What is the difference in treatment approach between intertrochanteric and subtrochanteric fractures?

Intertrochanteric vs Subtrochanteric Fractures: Treatment Approach Differences

Intertrochanteric fractures should be treated with sliding hip screws for stable fractures and antegrade cephalomedullary nails for unstable fractures, while subtrochanteric fractures require cephalomedullary nails (preferably long nails) due to their biomechanical challenges and higher complication risks. 1

Anatomical and Clinical Differences

• Intertrochanteric fractures: Occur between the greater and lesser trochanters
• Subtrochanteric fractures: Occur below the lesser trochanter (within 5 cm distally)
• Blood loss: Extracapsular fractures (both types) have greater blood loss than intracapsular fractures, with subtrochanteric fractures typically having more bleeding due to greater periosteal disruption 1
• Pain levels: Extracapsular fractures are considerably more painful than intracapsular fractures due to greater periosteal disruption 1

Treatment Approach Differences

Intertrochanteric Fractures

• Stable intertrochanteric fractures: Sliding hip screw is the preferred fixation method 1
• Unstable intertrochanteric fractures: Antegrade cephalomedullary nail is recommended 1
• Surgical time: Generally shorter than for subtrochanteric fractures 2

Subtrochanteric Fractures

• Strong evidence supports: Cephalomedullary devices should be used 1
• Nail length: Long reconstruction nails are preferred over standard nails 3
• Distal locking: Necessary, with dynamic locking preferred to allow compression along the nail axis 3
• Challenges: More difficult reduction due to muscle forces (gluteus medius and vastus lateralis) causing displacement of the proximal fragment 3

Special Considerations for Trochanteric Fractures with Subtrochanteric Extension

For fractures that span both regions (11.6% of peritrochanteric fractures), recent evidence suggests:

• Long nails demonstrate advantages in preserving mobility scores and managing fracture extension 2
• Standard nails have the advantage of reduced surgical time 2
• Both options show comparable outcomes for mortality, surgical complications, and hematological parameters 2

Critical Technical Considerations

• Medial cortex restoration: Restoring continuity in the medial cortex of the femoral neck (Adams arch) is essential for stability 3
• Reduction quality: No implant can compensate for poor reduction - accurate reduction is critical 3
• Complications: Most complications relate to technical errors such as insufficient reduction or incorrectly inserted implants 3

Postoperative Management

• Weight-bearing: Early mobilization and immediate weight-bearing are recommended for both fracture types when rigid fixation is achieved 4
• Rehabilitation: Should include early physical training, muscle strengthening, and long-term balance training 1

Common Pitfalls to Avoid

1. Treating subtrochanteric fractures like intertrochanteric fractures: This can lead to formidable complications 5
2. Inadequate fixation strength: Subtrochanteric fractures may take up to a year to unite and require stronger fixation 5
3. Neglecting bone quality: Consider bone grafting for subtrochanteric fractures to shorten healing time 5
4. Improper nail selection: Using short nails for subtrochanteric fractures increases failure risk 3

The key to successful management is recognizing the biomechanical differences between these fracture types and selecting the appropriate fixation method accordingly, while ensuring proper surgical technique and reduction quality.