General considerations
In extracapsular fractures there is minimal risk of osteonecrosis of the femoral head.
In simple pertrochanteric fractures the fracture line can begin anywhere on the greater trochanter and end either above or below the lesser trochanter. The medial cortex is interrupted in only one place.
These fractures cause significant shortening, but they are stable after reduction and fixation, largely because of the excellent contact of the fracture surfaces and lack of comminution. The lesser trochanter, the so-called medial buttress, is intact.
These fractures may be treated with a sliding hip screw and plate, or a cephalomedullary nail.
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.
| MIO - Sliding hip screw | ||
| Main indication | Skill | Equipment |
|---|---|---|
| Surgeon's preference; closed reduction possible |  |
 |
Indications
- All fractures that can be reduced closed
- Patient is medically fit for surgery
Contraindications
- Irreducible fracture
- Significant hip joint arthritis
- Patient not fit for surgical treatment
- Severe soft-tissue problems in surgical area (pressure sores, acute infection, burns etc)
Advantages
- Less expensive implant than IM nail
- May convert to ORIF for reduction or improved fixation
- Fracture stability
- Early mobilization
- Semi-open procedure, fracture site left untouched
Disadvantage
- Risks of surgery
| Nailing | ||
| Main indication | Skill | Equipment |
|---|---|---|
| Surgeon's preference; unstable fracture; closed reduction possible | |
 |
Indications
- Fractures which can be reduced closed
- Desire for smaller surgical wound
- Patient is medically fit for surgery
Contraindications
- Bone deformity or previous surgery that prevents nailing
- Irreducible fracture
- Significant hip joint arthritis
- Severe soft-tissue problems in surgical area (pressure sores, acute infection, burns etc)
- Patient not fit for surgical treatment
Advantages
- Improved fixation stability, with reduced risk of secondary displacement
- Early mobilization
- Semi-open procedure, fracture site left untouched
Disadvantages
- Demanding technique
- More expensive implant than sliding hip screw
- Risks of surgery
| ORIF - Sliding hip screw | ||
| Main indication | Skill | Equipment |
|---|---|---|
| Inability to achieve closed reduction |  |
|
Indications
- Irreducible fractures
- Inadequate closed reduction
- Patient is medically fit for surgery
Contraindications
- Significant hip joint arthritis
- Patient not fit for surgical treatment
- Severe soft-tissue problems in surgical area (pressure sores, acute infection, burns etc)
Advantages
- Anatomical reduction
- Increased stability with reduced risk of secondary displacement
- Early mobilization
Disadvantages
- Bone devitalization
- May delay healing
- Risks of surgery
| *Skill | |
|---|---|
 |
Basic surgical experience, no specialized skills |
|
Some specialized surgical experience |
|
Highly experienced and skilled surgeon |
| *Equipment | |
|---|---|
 |
Basic equipment only |
|
Simple surgical and imaging resources |
|
Full specialized surgical and imaging resources |