What is the best course of treatment for an elderly patient with an intertrochanteric fracture, possibly due to underlying conditions such as osteoporosis?

Intertrochanteric Fracture Management in Elderly Patients

Surgical Treatment Algorithm

For elderly patients with intertrochanteric fractures, stable fractures should be treated with a sliding hip screw, while unstable fractures require an antegrade cephalomedullary nail, with surgery performed within 48 hours of admission to minimize mortality. 1, 2

Fracture Stability Classification and Implant Selection

• Stable intertrochanteric fractures: Use a sliding hip screw as first-line treatment, which allows controlled fracture impaction and has decades of proven reliability 2
• Unstable intertrochanteric fractures: Use an antegrade cephalomedullary nail, which provides superior biomechanical stability in comminuted or osteoporotic bone 3, 2
• Subtrochanteric or reverse oblique fractures: Cephalomedullary devices are mandatory based on strong evidence 3, 2

Alternative Approach for High-Risk Unstable Fractures

While internal fixation remains the standard, hemiarthroplasty is a reliable alternative for elderly osteoporotic patients with highly unstable or comminuted intertrochanteric fractures who are at high risk of fixation failure 4, 5. This approach should be considered when:

• Severe osteoporosis is present with grossly comminuted fracture patterns 6
• The patient cannot tolerate prolonged bedrest or requires rapid restoration of locomotor function 5
• There is concern about fixation failure in very poor bone quality 7

The research evidence shows encouraging functional outcomes with hemiarthroplasty in this select population, with 90% achieving excellent to fair results and earlier weight-bearing compared to internal fixation 6. However, this remains an alternative rather than first-line treatment, as guidelines prioritize internal fixation for most intertrochanteric fractures 3, 2.

Perioperative Management

Timing and Optimization

• Surgery must be performed within 48 hours of admission, as delays beyond this timeframe significantly increase mortality 1
• Provide adequate pain relief with multimodal analgesia including preoperative nerve blocks 2
• Optimize medical conditions without unnecessarily delaying surgery 1
• Administer tranexamic acid perioperatively to reduce blood loss 2

Anesthesia

• Either spinal or general anesthesia is appropriate for intertrochanteric fracture surgery 2

Postoperative Care Protocol

Immediate Postoperative Period

• Begin early mobilization with immediate full weight-bearing to prevent recumbency complications including pneumonia, deep vein thrombosis, and pressure ulcers 1, 2
• Implement comprehensive pain management 1
• Provide antibiotic prophylaxis 1
• Correct postoperative anemia as needed 1

Ongoing Assessment

• Regularly assess cognitive function, nutritional status, renal function, and pressure sore risk throughout the perioperative period 1
• Obtain post-operative radiographs to confirm adequate reduction with restoration of medial cortical continuity, proper implant position, and appropriate neck-shaft angle 2
• Monitor serial radiographs for fracture healing, maintenance of reduction, hardware complications, and excessive varus collapse 2

Orthogeriatric Comanagement

All elderly patients with hip fractures require orthogeriatric comanagement to improve functional outcomes, reduce hospital stay, and decrease mortality 1. This multidisciplinary approach is essential and should not be underestimated, as failure to implement it leads to suboptimal outcomes 1.

Rehabilitation Program

• Initiate early postfracture physical training and muscle strengthening, followed by long-term balance training and multidimensional fall prevention 1
• Tailor the rehabilitation program to the patient's prefracture functional status and comorbidities 1
• Historical data demonstrates that 76% of patients who ambulated before fracture can walk again after surgery with proper rehabilitation, though many lose one grade level of walking ability 8

Secondary Fracture Prevention

Systematic Evaluation

Every patient aged 50 years and over with an intertrochanteric fracture requires systematic evaluation for subsequent fracture risk using a Fracture Liaison Service (FLS) model, which is the most effective organizational structure for secondary prevention 3, 1, 2.

Diagnostic Workup

• Order outpatient DEXA scan for bone mineral density assessment 2
• Check vitamin D level, calcium level, and parathyroid hormone level 2
• Perform imaging of the spine for vertebral fractures 3
• Evaluate falls risk 3
• Identify secondary causes of osteoporosis 3

Treatment Initiation

• Use pharmacological treatment with medications demonstrated to reduce vertebral, non-vertebral, and hip fracture risk 1
• Monitor regularly for tolerance and adherence 1
• The FLS coordinator (typically a well-educated nurse under physician supervision) should manage identification, investigation, and intervention for all aspects of secondary prevention 3

Critical Pitfalls to Avoid

• Delaying surgery beyond 48 hours significantly increases mortality risk 1
• Failing to provide orthogeriatric comanagement leads to worse functional outcomes and higher mortality 1
• Neglecting comprehensive rehabilitation and secondary fracture prevention increases risk of poor functional recovery and future fractures 1
• Inadequate attention to postoperative nutritional support, cognitive assessment, and early mobilization increases complication rates 1
• Using sliding hip screws for unstable fractures increases fixation failure risk; cephalomedullary nails are required for unstable patterns 3, 2