What is the diagnosis and treatment for an intertrochanteric fracture of the right femur with varus angulation?

From the Guidelines

An intertrochanteric fracture of the right femoral neck with varus angulation requires prompt surgical intervention, typically with internal fixation using a sliding hip screw for stable fractures or an antegrade cephalomedullary nail for unstable fractures, as recommended by the most recent guidelines 1. The choice of surgical method depends on the stability of the fracture, with sliding hip screws favored for stable intertrochanteric fractures and antegrade cephalomedullary nails for unstable ones 1. Surgery should be performed within 24-48 hours of injury to reduce complications and mortality. Prior to surgery, the patient should receive adequate pain management with medications such as acetaminophen 1000mg every 6 hours, supplemented with opioids like morphine 2-5mg IV every 4 hours as needed. Thromboprophylaxis with low molecular weight heparin (enoxaparin 40mg subcutaneously daily) should be initiated upon admission and continued until the patient is fully mobile. Post-operatively, early mobilization within 24 hours is crucial, beginning with sitting at the edge of the bed and progressing to weight-bearing as tolerated with a walker or crutches, depending on the stability of the fracture fixation. Physical therapy should focus on strengthening exercises, gait training, and activities of daily living. The varus angulation (inward tilting) makes this fracture particularly unstable and prone to complications, necessitating careful surgical reduction to restore proper alignment. Without proper treatment, these fractures can lead to significant disability, as they occur in the load-bearing portion of the femur between the greater and lesser trochanters, disrupting the normal force transmission from the hip to the lower extremity. Some key points to consider in the management of intertrochanteric fractures include:

• The degree of comminution and the size of the bone fragments can affect blood loss and the choice of surgical method 2
• Extracapsular fractures, such as intertrochanteric fractures, are typically more painful and have greater blood loss than intracapsular fractures 2
• Conservative management of extracapsular fractures is associated with increased morbidity and mortality, and a reduced chance of the patient returning home 2

From the Research

Intertrochanteric Fracture of the Right Femoral Neck with Varus Angulation

• The goals of surgical treatment for intertrochanteric hip fractures include restoration of coronal plane alignment without varus angulation and early patient mobilization 3.
• Varus angulation is a complication that can occur in intertrochanteric hip fractures, and it is essential to avoid it to ensure proper healing and prevent further complications.
• The sliding hip screw procedure is a common treatment for intertrochanteric hip fractures, and it can be effective in restoring alignment and promoting healing 3.
• However, the quality of fracture reduction is more critical than the choice of implant, and a prospective study found no significant difference in walking ability with either sliding hip screws or intramedullary nails for stable intertrochanteric fractures [3, @8@].
• Comminution of the greater or lesser trochanter may require supplemental fixation, and careful scrutiny for signs of instability, such as lateral wall comminution or reverse obliquity, is necessary to prevent displacement of the fracture 3.

Treatment Options

• Surgical management by internal fixation is the mainstay of treatment for most intertrochanteric femur fractures, but hip arthroplasty is an alternative in older patients with high risk of fixation failure or concomitant intraarticular pathologies 5.
• The choice of surgical technique mainly depends on the surgeon's preferences and the fracture characteristics, and bipolar hemiarthroplasty is the most common type of prosthesis used 5.
• Hip arthroplasty has a better early functional outcome and lower rates of surgical complications as well as reoperations compared to intramedullary nails, but the functional outcome and mortality rate in the longer term tend to favor intramedullary nails 5.

Complications and Outcomes

• Postoperative complications and outcomes of hip fractures can vary depending on the anatomical subtype of fracture, and patients with intertrochanteric fractures had a higher risk-adjusted incidence of postoperative blood transfusion relative to femoral neck fractures 6.
• The overall risk-adjusted rate of minor and major medical adverse events within 30 days and risk-adjusted rate of wound complications was not significantly different between femoral neck, intertrochanteric, and subtrochanteric fractures 6.
• Patients with intertrochanteric fractures had a slightly lower risk-adjusted incidence of unplanned reoperation and hospital readmission than patients with femoral neck fractures 6.