Surgical Management of Intertrochanteric Femur Fractures with Cannulated Cancellous (CC) Screws
Critical Contraindication
Cannulated cancellous screws should NOT be used for intertrochanteric femur fractures (ICNF). This fixation method is indicated only for intracapsular femoral neck fractures, not intertrochanteric fractures 1, 2, 3.
Appropriate Fixation for Intertrochanteric Fractures
Device Selection Based on Fracture Stability
For stable intertrochanteric fractures: Use a sliding hip screw (Dynamic Hip Screw/DHS) as the preferred fixation method 1, 2, 3.
For unstable intertrochanteric fractures: A cephalomedullary nail is strongly recommended and mandatory 1.
Unstable patterns requiring intramedullary nailing include: comminuted fractures, reverse obliquity patterns, subtrochanteric extension, and fractures with posteromedial comminution 1.
Why CC Screws Are Inappropriate for Intertrochanteric Fractures
Cannulated cancellous screws are designed for intracapsular femoral neck fractures (Garden 1-4), not intertrochanteric fractures 4.
Using multiple screws in the inferior femoral neck region creates a stress riser in the subtrochanteric area, potentially inducing secondary fractures in weakened bone 5.
Peri-implant subtrochanteric fractures following inappropriate screw fixation are surgically challenging complications requiring revision surgery 6, 5.
Correct Surgical Procedure for Intertrochanteric Fractures (DHS Plating)
Preoperative Preparation
Timing: Perform surgery within 24 to 48 hours of admission for improved outcomes 1.
Antibiotics: Administer prophylactic antibiotics within one hour of skin incision 1, 2.
Avoid preoperative traction: This has no benefit and is specifically not recommended 1.
Anesthesia: Either spinal or general anesthesia is appropriate with no preference; consider peripheral nerve blocks for multimodal analgesia 1, 2.
Active warming: Implement intraoperative and postoperative warming strategies to prevent hypothermia, especially in elderly patients 1, 2.
Fluid management: Administer preoperative intravenous fluids routinely as many patients are hypovolemic; use cardiac output-guided fluid administration 1.
Surgical Technique for DHS Fixation
Patient positioning: Position supine on fracture table with sympathetic positioning to prevent pressure sores and neuropraxia; avoid excessive flexion and internal rotation of the non-operative hip 1.
Reduction: Obtain an impacted reduction at the time of surgery, as this is essential even though the sliding hip screw allows postoperative fracture impaction 3.
Posteromedial fragment management: If there is a large posteromedial fragment, attempt internal fixation with a lag screw or cerclage wire 3.
Screw placement: The most important aspect of DHS insertion is secure placement within the femoral head 3.
Postoperative Management
Weight-bearing: Allow immediate weight-bearing as tolerated 1.
Thromboprophylaxis: Administer fondaparinux or low molecular weight heparin for DVT prophylaxis; continue pharmacologic prophylaxis for 4 weeks postoperatively 1, 2.
LMWH timing: Time low molecular weight heparin administration between 18:00-20:00 to minimize bleeding risk with neuraxial anesthesia 1.
Sequential compression devices: Use while hospitalized 1.
Pain management: Continue regular paracetamol throughout the perioperative period; use opioids cautiously, especially in patients with renal dysfunction and avoid oral opioids in renal dysfunction 1, 2.
Avoid codeine: Do not administer due to constipation, emesis, and association with postoperative cognitive dysfunction 1.
NSAIDs: Use with extreme caution and avoid in renal dysfunction 1.
Early mobilization: Implement early mobilization protocols to reduce complications and improve outcomes 1, 2.
Transfusion threshold: Consider transfusion for symptomatic anemia; use a transfusion threshold no higher than 8 g/dL in asymptomatic patients 1.
Bone health: Arrange outpatient DEXA scan and referral to bone health clinic for osteoporosis evaluation and treatment 1.
Common Pitfall to Avoid
- Never use sliding hip screws or cannulated screws for pathologic fractures: These devices are not effective in patients with pathologic fractures due to lack of bone healing, particularly with planned subsequent bone radiation 7.