What is the recommended management for an intertrochanteric hip fracture?

Management of Intertrochanteric Fracture

For stable intertrochanteric fractures, use either a sliding hip screw or cephalomedullary nail; for unstable fractures (including those with posteromedial comminution, reverse obliquity, or subtrochanteric extension), a cephalomedullary nail is mandatory. 1

Surgical Device Selection Based on Fracture Stability

Stable Intertrochanteric Fractures

• Both sliding hip screw (SHS) and cephalomedullary nail are equally acceptable options for stable fractures with intact posteromedial cortex 1
• The sliding hip screw remains cost-effective and equally efficacious compared to intramedullary devices for stable patterns 2
• Quality of reduction is more critical than implant choice in stable fractures 2

Unstable Intertrochanteric Fractures (Strong Indication for Cephalomedullary Nail)

A cephalomedullary device is mandatory for: 1, 3

• Fractures with posteromedial comminution or loss of medial cortical support
• Reverse obliquity fracture patterns
• Subtrochanteric extension
• Lesser trochanter avulsion or involvement
• Comminuted fractures with lateral wall compromise

The failure rate of sliding hip screws exceeds 50% in unstable patterns with osteoporosis, making intramedullary fixation the only appropriate choice 3

Preoperative Management

Timing and Preparation

• Surgery must be performed within 24-48 hours of admission to reduce mortality and complications 1, 3
• Do not use preoperative traction—this has no benefit and is specifically contraindicated 1, 3
• Administer prophylactic antibiotics within one hour of skin incision 3

Analgesia

• Implement multimodal analgesia with preoperative nerve block in the emergency department or preoperatively 1, 3
• Continue regular paracetamol throughout the perioperative period 3
• Use opioids cautiously, especially in renal dysfunction; avoid codeine due to constipation and cognitive dysfunction risk 3

Anesthesia

• Either spinal or general anesthesia is appropriate with no preference between the two 3
• Monitor depth of anesthesia with BIS monitoring in elderly patients to avoid cardiovascular depression 3

Intraoperative Considerations

Reduction Technique

• Achieve anatomic reduction with restoration of medial cortical continuity and normal neck-shaft angle (130-135 degrees) under fluoroscopic guidance 3, 4
• Inadequate reduction before fixation leads to malunion and hardware failure—this is a critical technical pitfall 3

Sliding Hip Screw Technique (for stable fractures only)

• Place guidewire in center-center or slightly inferior position on AP and lateral views 2
• Ensure lag screw reaches within 5-10 mm of subchondral bone 3
• Tip-apex distance must be optimized—superior placement increases cut-out risk 2
• Secure plate with 4-6 bicortical cortical screws 3

Adjunctive Measures

• Administer tranexamic acid to reduce blood loss and transfusion requirements 1
• Implement active warming strategies intraoperatively and postoperatively to prevent hypothermia 3
• Maintain systolic blood pressure within 20% of pre-induction values 3

Postoperative Management

Mobilization

• Allow immediate weight-bearing as tolerated—this is safe and recommended 1, 3
• Implement early mobilization protocols to reduce complications 3

Thromboprophylaxis

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

Transfusion Management

• Transfuse for symptomatic anemia 1
• Use a transfusion threshold no higher than 8 g/dL in asymptomatic postoperative patients 1, 3

Bone Health

• Order outpatient DEXA scan 1, 3
• Refer to bone health clinic for osteoporosis evaluation and treatment 1, 3

Interdisciplinary Care

Utilize interdisciplinary care programs involving orthopedics, geriatrics, anesthesia, and physical therapy to decrease complications and improve outcomes 1. This coordinated approach has strong evidence for reducing morbidity and mortality in hip fracture patients.

Common Pitfalls to Avoid

• Do not use sliding hip screw for unstable patterns—this leads to fixation failure rates exceeding 50% 3
• Avoid multiple guidewire entry attempts that can weaken the lateral cortex and propagate fractures 2
• Do not over-compress fractures in osteoporotic bone, which causes further comminution 3
• Watch for loss of reduction or femoral head malrotation during lag screw insertion 2
• Do not use DHS for pathologic fractures—these lack bone healing capacity and require alternative fixation or prosthetic replacement 3