What is the standard management approach for intratrochantric femur fractures?

Standard Management Approach for Intertrochanteric Femur Fractures

Surgical stabilization is the standard treatment for intertrochanteric femur fractures, with device selection based on fracture stability: use a sliding hip screw (SHS) or cephalomedullary nail for stable fractures, and a cephalomedullary nail for unstable, subtrochanteric, or reverse oblique fractures. 1

Fracture Classification and Device Selection

The critical first step is determining fracture stability based on the status of the posteromedial cortex 2:

Stable Intertrochanteric Fractures

• Either a sliding hip screw or cephalomedullary device is appropriate 1
• The sliding hip screw remains a valid option with equivalent outcomes 1
• Cephalomedullary nails offer 23% less surgical time and 44% less blood loss in some studies, though require 70% greater fluoroscopic time 3
• Despite equivalent evidence, 68% of U.S. surgeons now primarily use cephalomedullary nails due to perceived ease of technique 4

Unstable Intertrochanteric Fractures

• A cephalomedullary nail is strongly recommended 1
• Unstable patterns include those with large posteromedial fragments or significant comminution 2
• If using SHS for unstable fractures, attempt internal fixation of large posteromedial fragments with lag screws or cerclage wire 2

Subtrochanteric or Reverse Oblique Fractures

• A cephalomedullary device is mandatory 1
• These fracture patterns have significantly higher reoperation rates with SHS (6.4% vs 3.8% with intramedullary nails at one year) 5
• Patients treated with intramedullary nails for these patterns report less pain (VAS 27 vs 30) and greater satisfaction (VAS 36 vs 31) 5

Surgical Timing and Preoperative Management

• Perform surgery within 24 to 48 hours of admission for improved outcomes 1
• Do not use preoperative traction—this is a strong recommendation against routine use 1
• Administer prophylactic antibiotics within one hour of skin incision 6

Anesthesia Selection

• Either spinal or general anesthesia is appropriate—this is a strong recommendation with no preference 1
• Consider peripheral nerve blocks for postoperative pain management 6
• Implement active warming strategies to prevent hypothermia, particularly important in elderly patients 6

Surgical Technique Principles

• The most critical technical aspect is secure placement of the lag screw within the femoral head 2
• Obtain an impacted reduction at the time of surgery, even though the sliding hip screw allows postoperative fracture impaction 2
• Early mobilization protocols should be implemented postoperatively to reduce complications 6

Alternative: Hip Arthroplasty

Hip arthroplasty is reserved for specific high-risk scenarios 7:

• Highly comminuted fractures at high risk of fixation failure
• Poor bone quality precluding stable fixation
• Patients who cannot tolerate prolonged bedrest
• Concomitant intraarticular hip pathology requiring treatment

However, this remains controversial with no clear guidelines defining its role, and longer-term outcomes may favor intramedullary fixation 7.

Postoperative Management

• Allow weight-bearing as tolerated immediately postoperatively (67% of surgeons use this approach) 4
• Provide thromboprophylaxis with fondaparinux or low molecular weight heparin 6
• Manage pain with regular paracetamol and cautious opioid use, especially in patients with renal dysfunction 6

Common Pitfalls

The main pitfall is the increasing use of cephalomedullary nails for all fracture patterns based on ease of technique rather than evidence-based indications 4. While cephalomedullary nails are appropriate for unstable patterns, the sliding hip screw remains equally effective for stable fractures with potentially lower cost 1, 4. The choice should be driven by fracture characteristics—specifically posteromedial cortex integrity—rather than surgeon preference or perceived technical ease 1.