What is the best course of treatment for a patient with a displaced intertrochanteric fracture of the left femur, subsequent encounter for closed fracture with delayed healing, and weakness in the left leg?

Management of Delayed Healing Intertrochanteric Femur Fracture with Persistent Weakness

Continue conservative management with continued weight bearing as tolerated, progressive strengthening exercises, and follow-up imaging in 6 months as currently planned. This patient is demonstrating appropriate clinical progress with improving pain despite radiographic evidence of delayed healing at 6 months post-revision surgery 1.

Current Clinical Status Assessment

The patient demonstrates several positive prognostic indicators:

• Minimal pain with ambulation and no pain at rest - this improvement in pain is a favorable sign despite visible fracture lines on imaging 2
• Good cement fixation within the femoral head and neck region on current radiographs 2
• Functional hip range of motion with flexion to 90 degrees and ability to perform straight leg raise 2
• No signs of hardware failure with good placement of the intramedullary nail 2

The persistent weakness in the left lower extremity is expected given his surgical history of multiple procedures over 2 years and does not indicate treatment failure 2.

Weight Bearing Protocol

The patient should continue full weight bearing as tolerated immediately, which is the standard recommendation following intramedullary nail fixation of intertrochanteric fractures 1, 3. The AAOS provides a limited strength option for immediate, full weight bearing as tolerated after surgery for femoral fractures treated with intramedullary fixation 1.

• Early weight bearing correlates with decreased length of stay and quicker return to activities during the first 6 months compared to restricted weight bearing protocols 3
• For unstable intertrochanteric fractures treated with cephalomedullary nails (as in this case), immediate full weight bearing is appropriate when adequate fixation has been achieved 1
• Studies demonstrate no increased complication rates with immediate weight bearing protocols in subtrochanteric and intertrochanteric fractures 3

Strengthening and Rehabilitation

Aggressive physical therapy focusing on lower extremity strengthening should be the primary intervention for his persistent weakness 2:

• The weakness is likely multifactorial: prolonged immobilization, multiple surgeries, and muscle atrophy from the initial injury and subsequent revision 2
• Gait training with proper weight bearing technique should be emphasized 1
• Progressive resistance exercises targeting hip abductors, extensors, and quadriceps are essential 2

Monitoring Strategy for Delayed Healing

The current plan for 6-month follow-up with repeat radiographs is appropriate 2. Some degree of reduction loss during healing is common even with optimal surgical technique:

• Even with anatomically reduced fractures and properly positioned cephalomedullary nails, some loss of reduction occurs during the healing process 4
• The visible fracture line at 6 months does not necessitate intervention if the patient is clinically improving with minimal pain 2
• Mean femoral neck shortening of 4.47 mm and loss of neck-shaft angle of 5.4° can occur even with optimal fixation 4

Red Flags Requiring Earlier Intervention

The patient should return sooner if he develops 2:

• Increased pain or new onset of pain at rest or night pain
• Changes in symptoms suggesting hardware failure (sudden increase in thigh pain, inability to bear weight)
• New neurological symptoms (numbness, tingling, weakness progression)
• Signs of infection (fever, wound drainage, increasing warmth or erythema)

Rationale for Conservative Approach

Surgical revision is not indicated at this time because 2:

• The fracture shows "good cement fixation" on current imaging, indicating stability 2
• Clinical improvement (decreasing pain) is more important than radiographic appearance at this stage 2
• The AAOS guidelines support continued observation for delayed healing when hardware is well-positioned and the patient is clinically improving 2
• Unstable intertrochanteric fractures treated with cephalomedullary nails have good outcomes with conservative management even when healing is slower than expected 2, 5

Common Pitfalls to Avoid

• Do not restrict weight bearing based solely on radiographic appearance of persistent fracture lines when the patient is clinically improving 1, 3
• Do not rush to surgical revision for delayed healing at 6 months when pain is improving and hardware is well-positioned 2, 4
• Do not attribute all weakness to the fracture - consider deconditioning from his incarceration setting and limited access to structured physical therapy 2
• Do not overlook bone health optimization - ensure adequate calcium, vitamin D supplementation, and consider osteoporosis evaluation given his fracture history 2