Intertrochanteric Fractures

DefinitionHip Intertrochanteric Fracture Type 3


Fracture which extends between the trochanters of the proximal femur

- lower limit is inferior border of lesser tuberosity




Extra capsular / well vascularized


The key to stability is the posteromedial cortex





- 90% > 65

- peak at 80 years


F:M 2:1


NHx 1st year

- 1/3 die

- 1/3 worse function

- 1/3 same function


Mechanism of injury


Low energy injuries in osteoporotic patient

- direct = blow to GT

- indirect = torque force secondary to fall





- shortened

- externally rotated

- groin pain with leg movement




Judicious use of medications

- avoid confusing / sedating


Poor vision

- adapt home environment

- avoid slippery rugs etc


Adapt bathrooms for safety / stability


Hip pads


Dx Occult Hip Fractures




Hip pain

Normal Xray




CT scan

- easily obtained in emergency departments


Bone Scan

- 100% sensitive at 72 hours



- sensitive within 24 hours

- more expensive and difficult to obtain




Lubovsky et al Injury 2005

- compared CT and MRI

- MRI more accurate

- 4/6 CT inaccurate


Evans Classification 


Two main types

- Type 1 Intertrochanteric

- Type 2 Reverse Oblique



- depends on medial cortical reduction



- collapse into varus or shaft medialises

- comminuted PM cortex

- reverse oblique

- subtrochanteric extension


Type 1 Intertrochanteric


1.  2 part undisplaced & stable


Hip Intertrochanteric Fracture Type 3


2.  2 part displaced, but stable on reduction


Hip Displaced Intertrochanteric Fracture


3.  3 part with posterolateral support (GT fracture)


4. 3 part without posteromedial support (LT fracture)


Hip Intertrochanteric fracture Type 4


5. 4 part without posterolateral or medial support (combination 3 and 4)


Four Part Inter trochanteric fracture


Type II Reverse Oblique Type



Inherently unstable

- 2° tendency of femoral shaft fragment to shift medially


Modified Boyd Classification


Type I   21%

- nondisplaced & stable 


Type II   36%

- stable, but displaced fractures

- stable construct with pin and plate


Type III   28%

- unstable with pin and plate

- large posteromedial comminution 


Type IV  15%

- intertrochanteric with subtrochanteric component


Isolated GT Fracture


Isolated Greater Trochanter Fracture




Non operative




Little place for non operative treatment


Immobilization = Severe morbidity

- bed sores

- chest infection

- non-union




Unit for surgery


Incomplete fractures


Alam et al JBJS Br 2005

- 5 partial intertrochanteric fractures treated non operatively, 3 operatively

- no refractures

- similar length of hosptial stay




Medical Workup


1.  Improve any reversible medical disease


Otherwise surgery in first 24 hours


Consider Cause of fall

- exclude medical cause

- TIA / UTI / MI / Arrythmia



- electrolyte imbalance / anaemia

- pneumonia / UTI

- arrythmias


2.  Patient on anticoagulation

- operate if on plavix

- on warfarin, wait or use FFP to reduce INR < 1.6




Zuckerman et al JBJS Am 1995

- delay > 2 days increases mortality within the first postoperative year




Obtain stable anatomical reduction and allow early mobilisation




Sliding Hip Screw and Plate

Intramedullary Hip Screw

Calcar Replacing Prosthesis


Post operative


Mobilise +++


DVT prophylaxis

- chemical and mechanical




Foster et al J Orthop Trauma 1990

- higher morbidity if albumin< 3 (70%) than > 3 (17%)


Prevent secondary fractures

- vitamin D + calcium to all patients

- bisphosphonates if tolerated


Sliding hip screw and Plate


Hip Pin and Plate APHip Pin and Plate Lateral




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



1.  No lateral buttress 

2.  Reverse oblique fracture

3.  Subtrochanteric extension




Set up

- traction table with anatomic reduction

- traction, adduction, IR

- other leg: hip and knee flexed with hip abducted to allow II

- lateral approach to femur


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

- strong predictor of cut out

- < 25 mm, virtually zero

- > 25 mm, increases cut out


Measure angle

- wire in centre of neck / centre of head

- usually 130o prosthesis

- often only 135o available / need to be lower in neck

- being in the centre of the head is most important


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 

- medializes shaft

- +/- lateral wedge removed / Sarmiento Valgus Osteotomy


Cochrane Database Sytemic Review 2009

- no evidence for improved outcome

- higher blood loss


B.  Trochanteric stabilisation plate



- buttresses the GT and prevents lateral displacement


Madsen et al J Orthop Trauma 1998

- compared first generation Gamma nail / CHS and DSH/TSP in unstable fractures

- DHS/ TSP had lowest rate of varus malunion / lag screw cutout / excessive lag screw sliding with medialisation

- CHS still had lowest rate of reoperation


Intra-medullary Hip Screw


Hip Intertrochanteri Fracture IMNHip Intertrochanteric IMN Lateral


Mechanical Advantages

- load sharing rather than load bearing

- decreases lever arm

- supports medial cortex

- less distance for collapse


Theoretical Surgical Advantages

- smaller incision / mini invasive

- reduced blood loss

- shorter surgical times



- reverse oblique

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

- intertrochanteric extension

- pathological fractures




First generation Gamma Nail (Stryker) had 5% distal femoral fracture rate


Reasons for distal fracture

- fit and fill caused increased distal stresses (higher fracture with 16 mm diameter nail)

- no anterior bow

- poor distal locking technique (missed holes caused fractures)

- 2 distal screws


Second Generation intra-medullary hip screws


IMHS / Gamma Nail

- trochanteric entry

- decreased distal diameter

- shorter length (180 mm v 200mm)

- only 4o valgus offset

- 125 - 130o angle

- one distal screw with jig


Hip Reverse Obliquity Fracture IMN




Second Generation IMN v Sliding hip screws

- several prospective randomised studies

- very similar rates of complications

- similar cut out, blood loss, time of operation

- slight risk femoral fracture IMN

- learning curve for IMN (25 cases)


Cochrance database review 2008

- no evidence of superiority of IMN over sliding hip screw

- increased complications with nail


3.  Calcar replacing prosthesis



- salvage of failure of fixation

- severe comminution

- RA



- high cost

- higher morbidity / mortality

- high risk of dislocation




1.  Screw Cut Out 6%


Hip Pin and Plate Screw Cut outIntertrochanteric NOF Screw Cut out



- poor screw position

- 150° screw

- high tip apex distance



- 95o DCS

- THR / calcar replacing prosthesis


THR Issues


A.  Cemented 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


THR Post Pin and PlateIntertrochanteric NOF Calcar Replacing THR


Barrel Impingement / Excessive Lateral sliding / Shaft medialisation




1.  Long screw

2.  Collapse with insufficent lateral buttress

3.  Reverse obliquity fracture


Intertrochanteric Fracture Barrel Impingement




1.  Fracture united

- remove screw


2.  Fracture non union

- revise fixation in young patient



Lateral Slide Off Proximal Fragment


Femoral medialisation


Due to

- insufficient lateral cortex

- reverse obliquity fracture


Use 95° plate


Non Union


Uncommon / 1%

- exclude infection



- continued pain (case 1)

- hardware failure (case 2)


Case 1


NOF Intertrochanteric Non unionNOF Intertrochanteric Nonunion CT


Case 2


Hip Broken Intertan NailHip Broken Intertan Non Union salvage




A. Closing lateral wedge valgising osteotomy + graft

- success 90% / indicated in younger patients

B.  95 degree DCS Plate

C.  Revision IMN



Infection 2-5%


Intertrochanteric Infected NonunionIntertrochanteric Infected Nonunion Spacer





- posterior sag of femur in unstable fracture

- get malrotation if use excessive IR to "reduce" fracture on II


Periprosthetic fracture


Usually fracture at tip of plate

- remove distal screws and insert retrograde nail