12/24/22, 11:33 PM Intertrochanteric Femur Fracture - StatPearls - NCBI Bookshelf

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.

Intertrochanteric Femur Fracture

Authors

Basem Attum1; Holly Pilson2.

Affiliations
1 Vanderbilt University Medical Center
2 Wake Forest Baptist Medical Center

Last Update: August 8, 2022.

Continuing Education Activity

Intertrochanteric femur fractures are a very common injury seen in the elderly. Understanding the pathophysiology as
well as the proper treatment options will significantly decrease the risk of mortality and morbidity of this injury. This
activity reviews the evaluation and treatment of intertrochanteric femur fractures and highlights the role of the
interprofessional team in evaluating and treating patients with this condition.

Objectives:

Describe the most common mechanisms of injury that can result in intertrochanteric femur fractures.

Summarize the diagnostic approach for an evaluation and assessment of a patient presenting with a potential
intertrochanteric femur fracture, including any indicated imaging studies and potential differentials.

Outline the treatment options for intertrochanteric femur fractures, depending on patient population and fracture
severity and location.

Outline interprofessional team strategies for improving care coordination and communication to improve
outcomes with intertrochanteric femur fracture treatment.

Access free multiple choice questions on this topic.

Introduction
Intertrochanteric fractures are defined as extracapsular fractures of the proximal femur that occur between the greater
and lesser trochanter. The intertrochanteric aspect of the femur is located between the greater and lesser trochanters
and is composed of dense trabecular bone. The greater trochanter serves as an insertion site for the gluteus medius,
gluteus minimus, obturator internus, piriformis, and site of origin for the vastus lateralis. The lesser trochanter serves
as an insertion site for the iliacus and psoas major, commonly referred to as the iliopsoas. The calcar femorale is the
vertical wall of dense bone that extends from the posteromedial aspect of the femur shaft to the posterior portion of
the femoral neck. This structure is important because it determines whether or not a fracture is stable. The vast
metaphyseal region has a more abundant blood supply, contributing to a higher union rate and less osteonecrosis
compared to femoral neck fractures.[1][2]

Etiology
These fractures occur both in the elderly and the young, but they are more common in the elderly population with
osteoporosis due to a low energy mechanism.  The female to male ration is between 2:1 and 8:1. These patients are

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also typically older than patients who suffer femoral neck fractures. In the younger population, these fractures
typically result from a high-energy mechanism.[3]

Epidemiology
These fractures along with other hip fractures are associated with high morbidity and mortality. Currently, 280,000
fractures occur annually with nearly half of these due to intertrochanteric fractures. By 2040, it is estimated to
increase 500,000.[4]

Pathophysiology
These fractures are usually a result of a ground-level fall in the elderly population and are classified as either stable or
unstable. Determination of stability is important as it helps determine the type of fixation required for stability. Stable
fractures have an intact posteromedial cortex and will resist compressive loads once reduced. Examples of unstable
fractures include: comminution of the posteromedial cortex, a thin lateral wall, displaced lesser trochanter fracture,
subtrochanteric extension and reverse obliquity fractures.  This Evans classification breaks down intertrochanteric
femur fractures based on displacement, number of fragments and the type of fragment displaced. Type I is a 2 part
fracture, Type II are 3 part fractures and Type III are 4 part fractures. The A subclassification in type I fractures is
used for non displaced fractures while B fractures are displaced. In type II fractures, the A subclassification describes
a 3 part fracture with a separate GREATER trochanter fragment while the B subclassification describes a 3 part
fracture with a LESSER trochanter fragment. Type III fractures are 4 part fractures.

History and Physical

These patients typically present with a short and externally rotated lower extremity. Past medical and social history
should be obtained to optimize perioperative management and to prepare for postoperative rehabilitative care. It is
important to evaluate the skin (open versus closed fracture) and the neurovascular status. Evaluation of a range of
motion is typically not possible due to pain. Basic lab studies such as complete blood count, comprehensive metabolic
panel, and coagulation studies should be obtained to recognize abnormalities that may need time to correct prior to
surgical stabilization. Early involvement of an interprofessional team including anesthesia and internal medicine or
geriatrics is ideal to medically optimize surgical candidates for operative repair.

Evaluation
Plain radiographs are the initial films chosen to evaluate for these fractures. The recommended views include the
anteroposterior (AP) pelvis, AP and cross-table lateral of the affected hip and full-length radiographs of the affected
femur. Although the diagnosis can be made without pelvic films, pelvic radiographs are useful to assist in
preoperative planning for restoration of the proper neck-shaft angle. Full-length radiographs of the femur are useful to
assess for deformities of the femur shaft which could affect the placement of an intramedullary nail and evaluation of
prior implants in the distal femur. CT and MRI are typically not indicated but can be used if radiographs are negative,
although the physical exam is consistent with a fracture. MRI is indicated if there is an isolated greater trochanteric
femur fracture and intertrochanteric extension is of concern.  Additionally, a physician-assisted AP traction view of
the injured hip can be helpful in further characterizing fracture morphology and feasibility of closed reduction or need
for open reduction techniques.[5][6]

Treatment / Management
[2]Nonoperative treatment is rarely indicated and should only be considered for non-ambulatory patients and patients
with a high risk of perioperative mortality or those pursuing comfort care measures. The outcomes of this method of
treatment are poor due to an increased risk of pneumonia, urinary tract infection, decubiti, and deep vein thrombosis.
[7][1]

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The type of surgical treatment is based on the fracture pattern and its inherent stability, as the failure rate is highly
correlated with the choice of implant and fracture pattern. Fractures with involvement of the lateral femoral wall are
considered an indication for intramedullary nailing and would not be treated with a sliding hip screw. Unstable
fracture patterns such as fractures with comminution of the posteromedial cortex, a thin lateral wall, displaced lesser
trochanter fractures, subtrochanteric extension of the fracture and reverse obliquity fractures are also indications for
intramedullary nailing. 

Operative management of these fractures is considered urgent, not emergent. This allows the many comorbidities with
which patients often present to be optimized preoperatively, to reduce morbidity and mortality. Most of these fractures
are treated operatively with either a sliding hip screw or intramedullary hip screw, although arthroplasty is a rare
option. Indications for the sliding hip screw include stable fracture patterns with an intact lateral wall. When used for
the appropriate fracture pattern, this treatment affords outcomes similar to intramedullary nailing. The advantages of
the dynamic hip screw are that they allow for dynamic interfragmentary compression and are low cost compared to
intramedullary devices. The main disadvantages include increased blood loss and open technique. Implant failure can
occur due to a lack of integrity of the lateral wall or the placement of the screw, which should be placed at a tip apex
distance of less than 25 millimeters.

Intramedullary nailing can be used to treat a broader range of intertrochanteric fractures, including the more unstable
patterns such as reverse obliquity pattern. One proposed advantage of the intramedullary hip screw is its minimally
invasive approach which minimizes blood loss. Although there are is no data suggesting that an intramedullary hip
screw is more effective than a sliding hip screw in treating stable fracture patterns, it is becoming more and more
commonly used by young surgeons. The choice for short or long intramedullary implants is debatable in these
fractures.

Arthroplasty is typically not indicated as primary management and is reserved for severely comminuted fractures,
patients with a history of degenerative arthritis, salvage of internal fixation, and osteoporotic bone that is unlikely to
hold internal fixation.

Differential Diagnosis
Extracapsular

Intertrochanteric femur fracture

Trochanteric femur fracture

Proximal

Intracapsular

Femoral head fracture

Femoral neck fracture

Shaft

Mid-shaft femur fracture 

Complications
Regardless of treatment choice, there remains a 20% to 30% mortality risk in the first year following fracture, with
males having a higher mortality rate compared to females. In patients who are treated nonoperatively,
cardiopulmonary, thromboembolic events and sepsis are the most common complications seen.[8]

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Operative complications include blood loss anemia, infection, nonunion, and collapse, among others. One of the more
recognized complications of implant-related failure is screw cutout, which is usually caused when the
cephalomedullary screw is placed at a tip apex distance greater than 25 millimeters. If this occurs, a corrective
osteotomy with open revision reduction and internal fixation is usually needed in the young patient, whereas in the
elderly, treatment for this complication is typically conversion to hip arthroplasty. Another recognized
complication with the placement of a long intramedullary device in the elderly population is anterior perforation of
the distal femur cortex.  This is the result of a mismatch of the radius of curvature of the femur and the implant. The
incidence of nonunion is low, less than 2%. 

Postoperative and Rehabilitation Care

The postoperative protocol consists of weight-bearing as tolerated, chemical VTE prophylaxis for up to 6 weeks, and
progressive physical therapy beginning in the immediate postoperative period.[9]

Consultations
A multidisciplinary care team is most effective for the comprehensive treatment of these patients, both pre- and
postoperatively. This includes early involvement of geriatric or internal medicine, anesthesia, orthopedics, and any
other subspecialty service needed, depending on the patient's comorbidities.

Deterrence and Patient Education

Patients should be educated regarding the overall morbidity and mortality of their injury, including the challenges they
will face when returning to pre-injury function. They should be encouraged that active participation in therapy plans
will play a significant role in preventing morbidity and mortality and regaining mobility.

Enhancing Healthcare Team Outcomes

The majority of patients with intertrochanteric fractures present to the emergency room. Besides the triage nurse, the
nurses on the orthopedic floor should be aware of this fracture and its management. Because many of these patients
are initially at bed rest, prophylaxis for deep vein thrombosis is vital.

The main concern of intertrochanteric fractures is the 20% to 30% mortality risk in the first year following fracture,
with males having a higher mortality rate compared to females. If the fracture is not operatively treated within two
days of injury, mortality risk increases. Other factors increasing mortality include age greater than 85 years, two or
more pre-existing medical conditions, ASA classification (ASA III and IV increases mortality).  Early medical
optimization and co-management with medical hospitalists or geriatricians can improve outcomes. The most
predictive factor of functional outcomes following operative treatment is a pre-injury function, age, and dementia.
With stable fracture patterns, more than half of patients will regain pre-injury walking function and pre-fracture level
of activity of daily living function. Unstable fracture patterns tend to have worse outcomes when compared to the
stable fracture patterns, with most patients experiencing a decline in mobility. Immediate postoperative management
is imperative as older adults with these fractures have a five- to eight-time increase in risk for all causes of mortality
during the 90-day postoperative period.[10][11]

Review Questions

Access free multiple choice questions on this topic.

Comment on this article.

References

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1. Karakus O, Ozdemir G, Karaca S, Cetin M, Saygi B. The relationship between the type of unstable intertrochanteric
femur fracture and mobility in the elderly. J Orthop Surg Res. 2018 Aug 22;13(1):207. [PMC free article:
PMC6103983] [PubMed: 30134930]
2. Sharma A, Sethi A, Sharma S. Treatment of stable intertrochanteric fractures of the femur with proximal femoral
nail versus dynamic hip screw: a comparative study. Rev Bras Ortop. 2018 Jul-Aug;53(4):477-481. [PMC free
article: PMC6052185] [PubMed: 30027082]
3. Kani KK, Porrino JA, Mulcahy H, Chew FS. Fragility fractures of the proximal femur: review and update for
radiologists. Skeletal Radiol. 2019 Jan;48(1):29-45. [PubMed: 29959502]
4. Yang Y, Lin X. [Epidemiological features of 877 cases with hip fraction]. Zhonghua Liu Xing Bing Xue Za Zhi.
2014 Apr;35(4):446-8. [PubMed: 25009039]
5. Park JH, Shon HC, Chang JS, Kim CH, Byun SE, Han BR, Kim JW. How can MRI change the treatment strategy
in apparently isolated greater trochanteric fracture? Injury. 2018 Apr;49(4):824-828. [PubMed: 29566988]
6. Gong J, Liu P, Cai M. Imaging Evaluation of the Safe Region for Distal Locking Screw of Proximal Femoral Nail
Anti-Rotation in Patients with Proximal Femoral Fracture. Med Sci Monit. 2017 Feb 08;23:719-724. [PMC free
article: PMC5312236] [PubMed: 28178228]
7. Wang F, Meng C, Cao XB, Chen Q, Xu XF, Chen Q. [Hemiarthroplasty for the treatment of complicated femoral
intertrochanteric fracture in elderly patients]. Zhongguo Gu Shang. 2018 Sep 25;31(9):818-823. [PubMed:
30332874]
8. Cha YH, Lee YK, Koo KH, Wi C, Lee KH. Difference in Mortality Rate by Type of Anticoagulant in Elderly
Patients with Cardiovascular Disease after Hip Fractures. Clin Orthop Surg. 2019 Mar;11(1):15-20. [PMC free
article: PMC6389530] [PubMed: 30838103]
9. Kim CH, Chang JS, Kim JW. Clinical outcomes of dynamic hip screw fixation of intertrochanteric fractures:
comparison with additional anti-rotation screw use. Eur J Orthop Surg Traumatol. 2019 Jul;29(5):1017-1023.
[PubMed: 30847679]
10. Tucker A, Donnelly KJ, Rowan C, McDonald S, Foster AP. Is the Best Plate a Nail? A Review of 3230 Unstable
Intertrochanteric Fractures of the Proximal Femur. J Orthop Trauma. 2018 Feb;32(2):53-60. [PubMed:
29040233]
11. Shin WC, Seo JD, Lee SM, Moon NH, Lee JS, Suh KT. Radiographic Outcomes of Osteosynthesis Using
Proximal Femoral Nail Antirotation (PFNA) System in Intertrochanteric Femoral Fracture: Has PFNA II Solved
All the Problems? Hip Pelvis. 2017 Jun;29(2):104-112. [PMC free article: PMC5465391] [PubMed: 28611961]

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Figures

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Reverse Obliquity Intertrochanteric femur fracture. Contributed by Holly Pilson, MD

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Intra-op and Post-op images of IT femur fracture treated with DHS. Contributed by Holly Pilson, MD

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IT femur fracture with incompetent lateral wall. Contributed by Holly Pilson, MD

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