Intertrochanteric Fracture

Definition and Overview

Sites of proximal femoral fractures showing intracapsular vs extracapsular regions.

Epidemiology and Etiology

• Predominantly affects the elderly (especially post-menopausal women with osteoporosis)
• Usually follows a low-energy fall from standing height - often sideways onto the hip
• Reduced bone density (osteopenia/osteoporosis), sarcopenia, impaired balance, visual problems, and multiple medications all contribute
• In ~4% of cases, an associated fracture is present (most commonly ipsilateral distal radius 2%, or proximal humerus 1%)
• After one hip fracture, a second contralateral hip fracture occurs in up to 1 in 3 patients within 1.5 years

• Increased age, concurrent illness, mental impairment, gait/balance disorders
• Physical disability, visual abnormalities, prior stroke
• Medications: tranquilizers, antihypertensives, multiple drug polypharmacy, alcohol

Classification (OTA/AO - 31.A)

OTA/AO Classification: A1 (stable two-part), A2 (unstable comminuted), A3 (reverse/transverse)

Clinical Features (Diagnosis)

• Acute pain around the hip and thigh; inability to stand or walk
• Pain may radiate to the ipsilateral knee
• Affected leg is shortened and externally rotated (due to deforming muscle forces)
• In a nondisplaced fracture, axial compression pain may be the only finding

• Contusion or hematoma around the hip
• Passive range of motion painful
• Unlike femoral neck fractures, the patient typically gives a history of tripping over a carpet, pet, or step (direct sideways fall)

Imaging

• AP pelvis (both hips included) + lateral hip
• The non-involved hip helps assess normal anatomy for comparison
• Comminuted fractures are easily identified; minimally displaced fractures can be occult (~1%)

• Most sensitive and specific; indicated when fracture is suspected but radiographs are normal
• Detects incomplete fractures, bone bruise, and soft tissue damage

• Useful alternative when MRI is unavailable
• Helps identify comminution, lateral wall status, and fracture pattern
• A traction view can elucidate fracture location and lateral wall status

Comminuted intertrochanteric fracture on the left (AP pelvis radiograph)

Anatomy of Relevance

• The trochanteric region contains cortical and cancellous bone
• The calcar femorale (Adam's arch) - a strong plate of posteromedial cortical bone - is the key structural element; it is most affected with posteromedial comminution
• Ward's triangle is a relatively weaker trabecular zone; peripheral to it, the structure transitions to the femoral medullary canal
• With aging, cortical bone thins and the calcar becomes weaker

Management

Preoperative Optimization

• Correct anemia, dehydration, electrolyte imbalance, cardiac and respiratory issues
• Anticoagulation management: Surgery should NOT be postponed for aspirin. For warfarin, reversal is debated but urgent surgery with intraoperative bleeding measures is acceptable for some. For DOACs, delay 1-2 days depending on renal function
• VTE prophylaxis: LMWH is standard; continue for at least 28 days postoperatively; start 12 hours post-wound closure
• Preoperative traction is no longer routinely recommended (no benefit in pain reduction; complicates nursing care)

Timing of Surgery

• Surgery should be performed as soon as possible, ideally within 24 hours once the patient is medically optimized
• British Hip Fracture Database data: 30-day mortality increases 10% after a 24-hour delay
• The HIP ATTACK trial found no advantage of accelerated surgery (median 6 hours) over standard care (median 24 hours) on mortality

Anesthesia

• Both regional (spinal) and general anesthesia are acceptable with equal mortality profiles
• Regional anesthesia is preferred when possible due to fewer pulmonary complications
• Femoral nerve block or fascia iliaca compartment block (ultrasound-guided) is recommended to reduce opioid use and postoperative delirium

Surgical Treatment

Internal Fixation

• The standard for stable (A1, A2) fractures with an intact lateral wall
• A large lag screw in the femoral head slides within a barrel on the plate, allowing controlled fracture collapse
• Avoids stress risers, allows some impaction at the fracture site

• Indicated for: A3 (reverse oblique) fractures, unstable fractures, subtrochanteric extension, and when DHS is contraindicated
• A nail inserted down the medullary canal with a proximal lag screw into the femoral head
• Superior mechanical advantage in A3 fractures; associated with better outcomes in unstable patterns
• The tip-to-apex distance (TAD) should be <25 mm to minimize risk of lag screw cutout

Tip-to-apex distance (TAD) calculation - a predictor of cut-out risk

• A sliding hip screw variant with smaller incision; theoretical advantages for lateral wall insufficiency
• Outcomes similar to SHS/IMN but technique more demanding

• NOT recommended as primary treatment for standard trochanteric fractures
• High failure rates due to static (non-collapsing) fixation
• May have a role in younger patients with complex fractures and good bone stock

• 95-degree condylar plate / blade plate - static fixation, high failure rate, replaced by cephalomedullary nails

Fracture Reduction (Key Principles)

• Patient placed supine on fracture table with injured leg in traction
• Reduction to anatomical or slight valgus position - associated with lowest implant cutout risk
• Varus position must be avoided - mechanically unstable, leads to progressive varus and implant cutout
• Lateral view reduction is equally important - translation or angulation must be corrected

Complications

Nonoperative Treatment

• Non-ambulatory patients (e.g., nursing home patients) where surgery risk is prohibitive
• Management: symptomatic analgesia; Buck's traction intermittently for pain control; mobilize to sitting within 2-3 days
• Even nondisplaced fractures are at high risk for displacement with minimal activity (rolling in bed)

Key Contrasts with Femoral Neck Fracture