See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/371808165

Early surgical treatment of closed reduction and internal fixation for a 30-day
old intertrochanteric fracture with hemiplegia after acute stroke A case report

Article  in  Medicine · June 2023

DOI: 10.1097/MD.0000000000034098

CITATIONS READS
0 5

5 authors, including:

Jie-Feng Huang
Zhejiang Chinese Medical University
47 PUBLICATIONS   389 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Foot and Ankle Trauma View project

Periprosthetic Femoral Fracture View project

All content following this page was uploaded by Jie-Feng Huang on 24 June 2023.

The user has requested enhancement of the downloaded file.

 Clinical Case Report Medicine ®

Early surgical treatment of closed reduction and

internal fixation for a 30-day old intertrochanteric
fracture with hemiplegia after acute stroke
Downloaded from http://journals.lww.com/md-journal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCy

A case report
wCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/24/2023

Zeng-Li Zhang, BSca, Xu-Song Li, MDb, Wei-Qiang Zhao, MSc, Jie-Feng Huang, PhDc,d,*  , Ya-Hong Zhu, BSce

Abstract
Rationale: Currently, there are no clear guidelines to determine whether and when to perform surgical hip repair in patients with
acute stroke and hip fracture.
Patient concerns: In this case report, we report a case of 75-year-old woman admitted with left hip pain and limited mobility
for 1 month.
Diagnoses: Patient had a history of acute cerebral infarction 42 days ago, and diagnosed with a left intertrochanteric fracture
at another hospital 30 days ago.
Intervention: Patient was treated with closed reduction and internal fixation with proximal femoral nail anti-rotation.
Outcomes: At 2-year follow-up, the patient’s basic function was restored. The fracture healed well, and the Harris hip score
was 75.
Lessons: Without consistent guidelines, individualized treatment strategies including surgical methods and timing of surgery
should be made to weigh the risks and benefits for patients with acute stroke and intertrochanteric fractures.
Abbreviations: CRIF = closed reduction and internal fixation, PFNA = proximal femoral nail anti-rotation.
Keywords: acute, intertrochanteric fracture, old, stroke, surgical treatment

1. Introduction The surgical treatment goals of intertrochanteric fractures

Hip fractures are a significant post-stroke complication.[1,2] The
incidence of hip fracture in stroke patients with hemiplegia is 2
to 4 times higher than that of healthy people.[3–7] Paradoxically,
hip fractures in elderly also increase stroke risk,[8] and needing
early surgical treatment to reduce morbidity and mortality.[9]
Prior studies have shown that hemiplegia after acute stroke
combined with hip fracture leads to worse neurological recov-
ery, prolonged hospitalization period, increased complications,
decreased patient prognosis, and increased 30-day and one-year
mortalities.[3,4]
were fracture stabilization, early patient mobilization, and
restoring to previous level of independence and function.[10]
The mainstream treatment is internal fixation (including intra-
medullary and extramedullary), and hip arthroplasty has also
been reported.[11–13] However, there is no accepted surgical pro-
cedure for old intertrochanteric fractures. At the same time,
acute cerebral infarction is a relative contraindication to hip
reconstructive surgery, therefore, most of these patients cannot
undergo surgical treatment.[4] In general, elective surgery after
acute stroke is best delayed by 2 weeks, preferably 6 weeks.
However, there are no clear guidelines to determine whether

This work was supported by Zhejiang Provincial Natural Science Foundation
(LY20H270012), Zhejiang Administration of Traditional Chinese Medicine
(2020ZB090), and Hua Jiang Famous Expert Inheritance Studio of Traditional
Chinese Medicine (GZS2021020).
Written informed consent was obtained from the patient for publication of this
article.
The authors have no conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are
available from the corresponding author on reasonable request.
e
Emergency Center, The First Affiliated Hospital of Zhejiang Chinese Medical
University, Hangzhou, China.
*Correspondence: Jie-Feng Huang, Department of Orthopaedics and
Traumatology, The First Affiliated Hospital of Zhejiang Chinese Medical University,
Hangzhou 310006, China (e-mail: 40983285@qq.com).
Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.
This is an open access article distributed under the Creative Commons
Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.

Ethical approval from the institutional review board was not required for this study.
a
Department of Orthopaedics and Traumatology, Songyang Hospital of Traditional
Chinese Medicine, Songyang, China, b Department of Orthopaedics and
Traumatology, Zhongshan Hospital of Traditional Chinese Medicine, Zhongshan,
China, c The First Clinical College, Zhejiang Chinese Medical University,
Hangzhou, China, d Department of Orthopaedics and Traumatology, The First
Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China,
How to cite this article: Zhang Z-L, Li X-S, Zhao W-Q, Huang J-F, Zhu Y-H.
Early surgical treatment of closed reduction and internal fixation for a 30-day
old intertrochanteric fracture with hemiplegia after acute stroke: A case report.
Medicine 2023;102:25(e34098).
Received: 11 April 2023 / Received in final form: 2 June 2023 / Accepted: 5 June
2023
http://dx.doi.org/10.1097/MD.0000000000034098

1
 Zhang et al.  •  Medicine (2023) 102:25Medicine

and when to perform surgical hip repair in patients with acute
stroke and hip fracture.
We report a case of an old femoral intertrochanteric fracture
with hemiplegia after acute stroke, treated with closed reduction
and internal fixation (CRIF) with proximal femoral nail anti-ro-
tation (PFNA).
Downloaded from http://journals.lww.com/md-journal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCy
wCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/24/2023
2. Case presentation
Informed consent was obtained from the patient for publication
of this case report details.
A 75-year-old woman was admitted with left hip pain and
limited mobility for 1 month. She had a history of acute cerebral
infarction 42 days ago (Fig. 1), and tripped during rehabilitation

Figure 1.  The brain MRI on the day of onset. Diffusion weighted imaging (DWI) scan showed hyperintensity shadow in the right paraventricular, corpus callosum
and temporo-occipital lobe.

Figure 2.  Left hip deformity and skin condition preoperative. A and B: The patient’s left lower limb showed obvious adduction and external rotation deformity.
C: The skin of the left hip appeared drug eruption due to external use of drugs. D: A third-degree pressure sores on the sacral tail skin.

2
 Zhang et al.  •  Medicine (2023) 102:25www.md-journal.com
Downloaded from http://journals.lww.com/md-journal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCy
wCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/24/2023

Figure 3.  Preoperative imaging findings of the patient. Radiographs (A), coronal (B), transverse (C), and sagittal (D). CT scans identified a left intertrochanteric
fracture accompanied by greater and lesser trochanteric fractures with varus deformity, and callus growth at the fracture end. CT = computed tomography.

Figure 4. Intraoperative imaging findings of the patient. A and B: After closed reduction, C-arm fluoroscopy was performed under traction showed
Intertrochanteric fracture of the left hip had basically reached anatomical reduction. C: Preoperative body surface positioning under traction bed. D–F: PFNA
was placed during the operation. PFNA = proximal femoral nail anti-rotation.

3
 Zhang et al.  •  Medicine (2023) 102:25Medicine

exercise 30 days ago. She was diagnosed with a left intertro-
chanteric fracture at another hospital, but the operation was
postponed due to acute cerebral infarction.
The patient’s left lower limb showed obvious adduction
and external rotation deformity (Fig. 2A and B). The skin of
the left hip appeared skin rash due to external use of Chinese
herbs (Fig. 2C), and there was a third-degree pressure sores
on the sacral tail skin (Fig.  2D). The muscle strength was
grade I of left lower limb, and grade III of left upper limb.
Downloaded from http://journals.lww.com/md-journal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCy
the activity daily living was heavily dependent and the Barthel
index14,15] was 30.
Radiographs and computed tomography identified a type I,
group IV intertrochanteric fracture according to Evans classi-
fication (Fig. 3). The Dual-energy X-ray absorptiometry of the
right hip was examined, and the T-score was −3.9.
After successful epidural anesthesia, the patient was
placed in the supine position. The partially bone union was
simply re-fractured using closed reduction manipulation,

Neurological function scores were evaluated preoperative, and the left lower limb was maintained traction and rotated
the National Institutes of Health stroke scale[14] was 7, and inward, then c-arm fluoroscopy was performed. When the
fracture had basically reached anatomical reduction, the
wCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/24/2023

patient underwent CRIF with percutaneous PFNA on trac-

Table 1
tion bed (Fig. 4).
The details of the patient’s rehabilitation methods. Cefuroxime (1.5 g intravenously twice a day) was given
Item 24 hours perioperative to prevent infection. Low molecular
weight heparin (1500 μL subcutaneous injection once per
Physical therapy day) was given to prevent deep vein thrombosis, and was
 Use bare hands Muscle strength training, focusing on hip flexors and bridged with aspirin (0.1 g orally, once a day) 5 weeks after
in bed quadriceps surgery. Atorvastatin (20 mg orally, once a day) was used to
Range of motion training, mainly active and passive range prevent recurrence of stroke. Anti-osteoporosis therapy was
of motion of the hip and knee also used.
MOTOmed training of limb in bed The patient was encouraged to move early on the bed with
Routine maintenance of the healthy side and left upper limb endurable pain. Postoperative rehabilitation treatment was
 Bedside sitting Bobath shake hands and roll over exercise
continued twice a day, including physical therapy, aerobic
or standing* Help off the bed turn to sit up, sit on the bed
Sitting balance training, from sitting to standing
training and physical agents therapy. Specific rehabilitation
exercises
Standing balance training, and the use of rehabilitation aids training measures need to be evaluated and adjusted according
 Gait training* Shift of weight, stride and step to the actual situation of the patient. Table 1 lists the details of
Aerobic Training Diaphragmatic breathing exercises rehabilitation methods. Acupuncture was also performed once
Resistance training of upper and lower limbs assisted with a day.
elastic bandage The pressure ulcer healed 2 weeks after operation. At 12
Assisted hand or power bike training weeks postoperatively, the fracture healed radiographically
Physical agents Neuromuscular electrical stimulation and the patient was able to stand on support or with the aid
therapy Infrared ray therapy† of a walker. At 2-year follow-up, the muscle strength was
Ultrashort wave therapy† grade IV of left lower limb, and grade V of left upper limb.
Transcranial magnetic stimulation The National Institutes of Health stroke scale was 0, and the
*When the patient’s left lower limb muscle strength reached grade III or above, standing training activity daily living was independent and the Barthel index was
and gait training was performed. 80. The fracture healed well, and the Harris hip score was 75
†Use within 2 weeks after surgery. (Figs. 5 and 6).

Figure 5.  The incision healed well and basic function was restored. The incision healed well and basic function was restored.

4
 Zhang et al.  •  Medicine (2023) 102:25www.md-journal.com

Author contributions
Conceptualization: Zeng-Li Zhang, Jie-Feng Huang, Ya-Hong
Zhu.
Data curation: Zeng-Li Zhang, Xu-Song Li, Wei-Qiang Zhao.
Formal analysis: Xu-Song Li.
Investigation: Xu-Song Li, Wei-Qiang Zhao, Ya-Hong Zhu.
Validation: Jie-Feng Huang.
Writing – original draft: Zeng-Li Zhang.
Downloaded from http://journals.lww.com/md-journal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCy

Writing – review & editing: Jie-Feng Huang, Ya-Hong Zhu.

References
wCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/24/2023

Figure 6.  Radiographs of the left hip showed good fracture healing at 2-year
follow-up. At 2-year follow-up, anteroposterior (A) and lateral (B) radiographs
of the left hip showed good fracture healing.
3. Discussion
Although acute cerebral infarction is a relative contraindication
to surgery, a small sample study (11 cases) in which the patients
and family members requested and insisted on hip reconstruc-
tive surgery has reported that surgical treatment can improve the
prognosis of patients with acute cerebral infarction.[4] However,
the study did not address the timing of surgery or the surgical
treatment method of hip reconstruction. A case of intertrochan-
teric fracture and acute stroke, focusing on individual factors to
reduce postoperative complications and recurrent stroke rate by
a multidisciplinary team, treated with PFNA has been reported.[16]
In our case, the 30-day intertrochanteric fracture had local callus
growth at the fracture end on images, which may due to brain
injury.[17] Meanwhile, acute post-stroke hemiplegia, pressure
sores, and drug eruption of the hip make treatment more difficult.
We prepared 2 surgical options. According to the healing process
of the 30-day intertrochanteric fracture, the fracture ends have been
connected by cartilage callus, and hard callus gradually appeared.
At this point, closed reduction was still possible. Intraoperative flu-
oroscopy after closed reduction also confirmed our judgment. If
closed reduction fails, hip arthroplasty would be chosen.
CRIF with PFNA has 3 advantages. First, it corrected the hip
deformity and relieved the pain. Second, compared with hip
arthroplasty, the operation is less traumatic and conducive to
postoperative rehabilitation. Third, revision hip arthroplasty is
still available after failed fixation.[18] Hemiplegia, pressure sores,
and drug eruption of the hip may increase the risk of dislocation
and infection after hip arthroplasty, therefore, only considered
as an alternative to the failure of closed reduction. At the same
time, total hip arthroplasty for old intertrochanteric fracture is
more difficult procedure than for osteonecrosis or osteoarthritis.
In conclusion, without consistent guidelines, individualized
treatment strategies including surgical methods and timing
of surgery should be made to weigh the risks and benefits for
patients with acute stroke and intertrochanteric fractures.
[1] Northuis CA, Crandall CJ, Margolis KL, et al. Association between
post-stroke disability and 5-year hip-fracture risk: the women’s health
initiative. J Stroke Cerebrovasc Dis. 2020;29:104976.
[2] Lee KB, Lee JG, Kim BJ, et al. The epidemiology of fracture in
patients with acute ischemic stroke in Korea. J Korean Med Sci.
2019;34:e164.
[3] Wang J, Luo H, Wang Q, et al. Analysis of the surgical outcomes in
elderly patients with hip fractures combined with hemiplegia. Clin
Interv Aging. 2022;17:1093–8.
[4] Yuan J, Zhu G, Zhao Y, et al. Effect of hip fracture on prognosis of
acute cerebral infarction. Clinics (Sao Paulo). 2021;76:e3059.
[5] Li K, Zheng Y. Internal fixation versus conservative treatment for
elderly patients with a trochanteric hip fracture in conjunction with
post-stroke hemiplegia. Injury. 2016;47:2169–72.
[6] Feng M, Zhang J, Shen H, et al. Predictors of prognosis for elderly
patients with poststroke hemiplegia experiencing hip fractures. Clin
Orthop Relat Res. 2009;467:2970–8.
[7] Luan L, Li R, Wang Z, et al. Stroke increases the risk of hip frac-
ture: a systematic review and meta-analysis. Osteoporos Int.
2016;27:3149–54.
[8] Pedersen AB, Ehrenstein V, Szépligeti SK, et al. Hip fracture, comorbid-
ity, and the risk of myocardial infarction and stroke: a Danish nation-
wide cohort study, 1995-2015. J Bone Miner Res. 2017;32:2339–46.
[9] Frenkel Rutenberg T, Assaly A, Vitenberg M, et al. Outcome of non-sur-
gical treatment of proximal femur fractures in the fragile elderly popu-
lation. Injury. 2019;50:1347–52.
[10] Lorich DG, Geller DS, Nielson JH. Osteoporotic pertrochanteric hip
fractures: management and current controversies. Instr Course Lect.
2004;53:441–54.
[11] Arirachakaran A, Amphansap T, Thanindratarn P, et al. Comparative
outcome of PFNA, gamma nails, PCCP, medoff plate, LISS and dynamic
hip screws for fixation in elderly trochanteric fractures: a systematic
review and network meta-analysis of randomized controlled trials. Eur
J Orthop Surg Traumatol. 2017;27:937–52.
[12] Zhou S, Liu J, Zhen P, et al. Proximal femoral nail anti-rotation versus
cementless bipolar hemiarthroplasty for unstable femoral intertrochan-
teric fracture in the elderly: a retrospective study. BMC Musculoskelet
Disord. 2019;20:500.
[13] Chu X, Liu F, Huang J, et al. Good short-term outcome of arthroplasty
with Wagner SL implants for unstable intertrochanteric osteoporotic
fractures. J Arthroplasty. 2014;29:605–8.
[14] Kasner SE. Clinical interpretation and use of stroke scales. Lancet
Neurol. 2006;5:603–12.
[15] Mahoney FI, Barthel DW. Functional evaluation: the barthel index. Md
State Med J. 1965;14:61–5.
[16] Lim JW, Ang GC. Approach to patients with hip fracture and concur-
rent stroke. BMJ Case Rep. 2021;14:e236064.
[17] Yang TY, Wang TC, Tsai YH, et al. The effects of an injury to the brain
on bone healing and callus formation in young adults with fractures of
the femoral shaft. J Bone Joint Surg Br. 2012;94:227–30.
[18] Liu P, Jin D, Zhang C, et al. Revision surgery due to failed internal
fixation of intertrochanteric femoral fracture: current state-of-the-art.
BMC Musculoskelet Disord. 2020;21:573.

View publication stats