What is the management of intertrochanteric fracture?

Management of Intertrochanteric Fracture

For stable intertrochanteric fractures, use a sliding hip screw (dynamic hip screw); for unstable fractures, use a cephalomedullary nail. 1

Surgical Device Selection Based on Fracture Stability

The choice of fixation device is determined by fracture pattern stability, which fundamentally impacts morbidity and mortality outcomes:

Stable Fractures

• A sliding hip screw (SHS/DHS) is the preferred device for stable intertrochanteric fractures with intact posteromedial cortex 1
• Stable patterns allow predictable union with early weight-bearing and minimal risk of fixation failure 2

Unstable Fractures

• A cephalomedullary nail is mandatory for unstable intertrochanteric fractures 1
• Unstable patterns include: comminuted fractures, posteromedial cortex disruption, lesser trochanter involvement or avulsion, reverse oblique patterns, and subtrochanteric extension 3, 4
• Strong evidence supports cephalomedullary devices for subtrochanteric or reverse oblique fractures 1
• Failure rates exceed 50% when sliding hip screws are used for unstable patterns in osteoporotic bone 3

Critical Pitfall

• Lesser trochanter fracture or avulsion specifically indicates an unstable pattern requiring intramedullary fixation rather than plating 3
• The posteromedial cortex status determines stability—disruption mandates cephalomedullary nail fixation 5, 4

Preoperative Management

Timing and Medical Optimization

• Surgery should be performed within 24-48 hours of admission to reduce mortality and complications 3
• Administer prophylactic antibiotics within one hour of skin incision 3
• Administer preoperative intravenous fluids routinely, as many elderly patients are hypovolemic 3
• Do not use preoperative traction—it provides no benefit and is specifically not recommended 3

Anesthesia Considerations

• Either spinal or general anesthesia is appropriate with no preference 3
• Monitor depth of anesthesia with BIS monitoring to avoid cardiovascular depression in elderly patients 3
• Implement active warming strategies intraoperatively and postoperatively to prevent hypothermia 3

Multimodal Analgesia

• Perform peripheral nerve block in the emergency department or preoperatively 3

Surgical Technique Principles

Reduction Goals

• Achieve anatomic reduction under fluoroscopic guidance in both AP and lateral views 3
• Restore medial cortical continuity and normal neck-shaft angle (approximately 130-135 degrees) 3
• Inadequate reduction before fixation leads to malunion and hardware failure 3

For Sliding Hip Screw Placement

• Ensure lag screw reaches within 5-10 mm of subchondral bone 3
• Position plate flush against lateral femoral cortex, aligned with femoral shaft axis 3
• Secure plate with cortical screws (typically 4-6 screws) with bicortical purchase 3
• Avoid over-compression, which can cause fracture comminution in osteoporotic bone 3

For Large Posteromedial Fragments

• Attempt internal fixation of the fragment with lag screw or cerclage wire to improve stability 5

Postoperative Management

Mobilization and Weight-Bearing

• Implement immediate weight-bearing as tolerated to reduce complications and improve outcomes 3
• Early mobilization protocols are essential for reducing morbidity 1, 3

Thromboprophylaxis

• Administer fondaparinux or low molecular weight heparin for DVT prophylaxis 1, 3
• Time low molecular weight heparin administration between 18:00-20:00 to minimize bleeding risk with neuraxial anesthesia 3
• Use sequential compression devices while hospitalized 3
• Continue pharmacologic prophylaxis for 4 weeks postoperatively 3

Pain Management

• Continue regular paracetamol throughout the perioperative period 3
• Use opioids cautiously, especially in patients with renal dysfunction; avoid oral opioids in renal dysfunction 3
• Do not administer codeine due to constipation, emesis, and association with postoperative cognitive dysfunction 3
• Use NSAIDs with extreme caution and avoid in renal dysfunction 3

Anemia Management

• Correct postoperative anemia appropriately 1
• Consider transfusion for symptomatic anemia; use transfusion threshold no higher than 8 g/dL in asymptomatic patients 3

Comprehensive Geriatric Care

• Perform routine systems examinations and regular assessment of cognitive function 1
• Assess for pressure sores, nutritional status, and renal function 1
• Assess and regulate bowel and bladder function 1
• Provide wound assessment and care 1

Secondary Fracture Prevention

Osteoporosis Evaluation

• Each patient aged 50 years and over should be evaluated systematically for risk of subsequent fractures 1
• Order outpatient DEXA scan and refer to bone health clinic for osteoporosis evaluation and treatment 3

Fracture Liaison Service

• Fracture Liaison Service (FLS) is the most effective organizational structure for risk evaluation and treatment initiation 1
• A dedicated coordinator (often a well-educated nurse under supervision of an orthopedic surgeon, endocrinologist, or rheumatologist) identifies all elderly patients with recent fractures, organizes diagnostic investigations, and initiates interventions 1

Contraindications to Standard Fixation

• Sliding hip screw is not effective for pathologic fractures due to lack of bone healing, particularly with planned subsequent radiation 3
• Consider alternative fixation methods or prosthetic replacement for pathologic fractures 3