What is the management of a femoral trochanteric fracture?

Management of Femoral Trochanteric Fractures

For stable intertrochanteric fractures, use a sliding hip screw; for unstable intertrochanteric fractures, subtrochanteric fractures, or reverse oblique patterns, use an antegrade cephalomedullary nail with immediate full weight-bearing postoperatively. 1

Surgical Treatment Selection

Stable Intertrochanteric Fractures

• A sliding hip screw (dynamic hip screw/DHS) is the preferred fixation device for stable intertrochanteric fractures, providing reliable outcomes with lower complication rates (1.1% intraoperative complications) 1, 2
• This extramedullary approach is sufficient when fracture stability is maintained after reduction 3

Unstable Intertrochanteric Fractures

• Antegrade cephalomedullary nailing is the treatment of choice for unstable intertrochanteric fractures, offering rotational stability and allowing immediate full weight-bearing 1
• Intramedullary devices show slightly higher intraoperative complication rates (1.8%) compared to DHS, but provide superior mechanical advantages in unstable patterns 2, 4
• The proximal femoral nail antirotation (PFNA) demonstrates excellent results with average operative time of 20.3 minutes and minimal blood loss (22.8 mL) 5

Subtrochanteric and Reverse Oblique Fractures

• Strong evidence supports mandatory use of cephalomedullary devices for subtrochanteric or reverse oblique fracture patterns 1
• Long intramedullary nails are mechanically superior for these patterns, preventing pivot transfer and managing distal fracture extension 3, 6

Perioperative Management

Initial Assessment and Stabilization

• Provide immediate immobilization with opioid analgesia, intravenous fluid therapy, and patient warming during ambulance transfer 1
• Implement fast-track triage systems for early radiographic diagnosis and rapid ward admission 1
• Address hypovolemia promptly as it is common in these patients; cardiac output-guided fluid administration reduces hospital stay 7

Pain Management Protocol

• Prescribe regular paracetamol routinely unless contraindicated 1
• Add carefully titrated opioid analgesia as needed, with dose reduction in renal impairment 1
• Avoid NSAIDs in patients with renal dysfunction 8
• Consider peripheral nerve blocks for additional analgesia, though effectiveness may be limited beyond the first postoperative night 1

Surgical Timing and Team

• Surgery should be performed within 36-48 hours of admission on dedicated trauma lists with consultant-level surgeons and anesthesiologists 1
• Hip fracture surgery should be prioritized over other elective procedures unless life-threatening trauma intervenes 1
• Operations require experienced teams including appropriately trained surgeons to minimize operative time, blood loss, and complications 1

Thromboprophylaxis

• Administer fondaparinux or low molecular weight heparin between 18:00-20:00 to minimize bleeding risk with neuraxial anesthesia 8
• Use thromboembolism stockings or intermittent compression devices intraoperatively 8
• Early mobilization is the most effective DVT prevention strategy 8

Temperature Management

• Maintain operating room temperature at 20-23°C with 50-60% humidity 1
• Implement active warming strategies during and after surgery to prevent hypothermia in elderly patients 8

Postoperative Care

Immediate Postoperative Period

• Administer supplemental oxygen for at least 24 hours postoperatively 1
• Continue regular paracetamol with opioid supplementation as needed for pain control 1
• Monitor patients in recovery or ward settings with 1:4 nurse-to-patient ratio 1

Mobilization and Weight-Bearing

• Allow immediate full weight-bearing postoperatively with appropriate fixation 1
• Begin mobilization as early as possible, ideally within the first postoperative week 6
• Approximately 58% of patients should be able to walk with crutches at discharge 2

Fluid and Nutrition Management

• Encourage early oral fluid intake rather than routine intravenous fluids 1
• Remove urinary catheters as soon as possible to reduce infection risk 1
• Provide nutritional supplementation as up to 60% of patients are malnourished on admission 1

Rehabilitation and Secondary Prevention

• Coordinate multidisciplinary rehabilitation with orthogeriatricians, physiotherapists, occupational therapists, and social workers 1
• Implement Fracture Liaison Service (FLS) for systematic evaluation and secondary fracture prevention, as this is the most effective organizational structure 1
• Address falls prevention and osteoporosis treatment in the early postoperative period 1

Common Pitfalls to Avoid

• Do not use extramedullary devices for unstable, subtrochanteric, or reverse oblique patterns as they lack sufficient rotational stability 1, 3
• Avoid positioning errors such as excessive flexion and internal rotation of the non-operative hip during surgery 8
• Do not delay surgery beyond 48 hours as this increases mortality risk 1
• Ensure precise blade/screw positioning in the center of the femoral head to prevent mechanical complications 6
• Monitor for bone cement implantation syndrome during cemented procedures by maintaining adequate intravascular volume 1

Monitoring and Follow-Up

• Perform serial radiographs to confirm proper bone healing and implant positioning 8
• Monitor for postoperative cognitive dysfunction (occurs in 25% of patients) with multimodal optimization including adequate analgesia, nutrition, hydration, and early mobilization 1
• Watch for complications including chest infection, silent myocardial ischemia, and urinary tract infection 1
• Average consolidation time is approximately 21.6 weeks for subtrochanteric fractures 6