From the Guidelines
An intertrochanteric fracture of the right femoral neck with varus angulation requires prompt surgical intervention, typically with internal fixation using an antegrade cephalomedullary nail, as this type of fracture is considered unstable. The management of such fractures should prioritize early surgery to reduce morbidity and mortality, with the goal of achieving stable fixation that allows for early mobilization and weight-bearing 1.
Preoperative Management
Preoperatively, the patient needs adequate pain management, which can be achieved with scheduled acetaminophen and supplemented with opioids as needed. Additionally, thromboprophylaxis with low molecular weight heparin should be initiated immediately to prevent venous thromboembolism, a common complication in patients with fractures 1.
Surgical Intervention
The choice of surgical intervention is crucial, and for unstable intertrochanteric fractures like the one described, an antegrade cephalomedullary nail is favored over other options due to its ability to provide stable fixation in the presence of comminution or varus angulation 1. This approach supports the patient's early mobilization and reduces the risk of fixation failure.
Postoperative Care
Postoperatively, early mobilization within 24 hours is crucial, with the goal of progressing to weight-bearing as tolerated. Physical therapy should be initiated early, focusing on strengthening exercises, gait training, and range of motion exercises to improve the patient's functional outcome and quality of life. The varus angulation of the fracture necessitates careful surgical reduction to restore the normal neck-shaft angle, which is critical for the stability of the fixation and the prevention of future complications.
Long-term Management
Long-term management of the patient should include osteoporosis assessment and treatment to prevent future fractures. This typically involves calcium and vitamin D supplementation, along with consideration of bisphosphonates or other anti-osteoporotic medications after fracture healing, to reduce the risk of subsequent fractures and improve the patient's quality of life 1.
From the Research
Intertrochanteric Fracture of the Right Femoral Neck with Varus Angulation
- An intertrochanteric fracture of the right femoral neck with varus angulation is a type of hip fracture that can be challenging to treat 2, 3.
- The treatment of intertrochanteric fractures with associated femoral neck fractures using a sliding hip screw has been reported to have a high failure rate, with 25% of fractures resulting in fixation failure, fracture nonunion, or lag screw cutout 3.
- The amount of collapse of the lag screw was found to be significantly greater in treatment failures compared to successfully treated fractures, with a mean collapse of 38 mm in failures and 20 mm in successes 3.
- A study comparing resuscitative status and mortality rates between intertrochanteric and femoral neck fractures found that intertrochanteric fracture patients had lower mean arterial pressures and received less intravenous fluid, despite having higher 30-day and 90-day mortality rates 4.
- Another study comparing complication profiles for femoral neck, intertrochanteric, and subtrochanteric geriatric hip fractures found that intertrochanteric fractures had a higher risk-adjusted incidence of postoperative blood transfusion, but a lower risk-adjusted incidence of unplanned reoperation and hospital readmission compared to femoral neck fractures 5.
Treatment Options
- Closed reduction and internal fixation with a dynamic compression hip screw and side plate is a common treatment option for intertrochanteric fractures, but may not be suitable for fractures with associated femoral neck fractures 2, 3.
- Open reduction and internal fixation, as well as cemented bipolar hemiarthroplasty, may be alternative treatment options for intertrochanteric fractures with varus angulation and associated femoral neck fractures 2.
- The choice of treatment should be based on the individual patient's needs and the specific characteristics of the fracture, including the degree of varus angulation and the presence of any associated fractures or comorbidities 2, 3, 4, 5.