Knowledge Base

Intertrochanteric Femur Fracture

Hip2 management options6 viva pearls

Classification systems

  • AO/OTA grouping for the trochanteric region, separating stable, unstable and reverse-oblique patterns

Mechanism

A simple fall from standing height with a direct impact on the greater trochanter in an osteoporotic elderly patient accounts for the overwhelming majority. High-energy trauma in the young produces the same fracture with more comminution and subtrochanteric extension. It is an extracapsular fracture, so the blood supply to the head is preserved and union is the rule.

Age considerations

Paediatric
Extremely rare and almost always high-energy or pathological; treatment is individualised with attention to the physis and the trochanteric apophysis.
Young adult
High-energy injury with comminution; anatomical reduction and a strong construct are required, and the fracture is often part of a polytrauma picture demanding damage-control thinking.
Elderly
The dominant group. Early surgery within the accepted window, optimisation of anaemia and cardiac status, regional analgesia, delirium prevention, and orthogeriatric co-management influence survival more than the choice of implant. Weight bearing must be immediate.

Management options

Dynamic hip screwshow

Indication

Stable two-part intertrochanteric fractures with an intact lateral wall.

Implant design notes

A large lag screw sliding within a barrel on a side plate: controlled collapse allows the fracture to impact and load-share, converting shear to compression. It relies absolutely on an intact lateral wall as a buttress. Screw position should be centre-centre or centre-inferior with a low tip-apex distance.

Approach

Lateral approach splitting vastus lateralis, on a traction table with image intensifier.

Steps overview

  1. Position supine on a traction table; reduce closed by traction and slight internal rotation, confirming on both views
  2. Lateral incision and vastus lateralis split down to the femoral cortex
  3. Insert the guide wire at the correct entry point and angle, aiming centre-centre
  4. Measure and confirm a tip-apex distance well within accepted limits
  5. Ream, tap in hard bone, and insert the lag screw
  6. Slide the barrel plate over the screw and fix to the shaft with cortical screws
  7. Add a compression screw if appropriate and confirm final position on both views
  8. Close and mobilise fully weight bearing on day one

Notes

Using a sliding hip screw in a reverse-oblique or lateral-wall-deficient fracture leads to medialisation of the shaft and implant cut-out; that is the classic error. A high tip-apex distance predicts screw cut-out.

Resident summary compiled from standard orthopaedic trauma teaching; verify against your departmental protocol.

Cephalomedullary nailshow

Indication

Unstable patterns, reverse-oblique fractures, lateral wall deficiency, and fractures with subtrochanteric extension.

Implant design notes

Intramedullary device with a proximal head-neck screw or blade, sitting closer to the mechanical axis so it carries load with a shorter lever arm than a side plate. The nail itself buttresses the medial cortex, so lateral wall integrity is no longer essential. A helical blade compacts osteoporotic cancellous bone rather than removing it.

Approach

Percutaneous tip-of-trochanter entry with a short proximal incision, plus a small distal incision for locking.

Steps overview

  1. Position supine on a traction table with the trunk adducted to allow instrument clearance
  2. Reduce closed by traction and rotation; accept nothing less than a good reduction before instrumenting
  3. Make the entry at the tip of the greater trochanter, confirmed on both views
  4. Open the canal, pass the guide wire, ream if required, and insert the nail
  5. Place the head-neck screw or blade centre-centre with a low tip-apex distance
  6. Lock distally, checking rotation and length against the other side
  7. Confirm no anterior perforation of the distal femur on the lateral view
  8. Close, and mobilise fully weight bearing the next day

Notes

Malreduction in varus or with distraction cannot be rescued by a nail. Anterior cortical perforation distally is a recognised complication of a straight nail in a bowed elderly femur.

Resident summary compiled from standard orthopaedic trauma teaching; verify against your departmental protocol.

Viva pearls

  • Tip-apex distance is the number examiners want: it predicts lag screw cut-out and must be kept low, measured on both views.
  • The lateral wall is the deciding anatomical feature between a sliding hip screw and a nail — say it explicitly.
  • Reverse-oblique and subtrochanteric extension patterns are intramedullary problems; a sliding hip screw fails in them.
  • This is an extracapsular fracture, so avascular necrosis is rare and union is expected — the discussion is about implant mechanics, not head viability.
  • Immediate full weight bearing and the orthogeriatric care bundle determine outcome more than the implant choice.
  • Do not forget the reduction: no implant compensates for a varus malreduction.

Sources for further reading

  • Rockwood and Green's Fractures in Adults — trochanteric and subtrochanteric femur
  • Standard operative orthopaedics textbook — hip fractures
  • National hip fracture care standards and departmental protocols

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