Orthopaedic Surgery - Intertrochanteric Hip Fracture

Basics

An intertrochanteric hip fracture is an extracapsular fracture of the proximal femur located between the greater and lesser trochanters.

The greater or lesser trochanter may separate as an individual fracture fragment.

These injuries are also called trochanteric or pertrochanteric fractures.

Classification

Many classification systems have been proposed, but their reproducibility is limited.

For practical treatment purposes, intertrochanteric fractures are commonly divided into:

Stable and unstable fractures.

Stable Fractures

A stable fracture generally has:

An intact or adequately reconstructed posteromedial cortex and a preserved lateral femoral wall or buttress.

These features allow the fracture to resist excessive collapse after fixation.

Unstable Fractures

Features of instability include:

Posteromedial comminution, disruption of the lateral wall, reverse-obliquity fracture configuration, subtrochanteric extension, or substantial comminution.

These patterns are more likely to shorten, collapse into varus, or fail mechanically if the fixation construct is inadequate.

Prevention

Prevention is directed primarily toward improving bone health and reducing falls.

Bone Health

Measures may include:

Adequate calcium and vitamin D intake, appropriate osteoporosis screening and treatment, antiresorptive or anabolic therapy when indicated, and regular weight-bearing exercise.

Bisphosphonates are commonly used in appropriate patients with osteoporosis.

Fall Prevention

Fall-risk reduction in older adults may include:

Canes or walkers, balance and strength training, medication review, correction of visual impairment, improved lighting, handrails, removal of loose rugs, and other home modifications.

Hip Protectors

External hip protectors may be considered in selected frail or institutionalized patients at particularly high risk of falls.

Epidemiology

Intertrochanteric fractures are substantially more common in women than men, largely because of the greater prevalence of postmenopausal osteoporosis.

Older series report female-to-male ratios ranging from approximately 2:1 to 8:1.

Incidence

Historical annual incidence has been estimated at approximately:

63 per 100,000 women and 34 per 100,000 men.

Proportion of Hip Fractures

Intertrochanteric fractures account for approximately 40–50% of all hip fractures.

Age

Incidence increases sharply with advancing age because of:

Osteoporosis, frailty, impaired balance, and increasing frequency of falls.

Risk Factors

The major risk factors are:

Advanced age, osteoporosis, frailty, gait instability, previous falls, and any condition that increases fall risk.

Pathologic Fracture

Intertrochanteric fractures may occasionally occur through abnormal bone weakened by:

Primary bone tumors, metastatic disease, or other pathologic processes.

Etiology

Most intertrochanteric fractures result from a fall, particularly in older adults.

Motor vehicle collisions are a less common but important cause, particularly in younger patients.

Mechanism of Injury

Typical mechanisms include:

Direct impact over the greater trochanter or axial loading transmitted through the femur.

Muscular forces acting on the trochanters can further displace the fragments after the fracture occurs.

Associated Conditions

Common associated conditions include:

Osteoporosis and frailty.

High-energy injuries may also be accompanied by:

Other fractures, soft-tissue trauma, neurologic injury, or vascular injury in the affected limb.

Diagnosis

Signs and Symptoms

Presentation depends partly on fracture stability and displacement.

Stable or Minimally Displaced Fractures

Some patients may remain able to stand or even walk, although weight bearing usually produces pain.

Pain is typically located in the groin, proximal thigh, or lateral hip.

Unstable or Displaced Fractures

Patients typically have:

Severe pain, inability to walk, substantial limitation of hip motion, swelling, and bruising over the lateral hip or greater trochanter.

History

The classic history is an older adult who sustains a low-energy fall from standing height.

In younger patients, the mechanism is more often high energy.

The clinician should also ask about:

Previous hip pain, preinjury mobility, osteoporosis treatment, use of anticoagulants, cognitive status, and medical comorbidities.

Physical Examination

Limb Position

A displaced intertrochanteric fracture typically produces a leg that appears:

Shortened and externally rotated.

External rotation can be pronounced because the distal fragment rotates under the influence of muscular forces, including the iliopsoas.

Inspection

Examine for:

Swelling, bruising, deformity, skin compromise, and wounds.

Hip Examination

Movement of the hip is usually extremely painful.

Forceful range-of-motion testing should be avoided once fracture is suspected.

Ipsilateral Knee and Limb Examination

The knee and remainder of the lower extremity should be assessed for associated injury, particularly after high-energy trauma.

Neurovascular Examination

Distal motor function, sensation, pulses, and capillary refill should be documented.

Imaging

Plain Radiographs

Initial imaging generally includes:

AP pelvis, AP view of the affected hip, and cross-table lateral hip radiograph.

Full-Length Femur

A full-length femoral radiograph may be useful to identify:

Additional fractures, distal deformity, previous implants, or other abnormalities relevant to surgical planning.

Occult Fracture

If the history and examination strongly suggest a hip fracture but plain radiographs are negative, MRI is the preferred test for detecting an occult fracture.

CT may be used when MRI is unavailable or contraindicated.

Treatment

General Principles

Most intertrochanteric fractures are treated surgically because fixation permits:

Earlier mobilization, earlier weight bearing, improved pain control, and reduced complications of prolonged bed rest.

Preoperative Care

Patients should generally remain protected from unrestricted weight bearing until definitive stabilization.

Traction

Routine preoperative traction has not been shown to provide meaningful benefit and is generally unnecessary.

Medical Optimization

Because many affected patients are elderly and medically complex, perioperative management should address:

Fluid status, anemia, anticoagulation, cardiac and pulmonary disease, pain control, delirium risk, nutrition, and osteoporosis.

Surgery should proceed promptly once the patient is medically optimized.

Nursing Care

Pressure-Injury Prevention

Special attention should be given to avoiding pressure over the:

Sacrum and heels.

Frequent repositioning and appropriate padding are important.

Delirium Prevention

Older patients are at high risk for acute delirium.

Useful measures include:

Frequent reorientation, adequate pain control, preservation of sleep-wake cycles, early mobilization, ensuring access to glasses and hearing aids, adequate hydration, and minimizing unnecessary sedating medications.

Nonoperative Treatment

Nonoperative management is rarely selected.

It may be considered in patients who:

Were already nonambulatory, have extremely limited life expectancy, or have medical conditions that make surgery disproportionately hazardous.

These patients still require aggressive pressure care, analgesia, pulmonary hygiene, thrombosis prevention, and gentle mobilization when possible.

Surgery

After closed or open reduction, the fracture is stabilized internally.

The implant is chosen according to fracture geometry and stability.

Sliding Hip Screw

A sliding hip screw, also called a dynamic hip screw (DHS), consists of a lag screw placed into the femoral head and neck that slides within a barrel attached to a side plate.

Mechanism

Controlled sliding permits the fracture to:

Impact and compress during weight bearing, improving bony contact and promoting union.

Indications

A sliding hip screw is particularly useful for stable intertrochanteric fracture patterns with an intact lateral wall.

Lateral Buttress

For a sliding hip screw to function properly, the lateral femoral wall must provide a mechanical stop.

If the lateral wall is deficient, uncontrolled lateralization or collapse can occur.

Cephalomedullary Nail

An intramedullary hip fixation device, usually a cephalomedullary nail, is commonly used for unstable patterns.

Indications

Particularly important indications include:

Reverse-obliquity fractures, subtrochanteric extension, lateral wall disruption, and highly comminuted unstable fractures.

The intramedullary implant itself provides a more medial load-sharing construct and can act as a buttress against excessive collapse.

Lag Screw Position

The position of the cephalic lag screw or blade within the femoral head is critical for preventing fixation failure.

Tip-to-Apex Distance

The tip-to-apex distance (TAD) is calculated by adding the distance from the tip of the lag screw to the apex of the femoral head on both the AP and lateral radiographs, corrected for magnification.

A target of approximately 25 mm or less is commonly recommended.

Failure Risk

A TAD greater than approximately 25 mm is associated with an increased risk of screw cutout and fixation failure.

Central or inferior-central placement within the femoral head is generally preferred depending on implant design.

Quality of Reduction

Successful fixation also depends on obtaining:

Appropriate neck-shaft alignment, restoration of medial cortical support, avoidance of varus, and satisfactory rotational alignment.

Good reduction is at least as important as implant selection.

Arthroplasty

Hip replacement is not the routine treatment for most intertrochanteric fractures.

However, arthroplasty may occasionally be considered in patients with:

Extreme comminution, severe preexisting hip arthritis, failed previous fixation, or fracture patterns unlikely to be reconstructed reliably.

Physical Therapy

Early rehabilitation is essential after fixation.

Mobilization

Patients should be mobilized as soon as medically safe, often beginning on the first postoperative day.

Weight Bearing

In many older patients with stable fixation, weight bearing as tolerated is encouraged.

Restrictions may be necessary in selected unstable fractures or when fixation quality is suboptimal.

Assistive Devices

A:

Walker, crutches, or cane

may be used according to balance, strength, and preinjury mobility.

Rehabilitation

Many elderly patients require a period of:

Inpatient rehabilitation, skilled nursing care, or structured home therapy

before they regain sufficient strength and independence.

Follow-Up

Main Rehabilitation Goal

The primary goal after surgery is early restoration of safe mobility while minimizing complications associated with immobility.

Prognosis

Fracture union is generally reliable because the intertrochanteric region contains well-vascularized cancellous bone.

However, recovery of overall function depends heavily on the patient’s preinjury health and mobility.

Functional Recovery

Historical studies suggest that only approximately 50% of patients return completely to their previous functional level after an intertrochanteric hip fracture.

Loss of independence is common in frail older adults.

Mortality

One-year mortality after hip fracture is substantial and is driven largely by:

Advanced age, frailty, and coexisting medical disease rather than the fracture alone.

Historical reports describe rates ranging from approximately 14–36%.

Complications

Delirium

Acute changes in mental status are common in older hospitalized patients.

Prevention and early treatment of postoperative delirium are important components of care.

Venous Thromboembolism

Deep venous thrombosis and pulmonary embolism are important complications.

Appropriate thromboprophylaxis should be used according to individual bleeding and thrombotic risk.

Options may include:

Low-molecular-weight heparin, direct factor Xa inhibitors, aspirin in selected protocols, or other anticoagulants together with mechanical prophylaxis and early mobilization.

Fixation Failure

Mechanical failure may produce:

Excessive fracture collapse, shortening, varus deformity, screw migration, or cutout through the femoral head.

Risk Factors for Mechanical Failure

Important causes include:

Poor reduction, varus alignment, inadequate fixation in the femoral head, excessive tip-to-apex distance, unstable fracture geometry, and severe osteoporosis.

Intra-Articular Penetration

The cephalic screw or blade can penetrate the femoral head and enter the hip joint if fixation fails or the implant is positioned too deeply.

This complication often requires revision surgery.

Peri-Implant Fracture

Stress concentration around the fixation device may rarely contribute to a new femoral fracture.

Nonunion

Nonunion is uncommon, historically occurring in fewer than approximately 2% of cases, because the intertrochanteric region has a rich blood supply.

Osteonecrosis

Femoral-head osteonecrosis is also uncommon compared with intracapsular femoral-neck fractures because the fracture generally lies outside the hip capsule and does not usually disrupt the main blood supply to the femoral head.

Salvage of Failed Fixation

Failed fixation with painful deformity, nonunion, or severe post-traumatic arthritis may require:

Revision fixation or conversion to total hip arthroplasty, depending on bone quality and joint condition.

Patient Monitoring

Patients should be followed clinically and radiographically until fracture healing is established.

Radiographic Surveillance

Radiographs should assess:

Fracture alignment, degree of controlled collapse, lag screw or blade position, maintenance of fixation, callus formation, and union.

Follow-up commonly continues for at least 1 year in complex cases.

CT

If union is difficult to determine on plain radiographs or nonunion is suspected, CT can help evaluate persistent fracture lines and bridging bone.

Long-Term Care

Following fracture recovery, attention should also be directed toward preventing future fragility fractures through:

Osteoporosis assessment and treatment, vitamin D optimization, fall-prevention strategies, strength and balance training, and review of modifiable risk factors.