Surgical Management of Comminuted Intertrochanteric Fractures
For a comminuted intertrochanteric fracture, a cephalomedullary nail is the recommended surgical intervention, as this represents an unstable fracture pattern that requires intramedullary fixation rather than a sliding hip screw. 1
Device Selection Based on Fracture Stability
The key to surgical decision-making is recognizing that comminuted intertrochanteric fractures are inherently unstable patterns:
Comminuted fractures specifically require cephalomedullary nail fixation rather than a dynamic hip screw (DHS), as they fall into the category of unstable fracture patterns. 1
The American Academy of Orthopaedic Surgeons explicitly lists comminuted fractures among the unstable patterns requiring intramedullary nailing, along with reverse obliquity patterns, subtrochanteric extension, and fractures with posteromedial comminution. 1
A sliding hip screw should only be used for stable intertrochanteric fractures, making it inappropriate for comminuted patterns. 1
Rationale for Cephalomedullary Nailing
The biomechanical advantage of intramedullary fixation in comminuted fractures includes:
Cephalomedullary nails are mandatory for unstable intertrochanteric fractures because they provide better load-sharing and stability when the posteromedial cortex is compromised. 1
In unstable fractures, intramedullary devices demonstrate 23% less surgical time and 44% less blood loss compared to extramedullary fixation. 2
Critical Surgical Timing
Surgery should be performed within 24 to 48 hours of admission to optimize outcomes and reduce morbidity and mortality. 1
Do not use preoperative traction, as it provides no benefit and is specifically not recommended by the American Academy of Orthopaedic Surgeons. 1
Common Pitfall to Avoid
The most critical error is selecting a DHS for a comminuted fracture based solely on the intertrochanteric location without assessing stability. Always evaluate for comminution, posteromedial cortex integrity, and reverse obliquity patterns—any of these features mandate cephalomedullary nail fixation. 1