Intertrochanteric Fracture Management
Classification and Surgical Decision-Making
For stable intertrochanteric fractures, use a sliding hip screw; for unstable fractures, use a cephalomedullary nail. 1, 2
Fracture Stability Assessment
The critical determinant of stability is the posteromedial cortex integrity—if this cortex is intact, the fracture is stable; if comminuted or absent, the fracture is unstable. 3 This single anatomic feature drives your entire surgical strategy.
Additional instability markers include: 4, 5
- Reverse oblique fracture pattern
- Subtrochanteric extension
- Significant comminution of the lateral wall
- Large posteromedial fragment displacement
Surgical Management Algorithm
Stable Intertrochanteric Fractures
Use a sliding hip screw as first-line treatment. 1, 2 Both sliding hip screw and cephalomedullary devices provide equivalent outcomes for simple two-part fractures without significant comminution. 2 The sliding hip screw is specifically favored for stable patterns because it allows controlled fracture impaction and has decades of proven reliability. 1
Unstable Intertrochanteric Fractures
Use an antegrade cephalomedullary nail for all unstable patterns. 1, 2 Strong evidence mandates cephalomedullary devices for subtrochanteric or reverse oblique fractures. 1 Among cephalomedullary options, PFNA (proximal femoral nail anti-rotating) demonstrates superior outcomes with lowest intraoperative blood loss and highest Harris hip scores compared to other nail designs. 6
Critical Technical Points
- Obtain impacted reduction at surgery—do not rely solely on postoperative settling. 3
- Secure placement within the femoral head is the most important aspect of sliding hip screw insertion. 3
- If a large posteromedial fragment exists, internally fix it with lag screw or cerclage wire to restore medial cortical support. 3
- Accurate reduction and implant placement are paramount regardless of device chosen. 4
Perioperative Protocol
Anesthesia and Analgesia
- Either spinal or general anesthesia is appropriate. 2
- Administer multimodal analgesia with preoperative nerve block to optimize pain control and facilitate early mobilization. 2
Blood Management
Give tranexamic acid perioperatively to reduce blood loss and transfusion requirements. 2 PFNA technique specifically minimizes blood loss compared to other fixation methods. 6
Avoid This Common Pitfall
Do not use preoperative traction—strong evidence shows no benefit and potential harm. 2
Postoperative Care
Immediate Postoperative Period
Comprehensive postoperative management includes: 1
- Appropriate pain management after reduction
- Antibiotic prophylaxis
- Correction of postoperative anemia
- Regular cognitive function assessment
- Pressure sore prevention
- Nutritional status optimization
- Renal function monitoring
- Bowel and bladder regulation
- Wound assessment
- Early mobilization with immediate full weight-bearing 1
Mobilization Strategy
The goal is unrestricted early weight bearing to prevent recumbency complications. 3, 4 Surgical stabilization enables immediate mobilization, which is critical for reducing mortality and maintaining independence in this elderly population. 5
Osteoporosis Management
All patients require systematic osteoporosis evaluation and treatment. 2 During hospitalization, order: 2
- Outpatient DEXA scan
- Vitamin D level
- Calcium level
- Parathyroid hormone level
Interdisciplinary Care
Implement interdisciplinary care programs involving orthopedics, geriatrics, nursing, and physical therapy to decrease complications and improve outcomes. 2
Secondary Fracture Prevention
Every patient aged 50 years and over requires systematic evaluation for subsequent fracture risk. 1 The Fracture Liaison Service (FLS) model is the most effective organizational structure, utilizing a dedicated coordinator (typically a specialized nurse) who identifies patients, organizes investigations, initiates treatment, and coordinates with primary care physicians. 1
Post-Operative Radiographic Assessment
Post-operative X-rays should confirm: 3, 4
- Adequate reduction with restoration of medial cortical continuity
- Implant position within the femoral head (tip-apex distance <25mm for sliding hip screws)
- Appropriate neck-shaft angle restoration
- No intra-articular hardware penetration
- Adequate fixation of any posteromedial fragments
Serial radiographs monitor for: 4, 5
- Fracture healing progression
- Maintenance of reduction
- Hardware complications (cutout, backing out, breakage)
- Excessive varus collapse