Executive Editor: Joseph Schatzker, Peter Trafton

Authors: Ernst Raaymakers, Inger Schipper, Rogier Simmermacher, Chris van der Werken

Proximal femur - Trochanteric fracture, intertrochanteric

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Glossary

General considerations

In extracapsular fractures there is minimal risk of osteonecrosis of the femoral head.

True intertrochanteric fractures are subdivided according to the fracture pattern. The fracture line passes between the two trochanters, above the lesser trochanter medially and below the crest of the vastus lateralis laterally. Both femoral cortices are involved.

These fractures cause significant shortening and tend to be unstable after reduction and fixation, because both cortices are involved.

These fractures may be treated with a sliding hip screw and plate (DCS), or a cephalomedullary nail. Whichever method of treatment is used, it can be difficult to obtain satisfactory reduction with a closed technique, and it is often necessary to perform an open reduction.

Only stable proximal femoral fractures can be treated with the dynamic condylar screw (DCS) plate. The DCS plate does not allow for controlled collapse and compression.

Note: Because healing of these fractures may take 12 or more weeks, if contraindications can be corrected soon enough, operative treatment of the fracture may be beneficial even if delayed.

If definitive treatment will be delayed for more than 2 or 3 weeks, temporary skeletal traction might be considered to help maintain alignment.

Nailing
Main indication Skill Equipment
Any intertrochanteric fracture Highly experienced and skilled surgeon Full specialized surgical and imaging resources

In trochanteric fractures with a subtrochanteric extension, a long intramedullary nail may be indicated.

Indications

  • Fractures with appropriate pattern
  • Easily reducible fracture 
  • Adequately reduced fractures

Contraindications 

  • Irreducible fracture 
  • Severe soft-tissue problems in surgical area (pressure sores, acute infection, burns etc) 
  • Hip joint arthritis
  • Patient not fit for surgical treatment

Advantages

  • IM nailing is potentially the most stable fixation for most fractures (alternatively 95° implant (DCS or blade plate) or sliding hip screw with trochanter
  • stabilizing plate (TSP) could be used)
  • Early mobilization of patient 
  • Semi-open procedure, fracture site left untouched

Disadvantages

  • Reduction may be difficult, but Schanz screws, clamps or other aids can be used through additional small incisions
  • Risk of secondary displacement
  • Risks of surgery
ORIF - Dynamic condylar screw
Main indication Skill Equipment
Any intertrochanteric fracture Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Indications

  • Fractures with appropriate pattern 
  • As an alternative to IM nailing 
  • Irreducible fractures 
  • Inadequate closed reduction

Contraindications

  • Severe osteoporosis 
  • Severe soft-tissue problems in surgical area (pressure sores, acute infection, burns etc) 
  • Significant hip joint arthritis
  • Patient not fit for surgical treatment

Advantages

  • Greater stability than sliding hip screw 
  • Early mobilization of patient 
  • Anatomical reduction

Disadvantages

  • Challenging technique 
  • Potentially extensive incision
  • Risks of surgery 
  • Bone devitalization 
  • May delay healing

Note: Sliding hip screw is less suitable for all fractures. The short IM nail is contraindicated if the fracture involves the subtrochanteric zone.

*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v2.0 2010-11-14