Management of Intertrochanteric Fracture

Surgical Device Selection Based on Fracture Stability

The American College of Surgeons recommends using a sliding hip screw for stable intertrochanteric fractures with intact posteromedial cortex 1, 2, 3, 4
A cephalomedullary nail is mandatory for unstable intertrochanteric fractures, which include comminuted fractures, posteromedial cortex disruption, lesser trochanter involvement or avulsion, reverse oblique patterns, and subtrochanteric extension 1, 2, 3, 4, 5
Strong evidence supports cephalomedullary devices for subtrochanteric or reverse oblique fractures 1, 2, 3, 4
Failure rates exceed 50% when sliding hip screws are used for unstable patterns in osteoporotic bone 5

Surgery should be performed within 24-48 hours of admission to reduce mortality and complications 5
Administer prophylactic antibiotics within one hour of skin incision 5
Administer preoperative intravenous fluids routinely, as many elderly patients are hypovolemic 5
Do not use preoperative traction—it provides no benefit and is specifically not recommended 5

Achieve anatomic reduction under fluoroscopic guidance in both AP and lateral views 5
Restore medial cortical continuity and normal neck-shaft angle (approximately 130-135 degrees) 5
Inadequate reduction before fixation leads to malunion and hardware failure 5
Ensure lag screw reaches within 5-10 mm of subchondral bone 5
Position plate flush against lateral femoral cortex, aligned with femoral shaft axis 5
Secure plate with cortical screws (typically 4-6 screws) with bicortical purchase 5
Avoid over-compression, which can cause fracture comminution in osteoporotic bone 5

Implement immediate weight-bearing as tolerated to reduce complications and improve outcomes 5
Early mobilization protocols are essential for reducing morbidity 3, 5
Administer fondaparinux or low molecular weight heparin for DVT prophylaxis 3, 5
Continue pharmacologic prophylaxis for 4 weeks postoperatively 5
Continue regular paracetamol throughout the perioperative period 5
Use opioids cautiously, especially in patients with renal dysfunction; avoid oral opioids in renal dysfunction 5
Do not administer codeine due to constipation, emesis, and association with postoperative cognitive dysfunction 5
Use NSAIDs with extreme caution and avoid in renal dysfunction 5
Correct postoperative anemia appropriately 3
Consider transfusion for symptomatic anemia; use transfusion threshold no higher than 8 g/dL in asymptomatic patients 5

Each patient aged 50 years and over should be evaluated systematically for risk of subsequent fractures 1, 2, 3, 4
Order outpatient DEXA scan and refer to bone health clinic for osteoporosis evaluation and treatment 5
Fracture Liaison Service (FLS) is the most effective organizational structure for risk evaluation and treatment initiation 1, 2, 3, 4
A dedicated coordinator identifies all elderly patients with recent fractures, organizes diagnostic investigations, and initiates interventions 1, 2, 3, 4

Sliding hip screw is not effective for pathologic fractures due to lack of bone healing, particularly with planned subsequent radiation 5
Consider alternative fixation methods or prosthetic replacement for pathologic fractures 5