Intertrochanteric Hip Fractures

Introduction

Fractures of the hip have long been held as an injury that is largely a result of altered bone metabolism, which can significantly affect the life of a patient with regard to mortality and function. The recognition of the importance of expeditious and safe care of elderly patients with an intertrochanteric femur fracture is apparent, and the development of geriatric co-management programs has successfully improved patient care while decreasing cost.

These fractures occur in both young patients with high-energy injuries and in patients with osteoporosis. The goals of successful treatment of these groups of patients are somewhat divergent but include the restoration of bony architecture, pain control, and eventual union. How this is achieved is often quite different for these patients, and as middle-aged patients continue to evolve as more active patients, the demographic intersection of these two groups becomes more difficult to delineate and demands that the treating orthopaedist be well versed in all facets of care of the patient with an intertrochanteric femur fracture.

The goals of surgical treatment for any fracture include the maintenance of overall length and alignment and the restoration of bony contact to maximize the ability for mobilization and weight bearing. Multiple factors are responsible for the reduction and fixation that a surgeon can achieve. Patient-directed factors include prefracture comorbidities, bone quality, concurrent injuries, and social support. The surgeon-specific variables include fracture reduction, implant selection, and position of the implant within the bone. Many of these can be modulated more successfully now than ever before, and careful attention must be paid to each aspect of the care of a patient with this fracture.

The intertrochanteric region of the femur is defined as the region from the extracapsular femoral neck to the area just distal to the lesser trochanter. This chapter describes the evaluation and treatment of both high- and low-energy intertrochanteric hip fractures.

Key Points: Anatomy, Diagnosis, and Classification

The surgeon has to be familiar with the bony and ligamentous architecture of the hip because this is the key point in reconstruction.
For proper planning, the plain radiography should be taken as a low anterior-posterior (AP) pelvis and with internal rotation and gentle traction of the legs.
There are many classification systems; however, in the end, all systems differentiate between stable and unstable fractures because this allows a recommendation for treatment.

Incidence and Epidemiology

The incidence of hip fractures worldwide is estimated at 1.6 million. In 2010, there were 258,000 hospital admissions for hip fractures in people age 65 years and older in the United States, according to the National Hospital Discharge Summary. This number decreased from 1996 to 2010, potentially because of the increased awareness and treatment of osteoporosis, but the incidence is still expected to rise by 12% from 2010 to 2030, therefore resulting in 289,000 annually. This does not account for patients younger than the age of 65 years or those with a high-energy fracture.

It has been estimated that 75% of all hip fractures occur in women and that one-third of all women reaching age 90 years will have sustained at least one hip fracture. Intertrochanteric femur fractures occur more often in older patients than femoral neck fractures. These patients also have a considerably poorer preinjury level of function, with many more comorbidities.

In 1984 Zain Elabdien and colleagues reported the inverse relationship between advancing age and bone quantity and linked that to the direct relationship between bone quality and fracture severity. In recent years, this is only compounded by the current multitude of medications and comorbidities that decrease bone quality, including hemodialysis, immunosuppression, and antiepileptic medications. The end result of this constellation of medical issues is an extremely complex surgical problem in an extremely complex patient.

The cost of caring for patients with hip fractures is rising dramatically. Estimates are that in 2030, the United States will spend $12.9 billion on hip fracture care. The care must not stop at the level of the initial operative care, however. Pike and colleagues demonstrated that the cost of a subsequent fracture in a Medicare patient after a nonvertebral fragility fracture is estimated at $31,904 annually versus $19,377 for those patients who incur no further fractures. Intervention to keep patients from sustaining a second fracture is critical for both their overall quality of life and for the improvement in healthcare quality.

Advancing the science of fall prevention remains a critical component of decreasing hip fractures. Low-energy falls continue to be associated with intertrochanteric fractures. These types of falls increase with advancing age for many reasons. Declines in visual and auditory acuity, changes in environment, sedating and disorienting medications, and other musculoskeletal limitations all lead to falls. This fall risk is markedly increased by cognitive decline. It is estimated that in the United States, 5.4 million people older than the age of 71 years have cognitive impairment without dementia. This overlooked population, combined with patients who suffer from dementia, leads to an extremely large cohort of patients who are at increased risk of falling. Those with cognitive deficiency have a 60% increased risk of falling compared with their age-matched control participants. Cummings and Nevitt suggested that four factors must be met to cause a hip fracture: an impact mechanism that directs the force at the trochanter, a decline in protective reflexes, decreased soft tissues about the hip, and diminished bone strength. These factors have not changed dramatically, and interventions aimed at fall prevention, including exercise interventions, home modifications, and vitamin D supplementation, along with medical management of osteoporosis, are critical.

The higher-energy fracture in the intertrochanteric region of the bone is an underappreciated fracture that is frequently extremely difficult to treat. This often occurs in younger patients with excellent bone quality. The mechanism is typically one that lends itself to extreme soft tissue disruption and often leads to a highly displaced fracture that might be a simple fracture pattern or an extremely complex one. Challenges associated with these high-energy fractures include obtaining and maintaining fracture reduction, preventing limb shortening, and achieving union. Historically, these fractures were treated with plate osteosynthesis because this would be facilitated by the open reduction techniques often required for reduction, which is in direct contrast to treatment modalities of osteoporotic fractures. This is not the only difference in these fracture patterns or the patients who present with them. These patterns usually require the management of a multitude of other injuries and the development of a surgical plan that appreciates the tenets of fracture fixation and bony healing.

Anatomy of the Intertrochanteric Region

Bony Anatomy

The intertrochanteric region of the proximal femur is extracapsular. It is distal to the basicervical femoral neck and proximal to the subtrochanteric region. To adequately understand the fixation of this region, the relationship of the femoral neck to the diaphysis must be appreciated because this is the connection between the two. The neck-shaft angle of a normal adult ranges from 120 to 135 degrees. As patients grow older, this angle decreases (increasingly varus neck-shaft angulation). The transverse plane alignment of the femoral neck to the shaft is 10 to 15 degrees of anteversion relative to the femoral condyles. In 1838 the trabeculae of the femoral neck were first described as both compressive and tensile. The primary compressive trabeculae are found along the region of the bone known as the calcar, and this dense bone provides excellent support for the proximal femur when intact ( Fig. 55.1 ). The primary tensile trabeculae fan out across the proximal femur nearly perpendicular to the axis of the diaphysis toward the lateral cortex. The secondary compressive trabeculae cross these from the greater trochanter to the lesser trochanter and comprise the calcar. The lack of continuity along the medial aspect of the proximal femur at the junction of these compressive trabeculae has led to the inclusion of fractures in this region as unstable intertrochanteric femur fractures and might change the implant selection based on the degree of acceptable shortening for an individual patient.

Fig. 55.1, Diagram of an anterior-posterior radiographic projection of a normal hip. Note the five trabecular groups and Ward's triangle (W).

Muscular and Neurovascular Anatomy

The complex muscular attachments of the proximal femur not only contribute to the dissipation of forces about the hip against impact but also result in significant displacement of unstable fracture patterns of the proximal femur once the bony constraint is disrupted. The typical deformity associated with intertrochanteric femur fractures is that of external rotation, abduction, and flexion of the proximal segment. The muscular forces about the hip create a foreshortening and an overall varus angulation of the proximal femur. As a patient loses continuity of the lower extremity to the proximal femur, the limb continues to externally rotate until the lateral aspect of the foot rests on the bed, preventing further external rotation. This leads to fracture stabilization and improved pain as a result. The external rotator muscles that insert on the proximal femur come from various origins, including the outer ilium and intrapelvic origin. These include the gluteus maximus, piriformis, superior and inferior gemelli, obturator externus and obturator internus, and quadratus femoris. Depending on the location of the fracture, these contribute to varying degrees of fracture displacement and the inability to attain a reduction.

The muscular attachments of the proximal femur include the abductors of the hip at the greater trochanter, the gluteus medius, the gluteus minimus, and the tensor fasciae latae. The medius and minimus attach to the greater trochanter directly, and the tensor fasciae latae originates from the outer table of the ilium anterior to the medius tubercle and inserts into the iliotibial band lateral to the trochanter. They abduct the proximal segment if the greater trochanter is intact or retract the greater trochanter if it is an independent fragment.

The hip joint adductors include adductor longus, adductor brevis, adductor magnus, gracilis, and pectineus. These originate on the ischial or pubic rami and insert on the proximal femoral diaphysis distal to the fracture zone, except for the pectineus, which inserts on the pectineal line of the femur. The adductor moment accentuates the varus deformity of the proximal femur, along with shortening and external rotation. Adductor contracture of the contralateral limb may prevent adequate positioning of the limb to allow for imaging of the proximal femur on the affected side.

Flexion of the proximal segment of the femur is facilitated by the iliopsoas, pectineus, sartorius, and rectus femoris. The primary contributor here is the iliopsoas, which inserts on the proximal femur at the lesser trochanter, a relatively posteromedial structure. This can contribute to flexion deformities of the intact proximal segment or aid in avulsion and destabilization of the posteromedial cortex.

Extension of the proximal femur is secondary to the hamstrings and gluteus maximus. This may lead to foreshortening of the limb and may rigidly hold the diaphysis posteriorly during fracture reduction. This can be severely limiting during reduction of high-energy fractures.

The capsuloligamentous anatomy of the proximal femur can also significantly affect the ability to attain reduction of a proximal femur fracture. The iliofemoral, pubofemoral, and ischiofemoral ligaments blend with the capsule to provide strong connections from the acetabular margin to the base of the femoral neck. Disruption of these attachments is rare, but one may need to identify and reflect the insertions in a proximal intertrochanteric fracture.

The vascular supply of the proximal femur is contributed by the extensive muscular attachments of the proximal femoral metaphyseal bone in the intertrochanteric region. It is therefore uncommon to go on to nonunion. The profunda femoris runs in close proximity to the bone below the lesser trochanter and can be at risk for injury because of screw penetration.

The critical components of neurologic anatomy about the proximal femur include the sciatic nerve that exits the pelvis through the greater sciatic notch and passes anterior to the piriformis and posterior to the remaining short external rotators in the posterior thigh. The lateral femoral cutaneous nerve of the thigh is found in the sheath of the sartorius and is unlikely to be injured during surgery for an intertrochanteric femur fracture. The femoral nerve should also be well medial to the exposure. Not uncommonly, the distribution of the femoral and lateral cutaneous nerve of the thigh is utilized for regional anesthesia in the control of perioperative pain.

Diagnosis

Radiographic Assessment

Radiographic evaluation of a proximal femur fracture should include both an adequate anterior-posterior (AP) image and a cross-table lateral projection of the hip. The goals of the radiographs are to allow for an adequate understanding of the proximal femoral anatomy bilaterally, so a low AP pelvis radiograph in addition to a dedicated AP of the affected hip is helpful. Ideally, the AP images are attained with the affected extremity internally rotated with gentle traction to most accurately neutralize the deforming forces and account for the anteversion of the unaffected hip ( Fig. 55.2 ). In addition, the entire femur should be imaged. Many of the affected patients may not be adequate historians to inform the surgical team of prior surgeries or potential for malignancy that might change a surgical plan. From a fracture anatomy standpoint, an adequate AP will demonstrate the fracture obliquity, the status of the greater trochanter, and any presence of femoral neck involvement, which is quite common in reverse obliquity types of fractures. The lateral radiograph will help to identify any posterior fragmentation and often will help delineate the size of the posteromedial cortex associated with the lesser trochanter if unstable. This should be performed as a cross-table lateral as opposed to a frog-leg lateral for patient comfort and for the most adequate image to allow for planning. Positioning of the patient may very well prove rate limiting in achieving adequate imaging due to pain. An alternative that can help to delineate the anatomy of an intertrochanteric femur fracture is an obturator oblique radiograph. The success of this image in re-creating the anatomy of the proximal femur is that it functions as an internal rotation view of an externally rotated femur and typically causes less pain.

$Fig. 55.2, (A) Injury radiograph showing an apparently stable intertrochanteric fracture. (B) Traction radiograph showing a transverse fracture, an unstable pattern. (C) Because of the unstable fracture pattern noted on the traction radiograph, the fracture was fixed with an intramedullary device instead of a side plate and screw construct.$

Computed Tomography or Magnetic Resonance Imaging for Negative Radiographs

Since the mid-1980s, there has been intermittent literature regarding the diagnosis of a fracture of the proximal femur not demonstrated on plain radiographs. The widespread availability of magnetic resonance imaging (MRI) led to increased utilization to diagnose fracture in the 1990s, but with the increasing availability of computed tomography (CT) scanning, this has become the modality of choice in many emergency departments. Recently, guidelines from the American College of Radiologists (ACR) were released when the ACR Appropriateness Criteria for the diagnosis of suspected hip fracture were published. Multiple studies have looked at both CT and MRI separately as diagnostic modalities, but only since 2005 have they been compared head to head. In 2008 Cabarrus and colleagues looked at 129 patients with an average age of 65 years who underwent both CT and MRI for pelvic and proximal femoral insufficiency fractures. The sensitivity of MRI was 99%, and the sensitivity of CT was 69% overall. For proximal femur alone, MRI sensitivity was 90%, and CT sensitivity was 70%. The utility of bone scanning has been challenged, and given the effectiveness of MRI, the role of this has been relegated to those who cannot undergo MRI. The overall sensitivity is akin to that of MRI, but a delay in patient care is evident, and it is less cost-effective than plain radiography or CT. These data have led the current recommendations to be plain film radiography followed by MRI in patients older than the age of 50 years. In younger patients, there have been little data to support these studies because these patients typically have high-energy fractures in which CT scanning is probably more helpful for preoperative planning.

Classification of Intertrochanteric Femur Fractures

The ideal fracture classification system should be easy to apply and communicate, guide treatment, predict outcome, be reproducible among different observers, and be consistent with a generalized classification scheme for all skeletal injuries. Unfortunately, no such system yet exists for intertrochanteric fractures. In fact, the classification scheme continues to be expanded by multiple authors in an attempt to provide adequate descriptions of fractures that require different classification.

Evans Classification

In 1949 Evans published a classification system based on the general direction of the fracture line and the ability to obtain and maintain a reduction with closed manipulation and skeletal traction. He emphasized the importance of reestablishing posteromedial contact in achieving a stable reduction. The Evans classification was modified by Jensen and Michaelsen in 1975. Their version describes decreasing stability as the number of associated lesser and greater trochanteric fractures increases. Type IA (nondisplaced) and type IB (displaced) fractures are simple two-part fractures. Type I fractures were considered stable because they could be reduced into anatomic position (no fracture gap >4 mm in either plane) in 94% of patients and, after adequate fixation, were followed by loss of position in only 9% of patients ( Fig. 55.3 ). The type IIA fracture pattern is a three-part fracture with a separate greater trochanteric fragment. Jensen and Michaelsen believed that these fractures tended to “sag” with reduction maneuvers, leaving the fracture malpositioned in the sagittal plane. Type IIB fractures are three-part fractures involving the lesser trochanter. Type IIB fractures could be anatomically reduced in only 21% of all patients, with displacement occurring in 61%. The problem primarily resulted from an inability to reduce and reestablish the medial cortical buttress ( Fig. 55.4 ). The type III pattern is a four-part fracture. Only 8% of these very comminuted fractures could be reduced, and displacement occurred later in 78%.

$Fig. 55.3, (A) Diagrams of a nondisplaced and displaced, stable, two-part intertrochanteric fracture (Evans-Jensen type I; AO/OTA 31-A1.1). The radiograph depicts a typical two-part fracture (AO/OTA 31-A1.1). (B) Diagram and anterior-posterior (AP) radiograph of an unstable three-part fracture (Evans-Jensen type IIB, AO/OTA 31-A2.1). (C) Diagram and AP radiograph of unstable four-part fracture (Evans-Jensen type III, AO/OTA 31-A2.2).$

$Fig. 55.4, Three-part fracture involving the greater trochanter (Evans-Jensen type IIA) with unsatisfactory reduction of translation as seen on a lateral radiograph after fixation with sliding screw and side plate.$

AO/OTA Classification

In The Comprehensive Classification of Fractures of the Long Bones, Müller and colleagues coded proximal hip fractures as part of an attempt to offer a uniform alphanumeric fracture classification that incorporates prognosis and suggests treatment for the entire skeleton. In this system, advocated by the Arbeitsgemeinschaft für Osteosynthesefragen/American Society for Internal Fixation (AO/ASIF) and also adopted by the Orthopaedic Trauma Association (OTA), type 31A fractures involve the trochanteric area of the proximal femur. These fractures are divided into three groups, and each group is further divided into three subgroups. Group 1 fractures are simple (two-part) fractures. The subgrouping defines the geometry of the fracture line. All group 1 fractures are inherently stable (i.e., they almost never displace after adequate reduction and internal fixation). Group 2 fractures are multifragmentary. The fracture line begins anywhere on the greater trochanter and extends medially in two or more places. This creates at least a third fracture fragment that can comminute the greater trochanter or isolate the lesser trochanter (or both). With the exception of a trivial lesser trochanteric fragment, fractures in this group are unstable. The subgrouping for group 2 fractures defines the number and geometry of the fragments. Group 3 fractures are by definition those with the lateral fracture line located beneath the vastus ridge of the greater trochanter, involving the shaft of the proximal femur; the subgroups describe fracture direction and comminution ( Fig. 55.5 ). Clearly identifying fractures with lateral cortical disruption in their own group is an advantage of this classification system because these fractures generally require different management strategies than fractures classified into the other groups. Although there has been shown to be only fair interobserver reliability at the subgroup level of the AO/OTA classification system even for experienced orthopaedic trauma surgeons, the reliability of this system at the group level is excellent. Additionally, despite its complexities, when compared with other classification systems (Evans, Kyle, and Boyd), the AO/OTA system has been shown to be more reliable among surgeons at both the group and subgroup levels. Its alphanumeric and standardized format make the system useful, particularly for research and documentation.

$Fig. 55.5, The comprehensive long bone classification of peritrochanteric femur fractures. To accurately classify the fracture subgroups, the full text should be consulted.$

The reader should realize that the common bond among all the classification systems is the concept of stability. A stable fracture is one in which the posteromedial cortex is fractured in only one place and can, after anatomic reduction and fixation, withstand compressive loads without redisplacement ( Fig. 55.6 ). A fracture is considered unstable when, owing to a large posteromedial fragment, multiple fragments, or a reverse oblique fracture line, despite realignment and appropriate fixation, it remains incompetent, and the fracture tends to collapse on axial loading. This intuitive, simple, and reproducible description of stable versus unstable helps guide treatment and suggest a prognosis. A majority of clinicians, and some respected researchers, prefer this binary description.

$Fig. 55.6, (A) Unstable type III fracture (AO/OTA 31-A2.2). (B) Anatomically aligned and fixed with a sliding hip screw. (C) Follow-up at 6 months shows impaction at the site of the fracture and backing out of the screw through the barrel. Alignment has been maintained, and the fracture has healed.$

Although limitations in the reliability and reproducibility of the historic classification systems have led to the use of this binary fracture description system (stable vs. unstable), more recent data question the use of the posteromedial fracture fragment as the benchmark of fracture stability. It has been suggested that it is the integrity of the lateral trochanteric wall after the fracture reduction that ultimately determines fracture stability and patient prognosis. The lateral cortex provides a buttress to fracture impaction after fixation, leading to fracture stability and avoidance of excessive collapse. The importance of the lateral trochanteric wall was emphasized by the findings of Im and colleagues in their review of so-called stable, low-energy intertrochanteric fractures. In their series, all patients who went on to fracture collapse and loss of reduction were found to have a fracture of the lateral cortex after surgical fixation. They found lateral cortical fracture and patient age to be predictors of fracture collapse despite a stable fracture pattern with a single posteromedial cortical fracture line. In reality, it is likely a combination of the posteromedial and lateral trochanteric cortex that is important in fracture stability because modern fixation devices allow fracture impaction in both a lateral and an axial direction. The treating physician must recognize the potential for excessive fracture displacement with axial loading in both of these directions and adjust treatment accordingly.

Assessment of the Patient

With the advent of multidisciplinary care of the fragility fracture patient, there have been sweeping advancements in medical management. Chapter 53 outlines the medical co-management guidelines that have been developed. An adequate history is often quite difficult to ascertain from the patient with many medical comorbidities. With this in mind, the best history is one taken from multiple sources that includes the patient, family members or caregivers, medical records, and primary care physicians. Critical to this understanding is the timing of the hip pain. Orthopaedic consultation is often attained after the diagnosis of hip fracture; therefore a careful interrogation of the patient to assess for comorbid injuries is critical. The incidence of other fractures and other injuries, including intracranial hemorrhage, rib fracture, pulmonary contusion, and intra-abdominal injuries, is unknown, and careful clinical evaluation and suspicion must be high given the relatively small reserve that these patients often have. Young patients with high-energy fractures often have other injuries that need to be evaluated and treated by the general surgery trauma team. However, in elderly patients with low-energy fractures, assessment of prefracture ambulatory status, social situation, and resources is critical to minimize hospitalization and the potential for medical complications.

The physical examination of a patient with an intertrochanteric femur fracture is classically described as a patient with a markedly externally rotated lower extremity. This is present for a patient with a displaced fracture, but in the occult fracture, the examination might be much less remarkable. Typically, however, motion of the affected extremity will elicit pain at the fracture site regardless of the displacement of the fracture. Some tests that should direct attention to the hip include a logroll in which the fully extended leg is internally and externally rotated on the hospital bed, which should reproduce pain in the acutely fractured patient. The lack of ability to straight leg raise and pain with heel strike also are indicative.

Examination of the contralateral extremity is also critical. The presence of an amputation on either side, skin ulcerations, postpolio syndrome, previous surgery (e.g., total hip arthroplasty), contractures of adductors or hip flexors, or prior injuries can limit positioning during surgery. A preexisting limb-length discrepancy might also be important to consider when treatment choices are selected because there will be expected loss of length that might be untenable to a patient with this problem.

Management

After the diagnosis of an intertrochanteric femur fracture has been made, the decision for nonoperative versus operative management must be made. Once discussions on the goals of care have decided on operative treatment, the focus should be on early mobilization, pain control, restoration of limb alignment, and minimization of medical risks. In young patients with high-energy fractures, the time to surgery is less critical than anatomic reconstruction for a patient. The decision-making pathway often coincides with the patient's comorbid injuries. In patients of advanced age whose mechanism is low energy and probably related to osteoporosis, the time to surgery is critical, along with the medical co-management.

Historical comparisons of operative versus nonoperative care for elderly patients with displaced fractures have suggested an improved outcome with operative intervention. However, in selected patients, there can be adequate outcomes with nonoperative care. This form of treatment requires highly skilled nursing care to prevent decubiti, pneumonia, and thromboembolic events and to provide adequate pain control.

In the early 1970s, a revolution in the care of elderly patients with intertrochanteric femur fractures came about when the sliding hip screw construct was developed. The sliding screw device has gone through multiple developmental changes, with the most current advances including the intramedullary device with a sliding screw. These developments and improvements in care for some fractures will be discussed. The evolution of these devices has proven to be a vast improvement over the fixed-length predecessors, which did not allow for postoperative compression at the fracture site. As a result, these devices would often fail before bony healing. Current devices can control bending and rotational forces during mobilization and therefore enhance bony contact and compression, encouraging bony union.

Nonoperative Management

There are numerous relative indications for the nonoperative care of intertrochanteric femur fractures. These include patients who are nonambulators; patients who have advanced dementia, current sepsis, skin breakdown at the surgical site, or incomplete fractures; hospice patients; and minimally symptomatic patients. In 1977 Lyon and Nevins proposed that nonoperative care in patients who had little chance to ever walk again was the more humane and less expensive modality for treatment. This concept has continued to develop within palliative care and hospice medicine and to a lesser extent among orthopaedic surgeons. In a recent review of all Medicare beneficiaries in hospice care older than the age of 75 years who sustained a hip fracture, Leland and colleagues found an overall improved survival in patients undergoing surgery. This study included 14,400 patients between 1999 and 2007. A total of 83.4% of these patients underwent surgery, and the median survival time from the time of hospitalization was 25.9 days for those patients treated nonoperatively and 117 days for those who underwent surgery. Although the study is observational, it does not preclude operative management for hospice patients. The orthopaedic surgeon must be an integral part of the decision making, along with the palliative care and medical teams. The choice of nonoperative care can be considered inhumane if inadequate nursing care is available for the patient.

Nonoperative care falls into two basic categories. The first is one of benign neglect in which the patient is probably a prefracture nonambulator who needs pain control and the long-term outcome of the fracture is completely unrelated to the bony architecture and relies solely on pain control and prevention of medical complications. These patients should be treated on specialty mattresses by dedicated orthopaedic rehabilitation nurses who are capable of mobilization of a patient who is in pain until this improves and the patient is able to resume prefracture care. The second cohort consists of patients in whom surgery would be indicated for an improved bony outcome but is precluded by a contraindication. These patients might be treated in skeletal traction through the distal femur or proximal tibia at 15% of the patient's body weight in balanced suspension. Aggressive physical therapy should be undertaken to maximize patient outcome.

Key Points: Management of Intertrochanteric Hip Fractures

Today, the nonoperative treatment of intertrochanteric fractures should be an exception for palliative care patients.
The overarching goal is the restoration of alignment of the major components of each fracture and internal fixation that allows for early mobilization and weight bearing with adequate pain control.
Most young patients have sustained a high-energy trauma. In this cohort, the dynamic compression implants of the older patients are often inappropriate because the resulting shortening is devastating for this group.
For the elderly, the overarching goal is the same as in the young. Timing is of the essence; the delay should only be dictated by correctable medical conditions.
An intact lateral wall is important for the later outcome, and the surgeon should be aware of this problem.
In unstable fracture patterns, an intramedullary device should be used.
An adequate reduction is the key point in treating these fractures.
Never stabilize a malreduced fracture! There is no implant that will improve the fracture position.
The guide pin should always be able to be placed deep and central on all views; this decreases the tip apex distance.
Because of the clockwise insertion of a lag screw, the fracture can be displaced, especially in the left hip. A slight turn backward often reconstitutes the reduction.
In the case of lateral wall fracture, an intramedullary device or a trochanteric stabilization plate should be considered.
For reverse oblique fractures, an intramedullary device is recommended.
In case of a greater trochanter fracture, further evaluation with CT or MRI should be done before stabilization.
The goal of surgery should be a stable situation for immediate mobilization.
The biomechanical forces to the hip of bed activities for nursing are somewhat higher than full weight bearing as tolerated.

Operative Management

The goals of the management of intertrochanteric femur fractures are quite different for young and elderly patients. The overarching goal is the restoration of alignment of the major components of each fracture and internal fixation that allows for early mobilization and weight bearing with adequate pain control.

High-Energy Fractures

The incidence of high-energy intertrochanteric femur fractures is unknown. The young patient typically has adequate bone stock but often has fractured the femoral neck or shaft, therefore influencing the surgical approach. The goals of treatment include anatomic reconstruction and avoidance of excessive shortening that, although well tolerated in an aged adult, can lead to long-term complications in a young patient. These fractures are commonly two-part fractures with minimal comminution that can be severely displaced, with resultant soft tissue stripping or interposition. They often require open reduction with additional soft tissues stripping. Implant options include blade plate fixation, sliding hip screw and side plate, sliding hip screw intramedullary devices, proximal femoral locking plates, and reconstruction intramedullary nail fixation. Concerns over blood loss and increased operative time have been examined in the literature, but no head-to-head comparison of these fixation strategies has been performed.

Complications often encountered after fixation of a high-energy intertrochanteric femur fracture in a young patient include delayed union, nonunion, malunion, avascular necrosis, need for reoperation, and loss of range of motion. Utilization of provisional reduction aids and compression at the fracture can aid in the avoidance of both early and late complications. The use of intramedullary fixation is favored over plate and screw fixation by many surgeons but can be more challenging if the goal is to avoid open reduction. In addition, the use of implants that are typically reserved for intertrochanteric femur fractures in elderly patients can be deleterious to young patients because they allow for significant dynamic compression that can result in loss of limb length . If the surgeon prefers such an implant, achieving significant bony contact at the time of the index surgery is critical to avoid excessive impaction at the fracture site, with resultant limb foreshortening. In addition, a comparison of the rotation of the contralateral extremity can be quite difficult, and it can be helpful to have both extremities in the surgical field for direct comparison after provisional fixation is achieved. Length can often be achieved through intraoperative distal femoral skeletal or manual traction. Anesthetic motor paralysis is critical in these often-muscular patients.

Fragility Intertrochanteric Fractures

The preponderance of intertrochanteric femur fractures occurs in adults older than the age of 60 years, and the primary age group that most orthopaedic surgeons will be involved with is older than the age of 75 years. Many features of the care of these patients are critical to the outcome. The preceding chapter on medical co-management outlines many of the salient features of a co-management system.

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