title: Pertrochanteric fractures (AO/OTA 31-A1 and A2) not amenable  to closed reduction: causes of irreducibility.
abstract: OBJECTIVE
  To define the unique radiographic features, operative treatment, and complications of pertrochanteric fractures (AO/OTA 31-A1 and A2) which are not amenable to the usual closed reduction manoeuvres.
  
  
  METHODS
  During a 2-year period (from August 2011 until December 2013), 212 patients with pertrochanteric fractures were treated at our level I trauma centre. A retrospective review was undertaken to determine which of these fractures were not reducible via the routine closed reduction manoeuvres and required some form of open reduction. These fractures were assessed for radiographic markers of irreducibility, surgical findings, reduction techniques, and perioperative complications.
  
  
  RESULTS
  Twenty-four patients had fractures, which were not amenable to closed reduction and underwent open reduction. These fractures could be grouped into four patterns. A preoperative CT scan was available for at least two cases of each pattern, which provided further insights into the cause of irreducibility by closed means. These included a variant where the proximal fragment is locked underneath the shaft fragment (3 cases), bisected lesser trochanter with a locked proximal fragment (3 cases), irreducibility due to entrapped posteromedial fragment at the fracture site (6 cases) and a variant where the proximal fragment is flexed passively by the underlying lesser trochanter (12 cases).
  
  
  CONCLUSIONS
  Pertrochanteric fractures, which are not amenable to closed reduction, are uncommon, but are heralded by unique radiographic features. These patients warrant special consideration in terms of recognition and management. The specific radiographic markers should alert the surgeon to this injury pattern and its related difficulty encountered during closed reduction. Once reduction is achieved, however, these fractures follow an uneventful course.
authors.forename: Gaurav
authors.initials: G
authors.lastname: Sharma
authors.forename: Kiran
authors.initials: K
authors.lastname: kumar G N
authors.forename: Sanjay
authors.initials: S
authors.lastname: Yadav
authors.forename: Devendra
authors.initials: D
authors.lastname: Lakhotia
authors.forename: Ravijot
authors.initials: R
authors.lastname: Singh
authors.forename: Shivanand
authors.initials: S
authors.lastname: Gamanagatti
authors.forename: Vijay
authors.initials: V
authors.lastname: Sharma
mesh_terms: D000077:Acetabulum / Q000000981:diagnostic imaging* / Q000293:injuries / Q000601:surgery*; D000328:Adult; D001863:Bone Screws; D005260:Female; D005265:Femoral Neck Fractures / Q000000981:diagnostic imaging* / Q000601:surgery*; D005593:Fracture Fixation, Internal / Q000379:methods*; D006801:Humans; D007194:India / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D011183:Postoperative Complications / Q000453:epidemiology; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D012307:Risk Factors; D014057:Tomography, X-Ray Computed; D014193:Trauma Centers / Q000706:statistics & numerical data*; D016896:Treatment Outcome