What is the treatment approach for a Greater Trochanteric (GT) fracture?

Treatment of Greater Trochanteric Fractures

For stable isolated greater trochanteric (GT) fractures, use a sliding hip screw, and for unstable patterns or those with occult intertrochanteric extension beyond the medial one-third of the femur, use a cephalomedullary nail. 1

Initial Diagnostic Approach

MRI is essential for all apparently isolated GT fractures on plain radiographs, as 90% have occult extension into the intertrochanteric region that changes management. 2 Without MRI, you risk missing unstable fracture patterns that will displace and require delayed surgery. 3

Treatment Algorithm Based on Fracture Pattern

Classification by MRI Findings

The treatment decision hinges on the extent of fracture line extension on MRI coronal imaging: 3

• Group 1 (Lateral one-third only): Conservative treatment
• Group 2 (Lateral to medial one-third): Conservative treatment
• Group 3 (Beyond medial one-third or reaching medial cortex): Surgical fixation required

Conservative Management Indications

Conservative treatment is appropriate for truly isolated GT fractures or those with minimal intertrochanteric extension (Groups 1 and 2). 3, 4 These fractures heal without displacement regardless of the percentage of extension into the intertrochanteric area. 4

Conservative management includes: 5

• Protected weight-bearing (not immediate full weight-bearing)
• Analgesics and activity modification 1
• Early mobilization when pain permits 1
• Expected hospital stay approximately 50 days 4

Critical caveat: Patients refusing surgery for Group 3 fractures risk complete intertrochanteric fracture displacement requiring delayed surgical intervention. 3

Surgical Fixation Indications

Surgery is mandatory for: 1, 3

• Fracture extension beyond the medial one-third of the femur on MRI (Group 3)
• Displacement >2 cm 5
• Young, active, or demanding patients who require full abductor strength 5, 6
• Athletes requiring return to high-level activity 6

Surgical Technique Selection

For stable intertrochanteric patterns, use a sliding hip screw. 1 This is the preferred fixation for stable fractures based on EULAR/EFORT guidelines.

For unstable patterns (including GT fractures with significant intertrochanteric extension), use an antegrade cephalomedullary nail. 1 Strong evidence supports cephalomedullary devices for unstable intertrochanteric, subtrochanteric, or reverse oblique fractures.

For young athletes with isolated displaced GT fractures, consider triple fixation combining: 6

• Partially threaded screws with washers for osteosynthesis
• Suture anchors for direct fracture approximation and tendon reinforcement
• Knotless double-row suture bridge tension band construct

This approach allows return to weightlifting by 4 months postoperatively. 6

Alternative: Arthroplasty

For elderly patients (>65 years) with osteoporotic bone or pre-existing hip arthritis, consider hemiarthroplasty, following the same decision framework used for displaced femoral neck fractures. 7 Cemented arthroplasty improves hip function and reduces residual pain compared to uncemented techniques. 1

Surgical Timing and Technical Points

Perform surgery within 24-48 hours of admission when surgical treatment is indicated. 7

Key technical requirements: 7

• Achieve anatomic reduction with medial cortical continuity restoration
• Restore normal neck-shaft angle (130-135 degrees)
• Avoid preoperative traction (provides no benefit)
• Allow immediate weight-bearing as tolerated postoperatively for surgically fixed fractures

Expected Outcomes

Both surgical and conservative treatments achieve fracture healing without displacement when appropriately selected. 4 There are no significant differences in:

• Functional ambulation scores at 1 week, 1 month, and 3 months 4
• Length of hospital stay (48 vs 51 days) 4
• One-year mortality 4

However, conservative treatment may result in decreased abductor function, particularly problematic for active patients. 5 Surgical fixation in appropriate candidates prevents Trendelenburg gait and restores full abductor strength. 6

Common Pitfalls to Avoid

• Never rely on plain radiographs alone—90% of "isolated" GT fractures have occult intertrochanteric extension on MRI 2
• Never allow immediate full weight-bearing with conservative treatment—this risks fracture displacement 5
• Never dismiss surgery in young active patients—they require full abductor function restoration 5, 6
• Never delay surgery beyond 48 hours when surgical treatment is indicated 7

Secondary Fracture Prevention

All patients ≥50 years with GT fractures require systematic evaluation for osteoporosis and subsequent fracture risk. 1 Implement Fracture Liaison Service coordination for identification, investigation, and osteoporosis treatment initiation. 1