eMedicine Specialties > Orthopedic Surgery > Hip

Intertrochanteric Hip Fractures: Treatment

Author: Richard S Goodman, MD, JD, FAAOS, Chair, Department of Surgery, SABA University Medical School; Consulting Staff, Department of Orthopedics, Long Island Jewish/North Shore University Hospital
Contributor Information and Disclosures

Updated: Nov 3, 2009

Treatment

Surgical Therapy

The patient with an intertrochanteric fracture is ready to proceed with surgery after the medical evaluation is completed and medical pathology is decreased or medical conditions stabilized without undue delay.

Preoperative Details

The patient is taken to the operating room after appropriate surgical consent has been obtained. Correct side identification and patient identification are completed. According to the judgment of the anesthesiologist, the patient is given either general anesthesia or spinal anesthesia. When adequate anesthesia has been administered, the patient is transferred to an orthopedic or fracture table.

Intraoperative Details

The patient and the affected extremity are positioned on the table, where closed reduction of the fracture is performed. The sequence for reduction commences with longitudinal traction in a well-relaxed patient. The fracture is fully extended when the top of the greater trochanter is at the center of the femoral head; at this point, the normal neck shaft angle is restored. The leg is then internally rotated to align the neck with the shaft in the lateral view and to ensure proper anteversion. Appropriate images are obtained with 1 or 2 fluoroscopic imaging (C-arm) machines.

If the reduction is not satisfactory, then adjustments are made by changing the rotation, abduction, or the amount of traction of the affected extremity. Surgery proceeds when an adequate, stable, or near-anatomic reduction is obtained, with correction of any problems with rotation, leg length, lateral angulation, and AP angulation.

Certain fracture patterns cannot be reduced in a closed manner; in such cases, open reduction is required. The lateral hip and femur are then prepared and draped.

A side plate is indicated to provide a more stable attachment of the device (pin, sliding nail, or screw) in the neck of the femur with the distal femoral shaft. The plate is applied to the outside or lateral side of the femur with screws going through the plate into one or both cortices of the femur. The upper end of the plate attaches to the device, which is placed in the femoral neck by using a nut or compression screw.

A lateral incision is made in the skin directly over the greater trochanter and continued down through the overlying fascia and muscles to the femur. The lateral femur is exposed and a guidewire is drilled from the lateral femur to the femoral head, so that the guidewire is centered in the femoral neck in both the lateral view and the AP view, as shown on the fluoroscopic images. The angle between the wire and the femoral shaft must equal the angle of the proposed fixation device, usually an angle of 135°. The tip of the guidewire must lie in the center of the femoral head and 1 cm from the subchondral line on both the AP and lateral views. This is the tip apex distance (TAD), as described by Baumgaertner. The TAD must be less than 2.5 cm for a minimal screw cutout.

If the guidewire is placed appropriately, the drilled hole is enlarged with the cannulated drills supplied with the fixation device over the already placed guidewire. The lag screw is inserted into the femoral head. The side plate and barrel are placed over the screw, and the guidewire is removed. The side plate is then attached to the femoral shaft with the appropriate screws. Fluoroscopic images are taken throughout the repair to ensure the maintenance of the reduced fracture position and the proper positioning of the fixation device.

Intramedullary nailing

Intramedullary nailing has been used as a treatment alternative for intertrochanteric fractures. Multiple thin-diameter solid nails (Enders nails) inserted from the knee in a retrograde fashion were popular in the 1970s and 1980s. This technique, however, led to excessive external rotation and knee pain and has been abandoned.

After the appropriate fixation device has been placed, the muscles, fascia, and skin are closed. The patient is then transferred to a recovery room.

Postoperative Details

The patient's nonorthopedic conditions continue to be treated following an intertrochanteric fracture repair. Preventive DVT protocol is followed with an appropriate combination or selection of antiembolism stockings and anticoagulants. The anticoagulants include, but are not limited to, aspirin, heparin or a heparin derivative, and warfarin (Coumadin) or a warfarin derivative. Anticoagulants require appropriate monitoring to ensure adequate dosage and to prevent overmedication and bleeding. With each medication or protocol, the dosage of medication is different, length of treatment is different, and combination of medications and use of anticoagulant socks vary. Follow the manufacturer's protocol.

Physical therapy is instituted to allow the patient to ambulate with the aid of physical therapists or other nursing personnel. Equipment includes walkers, crutches, 4-post canes, and other canes as recommended by the physical therapist and surgeon.

The physical therapist guides therapy and the use of assisted ambulatory supports on the basis of proper instructions from the surgeon. The surgeon indicates the differences between nonweightbearing, toe touching, partial weightbearing, and full weightbearing therapies and the proper techniques for use of various ambulatory devices. In patients of advanced age, it may be difficult to institute therapy beyond full weight bearing.

Complications

Intertrochanteric hip fractures have significant complication rates: 20-30% in the first year, including a 5% nonunion rate, a 5% infection rate, and an 11% rate of device failure. Important approaches to prevention of complications are to follow a careful preoperative sterilization technique, to do a careful preoperative study of radiographs, to perform meticulous insertion of devices, and to do careful postoperative monitoring with radiographs and a clinical examination to ensure healing of the fracture.

Medical complications of intertrochanteric hip fractures are secondary to any preexisting medical conditions that have or have not been recognized, diagnosed, or properly treated, depending on the limitations of time and facilities and the current level of medical care. Medical complications include cardiac, pulmonary, renal, hepatic, and vascular conditions.

Systemic complications can occur because of anesthesia (general or spinal) used in the procedure, stress from the surgical procedure, or even stress in general.

Local orthopedic complications can occur if an adequate stable reduction of the fracture is not obtained and maintained or if the correct position is lost before healing because of movement associated with daily activities and personal hygiene. Loss of position before healing can also occur from a failure of the fixation device because of improper insertion or from a failure of the fracture to heal before the end of the mechanical life of the device.

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