection encouraged its utilization in post-traumatic defects. Here we describe a case of post-traumatic skeletal defect in a 4 year-old girl treated with osteoarticular allograft reconstruction. Due to severity of the associated soft tissue injury and contamination at presentation staged treatment with antibiotic spacer followed by the reconstruction was carried out. At the end of one year the patient achieved 'Musculoskeletal tumor society' functional score of 27 points and radiographic score of 93%. Reconstruction immediately after healing of soft tissues prevented development of any varus or valgus deformity of the knee. Our case demonstrates utility of osteoarticular allograft in a pediatric post-traumatic skeletal defect.

Posterior Malleolar Fractures Associated With Tibial Shaft Fractures and Sequence of Fixation.

OBJECTIVES: The purpose of this study was to evaluate posterior malleolar injuries associated with nailed tibial fractures and to determine the quality of reduction based on the sequence of fixation in associated fracture patterns. DESIGN: Retrospective cohort study. PATIENTS: 1113 tibia fractures treated with an intramedullary nail at 3 level I trauma centers. INTERVENTION: Tibial shaft fractures with posterior malleolar injury were analyzed regarding type of fracture, mechanism of injury, energy of injury, fracture characteristic, surgical characteristics including sequence of fixation, obvious intraoperative displacement of the posterior malleolar fragment, and the quality of reduction. One group ("malleolus-first") consisted of patients in whom the posterior malleolus was fixed before tibial nailing and the other group ("tibia-first") included patients in whom tibial nailing was done before posterior malleolus fixation. OUTCOMES MEASURED: Intraoperative displacement, quality of reduction. RESULTS: Ninety-six of 1113 (9%) nailed tibial shaft fracture patients had a concomitant posterior malleolus fracture (9%). Of the 96 posterior malleolar fracture patients, 70 patients were operatively treated (73%). In the malleolus-first group (54 patients), intraoperative displacement of the posterior malleolar fragment was observed in 1 patient, and 1 case of poor reduction of the posterior malleolar fragment was observed (2%). In the tibia-first group (16 patients), obvious intraoperative displacement of the posterior malleolar fragment was observed in 5 patients (31%), and poor reduction of the posterior malleolar fragment was observed in 7 patients (44%). These percentages of patients with poor quality of reduction were statistically significantly different (p ≤ 0.01). CONCLUSION: Many low-energy tibia fractures with a spiral configuration do have an associated posterior malleolus fracture. In order to avoid intraoperative displacement and poor reduction, we recommend fixation of the posterior malleolar fragment before nailing of the tibia in associated fracture pattern. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Knee Injury Associated With Acetabular Fractures: A Multicenter Study of 1273 Patients.

OBJECTIVES: The purpose of this study was to determine the incidence and pattern of the knee injury associated with acetabular fractures. DESIGN: Retrospective cohort study. SETTING: Three level I and one level II trauma centers. PATIENTS: A total of 1273 skeletally mature patients treated at 4 trauma centers between November 2004 and December 2013 for acetabular fractures were retrospectively identified from orthopaedic trauma databases. INTERVENTION: Analysis of all acetabular fractures with knee injury regarding type of acetabular fracture, mechanism of injury, energy of injury, pattern of the knee injury, knee examination findings at initial presentation, intraoperative and on follow-up, requirement for surgery/conservative management, and the associated injuries. The clinical data entered during inpatient stay and office visits were analyzed. MAIN OUTCOME MEASURES: Incidence and pattern of the knee injury. RESULTS: One hundred ninety-three of 1273 patients (15%) were found to have ipsilateral knee symptoms within a period of 1 year from the date of injury. The patterns of knee injury included 56 fractures (29%), 49 ligamentous lesions (25%), and 88 miscellaneous (46%) causes including bone bruises, wounds, and swelling. Associated injuries included 85 patients with ipsilateral hip dislocation (45%), 59 pelvic injuries (31%), 61 extremity injuries (32%), 38 head injuries (20%), 37 chest injuries (20%), 23 abdominal and genitourinary injuries (12%), and 7 injuries of the spine (4%). CONCLUSION: Based on this study, we conclude that knee injuries associated with high-energy acetabular fractures constitute a significant portion of the patient population. Ligament injuries are frequently overlooked and thorough clinical evaluation and utilization of magnetic resonance imaging in selected cases will help in early detection and prevention of long-term complications. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

What makes an intertrochanteric fracture unstable in 2015? Does the lateral wall play a role in the decision matrix?

Intertrochanteric (IT) fractures pose a tremendous burden to the healthcare system. Although consistently good results are obtained while treating stable IT fractures, treatment failure rates with unstable fractures are much higher, and hence, it is imperative to identify unstable patterns. Presently, the conventionally classified unstable configurations (fracture with posteromedial comminution, reverse oblique, IT with subtrochanteric extension) and the recently added fracture patterns (IT fractures with avulsed greater trochanter and lateral wall breach) qualify as unstable IT fractures; however, the list is certainly not exhaustive. Disruption of lateral wall converts an IT fracture into a reverse oblique fracture equivalent and should be given a strong consideration in the decision matrix.