Intertrochanteric (IT) Fracture - Complete Guide

1. Definition and Anatomy

• The trochanteric region has abundant blood supply from the surrounding cancellous bone, so avascular necrosis (AVN) is NOT a major concern (unlike femoral neck fractures)
• The calcar femorale (Adam's arch) - a dense posteromedial bone plate - is the most critical structural support. When it is comminuted, the fracture becomes unstable
• The short external rotators remain attached to the distal fragment; the internal rotators attach to the proximal fragment
• The gluteus medius and short external rotators abduct and externally rotate the greater trochanter; adductors and hamstrings pull the shaft posteromedially - causing the classic shortening and varus deformity

2. Epidemiology and Risk Factors

• One of the most common fractures in the elderly (along with femoral neck fractures)
• Predominantly caused by low-energy falls in patients with osteoporotic bone
• 1-year mortality rate up to 30% - survival is most strongly related to patient age and preexisting comorbidities
• Life expectancy returns to normal among patients who survive that first year
• Only about 50% of patients regain their original level of ambulation

3. Classification

A. Number-of-Parts Classification (Practical/Simple)

• 2-part: One part connected to femoral head, one to shaft - relatively stable
• 3-part: Greater or lesser trochanter is additionally fractured - the muscles still pulling on that fragment create instability
• 4-part: Both trochanters fractured - most unstable

B. OTA/AO Classification (Gold Standard - Rockwood & Green's 2025)

Important: The A3 reverse oblique pattern is easily missed on plain X-ray. CT scanning or fluoroscopy on the traction table may be needed to identify it. It is critical to recognize because it mandates an intramedullary (IM) nail rather than a sliding hip screw.

Note on the additional OTA subdivisions (each group is further split into 3 subgroups): Studies have shown these finer subdivisions do NOT reliably guide treatment and have unacceptable inter/intraobserver variation - they are therefore not routinely used clinically.

C. Evans Classification (Historical)

4. The Lateral Wall - A Critical Concept

• If the lateral wall is intact (>20.5 mm thick): a Sliding Hip Screw (SHS) is appropriate
• If the lateral wall is <20.5 mm or deficient: risk of iatrogenic lateral wall fracture is high with SHS; a cephalomedullary (IM) nail is preferred
• A3-type fractures inherently have an unstable lateral wall and require IM nailing

5. Clinical Presentation

• Acute pain around the hip and thigh with inability to stand or walk
• Pain may radiate to the ipsilateral knee

• Shortened and externally rotated leg (the strong iliopsoas action on the lesser trochanter pulls the proximal fragment into this position)
• Contusion or hematoma around the hip
• Passive range of motion is painful
• In nondisplaced fractures: axial compression pain may be the only sign (limb may appear normal)

• Ipsilateral distal radius fracture (most common, ~2%)
• Ipsilateral proximal humerus fracture (~1%)
• Head trauma (suspect in all; CT head warranted in ~21% of low-energy fracture patients)
• A second contralateral hip fracture occurs in up to 1 in 3 patients within ~1.5 years

6. Diagnosis

Imaging

7. Management

A. General Principles

• Goal: stable fixation allowing early weight bearing
• Modifiable comorbidities should be corrected
• Surgery should be performed within the first 48 hours - early repair (24-48h) improves 1-year mortality
• Operating on the day of injury (before resuscitation) increases mortality risk - patients need preoperative optimization
• Multidisciplinary team approach (orthogeriatrics model) reduces 1-year mortality

B. Nonoperative Treatment

• Nondisplaced fractures in patients able to comply with non-weight-bearing
• Displaced fractures in nonambulatory patients or those with prohibitive operative risk
• Bedbound/end-of-life patients (frank discussion required)
• Management: touch-down weight bearing for 6-8 weeks with analgesic nerve blocks
• Associated with higher mortality compared to surgical management

C. Operative Treatment - Implant Selection

1. Sliding Hip Screw (SHS / Dynamic Hip Screw - DHS)

• Indicated for STABLE fractures (A1) with an intact lateral wall (>20.5 mm)
• A 2-hole side plate is sufficient for stable fractures
• Lag screw must be placed in center-center position in the femoral head
• Tip-Apex Distance (TAD) <25 mm is the key predictor of lowest screw cut-out rate (see diagram below)
• Lower cost than cephalomedullary nails
• Not suitable for unstable fractures - associated with more collapse, limb shortening, and medialization; higher revision rates in transverse/reverse oblique fractures

2. Cephalomedullary (Intramedullary) Nail

• Valid for ALL IT fractures - the preferred device for unstable patterns
• Mandatory for:
  • Reverse oblique fractures (A3)
  • Subtrochanteric extension
  • Fractures with comminution
  • Lateral wall deficient/intact <20.5 mm
• Provides an IM buttress effect - less collapse than SHS
• Short nails - for standard oblique fractures (distal interlocking optional)
• Long nails - for standard oblique, reverse oblique, and subtrochanteric fractures
• Single lag screw design: aim for center-center with TAD <25 mm to minimize cut-out

3. Fixed-Angle Devices (95° blade plate / Locking Proximal Femoral Plate)

• Indicated for: reverse oblique fractures, highly comminuted fractures, and nonunion repair

8. Complications

9. Quick Summary Table