Treatment of Displaced Right Intertrochanteric Fracture
For displaced right intertrochanteric fractures, cephalomedullary nailing is the treatment of choice as it significantly reduces morbidity and mortality compared to other fixation methods. 1
Surgical Management Based on Fracture Type
Unstable Intertrochanteric Fractures
- Antegrade cephalomedullary nail is the preferred surgical treatment 1
- Strong evidence supports using cephalomedullary devices for unstable intertrochanteric, subtrochanteric, or reverse oblique fractures 2, 1
Stable Intertrochanteric Fractures
- Sliding hip screw is favored for stable intertrochanteric fractures 2
- The most important aspect of sliding hip screw insertion is secure placement within the femoral head 3
Surgical Technique Considerations
- Obtain an impacted reduction at the time of surgery 3
- If a large posteromedial fragment exists, attempt to internally fix it with a lag screw or cerclage wire 3
- Consider using anterior and medial bone contact of the distal shaft piece to achieve stable reduction 4
Postoperative Care Protocol
Immediate Care
- Allow weight-bearing as tolerated immediately after surgery 1
- Implement multimodal analgesia including peripheral nerve blocks 1
- Administer supplemental oxygen for at least 24 hours postoperatively 1
- Provide antibiotic prophylaxis to prevent infection 1
- Consider blood transfusion for symptomatic anemia 1
Thromboprophylaxis
- Implement early thromboprophylaxis and continue for 4 weeks postoperatively 1
Monitoring and Prevention of Complications
- Regularly assess cognitive function 2, 1
- Monitor nutritional status and renal function 2, 1
- Correct postoperative anemia 2, 1
- Remove urinary catheters as soon as possible to reduce infection risk 1
- Encourage early mobilization to improve oxygenation and respiratory function 1
Rehabilitation and Follow-up
- Begin early mobilization with weight-bearing restrictions based on reconstruction stability 1
- Coordinate with orthogeriatricians for patient-centered care 1
- Conduct radiographic evaluations at 6 weeks, 3 months, 6 months, and 1 year 1
- Return to full activities typically occurs at 3-4 months based on radiographic healing and functional recovery 1
Management of Underlying Conditions
- Evaluate and treat underlying osteoporosis 1
- Refer patients to a bone health clinic 1
- Ensure adequate intake of calcium and vitamin D 2
- Advise smoking cessation and limitation of alcohol intake 2
Common Pitfalls and Caveats
- Failure to address malnutrition increases mortality risk 1
- Opioid analgesics as the sole adjunct can lead to respiratory depression and confusion 1
- Cognitive dysfunction and delirium occur in 25% of patients and require careful management 1
- Delayed mobilization can lead to complications of recumbency 5
- Improper reduction can result in varus malalignment 6
While conservative management with pain relief and early mobilization has shown some success for stable intertrochanteric fractures during exceptional circumstances like the COVID pandemic 5, surgical stabilization remains the standard of care for displaced intertrochanteric fractures to prevent complications and improve functional outcomes.