Surgical Approaches for Intertrochanteric (IT) Fractures

1. Patient Positioning (Common to All Approaches)

• Lithotomy position - flexed, abducted, and held in a stirrup (image intensifier passes between the legs)
• Scissor position - contralateral leg extended to the side (image intensifier approaches from the opposite side)

Patient on fracture table: injured leg in traction, uninjured leg in lithotomy stirrup

Fracture table is essential - fixation without it is not recommended as fracture reduction is difficult to maintain (Rockwood & Green's 10th Ed, p. 2714).

2. Approach A: Lateral Approach for Sliding Hip Screw (SHS/DHS) - Extramedullary Fixation

Incision

• A 5-7 cm lateral longitudinal skin incision is made just distal to the greater trochanter, centered over the lateral femoral cortex
• The fascia lata (iliotibial band) is divided in line with the skin incision

Muscle Handling - Vastus Lateralis

1. Retraction (preferred): Vastus lateralis is reflected anteriorly and held out of the way with a retractor attached to the support rail. This avoids splitting the muscle and reduces blood loss.
2. Splitting: A direct split through the muscle belly is made if needed for access.

Cross-section: Vastus lateralis retracted anteriorly to expose the lateral femur for sliding hip screw fixation

Key Surgical Steps (SHS)

1. Supine on fracture table, fracture reduced under fluoroscopy (AP + lateral)
2. 5-7 cm lateral incision just distal to greater trochanter
3. Divide fascia lata; reflect vastus lateralis anteriorly
4. Insert guidewire using an angle guide at 135° - aimed at central/low position on AP, central on lateral view
5. Measure guidewire to determine lag screw length
6. Ream over guidewire, insert lag screw - tip should be 5-7 mm from subchondral bone (tip-to-apex distance <25 mm)
7. Ensure rotational alignment by palpating the anterior fracture line
8. Apply barrel plate (usually 4-hole) to the lateral femur; fix with cortical screws
9. Close vastus lateralis split (if split), close fascia lata, subcuticular skin closure

3. Approach B: Lateral/Proximal Lateral Approach for Cephalomedullary Nail (Intramedullary) - IMN

Incision

• A short 3-5 cm proximal lateral incision starting at the tip of the greater trochanter and extending proximally
• Fascia lata is divided
• Gluteus medius is split in line with its fibers (or retracted) to access the tip or piriform fossa of the greater trochanter (entry point depends on nail design)

Entry Point

• Greater trochanter entry nails (e.g., PFNA): entry at the tip of the greater trochanter, slightly medial
• Piriformis fossa entry nails (less common for IT fractures, more for subtrochanteric)

Key Surgical Steps (IMN)

1. Supine on fracture table; closed reduction achieved under fluoroscopy
2. Short proximal lateral incision at tip of greater trochanter
3. Divide fascia lata; split or retract gluteus medius
4. Open entry point with awl at tip of greater trochanter
5. Pass guide rod down medullary canal; ream as required
6. Insert nail to correct depth
7. Insert cephalic lag screw or helical blade into femoral head via the nail's targeting arm - central/low on AP, central on lateral
8. Insert distal locking screw(s) with freehand or targeting arm technique
9. Close proximally in layers

Advantages Over SHS for Unstable Fractures

• Shorter lever arm - less bending moment
• Allows controlled collapse in anatomical position
• Less femoral medialization
• Norwegian Hip Fracture Registry (17,341 patients): lower reoperation rate and better 1-year mortality for unstable A2/A3 fractures with cephalomedullary nail vs SHS

4. Implant Selection by Fracture Type (AO/OTA Classification)

5. Arthroplasty (Hemiarthroplasty/THA)

• Severely comminuted fractures in elderly patients with pre-existing arthritis
• Failed internal fixation (non-union, hardware failure)
• Pathological fractures

6. Critical Technical Points

• Tip-to-apex distance (TAD): Should be <25 mm to minimize lag screw cut-out risk. Measured as the sum of distances from lag screw tip to femoral head apex on AP and lateral X-rays (corrected for magnification)
• Lag screw position: Central-inferior on AP, central on lateral (9-segment method) - inferior position reduces cut-out
• Anti-rotation: Prevent femoral head rotation during lag screw insertion by placing a finger on the anterior neck or using an anti-rotation pin
• Lateral wall integrity: If the lateral wall is deficient, a SHS risks failure - convert to cephalomedullary nail or add a trochanteric side plate