Intertrochanteric Fractures


IT 4 partHip Pin and Plate APHip Intertrochanteri Fracture IMN




Fracture which extends between the trochanters of the proximal femur


Extra capsular / well vascularized




50% of hip fractures

- elderly

- osteoporotic

- female





- shortened

- externally rotated

- groin pain with leg movement


Evans Classification 


Two main types

- Type 1 Intertrochanteric

- Type 2 Reverse Oblique


Type 1 Intertrochanteric


Hip Intertrochanteric Fracture Type 3

2 part undisplaced                             


2 part displaced2 part displaced

2 part displaced


3 part fracture GT3 part GT

3 part without posterolateral support (GT fracture)

Hip Intertrochanteric fracture Type 43 part

3 part without posteromedial support (LT fracture)


Four Part Inter trochanteric fracture4 part IT

4 part without posterolateral or posteromedial support


Type II Reverse Oblique Type


Inherently unstable - tendency of femoral shaft fragment to shift medially


Reverse oblique 1Reverse oblique 2

Reverse oblique fractures




Depends on medial cortical reduction


Unstable (AO 31.A2 + 31.A3)

- intact lateral wall

- posteromedial cortical fracture

- reverse oblique

- subtrochanteric extension


Isolated GT Fracture


Isolated Greater Trochanter Fracture




Non operative




Unfit for surgery

- high risk of DVT / PE

- pressure ulcers

- pain with nursing






Obtain stable fixation

Early mobilisation




Welford et al Bone Joint J 2021

- systematic review of 46 studies and 500,000 hip fractures

- surgery < 24 hours reduces mortality


Leer-Salveson et al Bone Joint J 2019

- Norwegian registry of 80,000 hip fractures

- no change in mortality (3 day, 1 year) if surgery < 48 hours




Griffiths et al Anaesthesia 2021

- PDF for guidelines for the management of hip fractures



- consent

- do not resuscitate

- preoperative hemoglobin

- anti-platelet / anticoagulation

- GA versus spinal




Hip Pin and Plate APHip Intertrochanteri Fracture IMNHemi


Sliding hip screw/dynamic hip screw

Cephalomdeullary nail

 - Short / long

 - one screw / two screws / blade

Fixed angle plate


- Calcar replacing prosthesis




DHS versus nail


Depends on stability

Requires intact lateral wall for DHS (or GT plate)

- post-operative fracture of lateral wall turns stable intertroch into unstable


Granhaug et al, BJJ 2022

- Norwegian hip registry review of 17341 patients

- DHS vs nail for unstable intertrochs (A1/2/3)

- Nails have lower re-operation, and lower mortality rate


Raj et al J Orthop 2023

- meta-analysis of 22 studies and 3000 patients including all types of extracapsular proximal femur fractures

- DHS v cephalomedullary nail

- no difference in mortality / reoperation / failure fixation / complications

- IMN had shorter operative times and reduced blood loss

- Did no delineate between fracture patterns


Single versus dual screws


Hip Intertrochanteri Fracture IMNDual screw nail


Yang et al J Orthop Surg Res 2023

- systematic review of single versus dual screw cephalomedullary nail

- 23 studies and 3500 surgeries

- dual screw reduced risk of failure and reoperation


Nail with helical blade vs screw


Kim et al, J Orthop Trauma 2021

- systematic review of 2331 femoral nails

- TFNA neck screw vs helical blade

- helical blade more likely to fail compared to screw (OR 5.33)

- non-union rate same


Long vs short nail


Cinque et al, Arch Orthop Trauma Surg. 2022

- meta-analysis of 3208 intertrochs

- long vs short nail

- short nails had less blood loss, and operative time

- no difference in re-operation, failure, or transfusion rates


ORIF versus hemiarthroplasty


Hongku et al Orthop Traumatol Surg Res 2022

- systematic review of 7 RCTs and 500 patients

- higher operative failure with DHS / PFN compared with hemiarthroplasty

- higher long term hip scores with PFN


Dynamic hip screw


Hip Pin and Plate APPin and plate lateral




Plate is a lateral tension band whilst the sliding screw allows controlled fracture impaction




Synthes technique guide PDF


Youtube step by step sawbone guide


Set up

- traction table with anatomic reduction

- traction, adduction, internal rotation


Lateral approach to femur

- elevate vastus lateralis and control bleeding from perforators


Guide wire

- centred in femoral head in 2 planes 

- tip-apex distance < 25 mm


Tip - apex distance

- from tip of screw to apex femoral head

- accumulative on AP and lateral

- > 25 mm, increases cut out


Measure angle

- wire in centre of neck / centre of head

- usually 130o prosthesis


Ream to within 5 mm of end of wire

- tap

- insert screw / tip apex distance < 25 mm

- attach plate


Options for improving stability


a.  Valgus Osteotomy for unstable Fractures



- reduces shear force

- increases compression

- stronger construct



- 135° plate placed in at 120°

- valgises proximal fragment and medializes shaft

- +/- lateral wedge removed / sarmiento valgus osteotomy


b.  Trochanteric stabilization plate



- buttresses the GT and prevents lateral displacement


Cephalomedullary nail / Proximal femoral nail


Hip Intertrochanteri Fracture IMNHip Intertrochanteric IMN Lateral


Mechanical advantages

- load sharing rather than load bearing

- decreases lever arm

- supports medial cortex


Surgical advantages

- smaller incision / minimally invasive

- reduced blood loss

- shorter surgical times



- reverse oblique

- unstable fracture / loss of lateral buttress / loss posteromedial support

- subtrochanteric extension




Vumedi surgical technique cephalomedullary nail


Stryker gamma nail technique animations


Smith&Nephew Intertan youtube animation


Hemiarthroplasty / Total hip replacement


Hemi for ITIT Hemi



- severe comminution

- salvage of failure of previous fixation



- may need calcar replacement

- may need greater trochanter fixation





Screw cut out


Non union


Periprosthetic fracture




Malreduction nailMalreduction plate


Screw Cut


Cut out 1Cut out 2Cut out 3



- malreduction

- poor screw position / high tip apex distance

- poor bone quality


Baumgartner et al, JBJS 1995

- Retrospective review of 198 intertrochs treated DHS

- none < 25mm cutout. > 25mm strong predictor of cut-out



- revised to 95o DCS

- hemiarthroplasty / THA


THA Issues


THR post pin and plateCalcar replacing


A. Femoral component

- cement will come out screw holes

- Option 1:  leave screws in laterally, and strip medially to insert small screws

- Option 2:  use uncemented stem


B.  Length of femoral stem

- should bypass distal screw hole by 2 cortical diameters


C.  Calcar

- normal stem usually sufficient if LT healed back on

- otherwise may calcar replacing


D. Greater trochanter

- may need plate / cables to reduce


Failed intertrochFailed IT


Failed intertrochRevision intertroch




Excessive lateral sliding / shaft medialisation



- collapse with insufficent lateral buttress

- reverse obliquity fracture


Intertrochanteric Fracture Barrel ImpingementMalunion




1.  Fracture united

- remove screw


2.  Fracture non union

- revise fixation in young patient

- hemiarthroplasty / THA


Non Union





- pain

- hardware failure

- exclude infection


NOF Intertrochanteric Non unionNOF Intertrochanteric Nonunion CT




A. Closing lateral wedge valgising osteotomy + graft - younger patients

B.  Revision fixation  - 95 degree DCS Plate / IM nail



Recon Nail Cut outRecon Nail Cutout LateralRecon Nail Cutout Salvage


Periprosthetic fracture


Peripros 1Peripros 2