• The incidence of intertrochanteric fractures is
gender- and race-dependent and varies from
country to Country.
• Some of the factors found to be associated with
a patient sustaining an intertrochanteric rather
than a femoral neck fracture include advancing
age, increased number of comorbidities,
increased dependency in activities of daily living,
and a history of other osteoporosis related
Mechanism of Injury
• Intertrochanteric fractures in younger individuals
are usually the result of a high-energy injury, such
as a motor vehicle accident (MVA) or fall from a
• Ninety percent of intertochanteric fractures in
the elderly result from a simple fall. The
tendency to fall increases with patient age and is
exacerbated by several factors, including poor
vision, decreased muscle power, labile blood
pressure, decreased reflexes, vascular disease,
and coexisting musculoskeletal pathology.
According to Cummings (4),four factors contribute to determining
whether a particular fall results in a fracture of the hip
• (a) Fall must be oriented so the person lands
on or near the hip
• (b) protective reflexes must be inadequate to
reduce the energy of the fall below a certain
• (c) local shock absorbers (muscle and fat
around the hip) must be inadequate.
• (d) bone strength at the hip must be
Signs and Symptoms
• The clinical presentation of patients who have
sustained an intertochanteric fracture can vary
widely depending on type, severity, and etiology.
• Displaced fractures are clearly symptomatic, such
patients usually cannot stand, much less
• nondisplaced fractures may be ambulatory and
experience minimal pain, and there are yet
others who complain of thigh or groin pain but
have no history of antecedent trauma.
• The amount of clinical deformity in patients with
an intertrochanteric fracture reflects the degree
of fracture displacement.
• Patients with a nondisplaced fracture may
present with a virtual absence of clinical
deformity, those with a displaced fracture exhibit
the classic presentation of a shortened and
externally rotated extremity. There may be
tenderness to palpation in the area of the greater
trochanter, Range-of-motion testing of the hip is
usually painful and should be avoided.
Older individuals who sustain an intertrochanteric
fracture as a result of a low-energy fall
occasionally have an associated osteoporosis
related fracture, such as a distal radius or
proximal humerus fracture.
• Intertrochanteric fractures in younger individuals
are usually the result of a high-energy injury, such
as a motor vehicle accident or fall from a height.
In these instances, assessment must be made of
possible associated head, neck, chest, and
• X-Rays and Other Imaging
1.(AP) view of the
2.AP and a cross-table
lateral view of the
When a hip fracture is suspected but not
apparent on standard x-rays, a technetium
bone scan or a magnetic resonance imaging
(MRI) scan should be obtained. MRI has been
shown to be at least as accurate as bone
scanning in identification of occult fractures of
the hip, and it will reveal a fracture within 24
hours of injury.
• Type1—two part undisplaced.
• Type2-- two part displaced.
• Type3—three fragment fracture without
posterolateral support (displaced GT Fragment).
• Type 4-- three fragment fracture without medial
support( displaced LT Fragment).
• Type 5—four fragment fracture without
posterolateral and posteromedial support.
• Type 6—reverse oblique fracture.
Orthopaedic Trauma Association (OTA)
Alphanumeric Fracture Classification
• Group 1 fractures are simple (two-part) fractures, with
the typical oblique fracture line extending from the
greater trochanter to the medial cortex; the lateral
cortex of the greater trochanter remains intact.
• Group 2 fractures are comminuted with a postero-
medial fragment; the lateral cortex of the greater
trochanter, however, remains intact. Fractures in this
group are generally unstable, depending on the size of
the medial fragment.
• Group 3 fractures are those in which the fracture line
extends across both the medial and lateral cortices;
this group also includes the reverse obliquity pattern.
CURRENT TREATMENT OPTIONS
• Nonoperative Treatment
• Before the introduction of suitable fixation
devices in the 1960s, treatment for
intertrochanteric fractures was of necessity
nonoperative, consisting of prolonged bedrest
in traction until fracture healing occurred
(usually 10 to 12 weeks), followed by a lengthy
program of ambulation training.
• In elderly patients, this approach was
associated with high complication rates;
typical problems included decubiti, urinary
tract infection, joint contractures, pneumonia,
and thromboembolic complications, resulting
in a high mortality rate. In addition, fracture
healing was generally accompanied by varus
deformity and shortening because of the
inability of traction to effectively counteract
the deforming muscular forces.
• Indications for Nonoperative Treatment
• 1.An elderly person whose medical condition
carries an excessively high risk of mortality
from anesthesia and surgery.
• 2.Nonambulatory patient who has minimal
discomfort following fracture
fixed-angle nail-plate devices
• The first successful implants were fixed-angle
nail-plate devices (e.g., Jewett nail, Holt nail)
consisting of a triflanged nail fixed to a plate
at an angle of 130 to 150 degrees, While these
devices provided stabilization of the femoral
head and neck fragment to the femoral shaft,
they did not allow fracture impaction.
Jewett nail, Holt nail consisting of a tri-flanged nail fixed to a plate at an
angle of 130 to 150◦
sliding nail-plate devices
• The experience with fixed-angle nail-plate
devices indicated the need for a device that
would allow controlled fracture impaction.
This gave rise to sliding nail-plate devices (e.g.,
Massie nail, Ken-Pugh nail),
Massie nail ,Ken-Pugh nail consisting of a nail that provided proximal
fragment fixation and a side plate that allowed the nail to
“telescope” within a barrel allowing bone on bone contact
The sliding nail-plate devices gave rise
to sliding hip screw devices.
• The sliding hip screw is the most
widely used implant for
stabilization of both stable and
fractures. Sliding hip screw side
plate angles are available in 5
degree increments from130 to
150 degrees. The 135 degree
plate is most commonly utilized;
this angle is easier to insert in the
desired central position of the
femoral head and neck than
higher angle devices and creates
less of astress riser in the
• Variations on the sliding hip screw's basic
design include the variable angle hip screw
(VHS) , Talon compression hip screw, greater
trochanteric stabilizing plates, the Medoff
plate, and the percutaneous compression
Talon compression hip screw utilizes a lag screw designed to
resist pull out though the femoral head.
• The Talon compression hip screw system
incorporates a series of four prongs that protrude
from the base of the threads of the lag screw The
prongs are designed to engage the cortical bone
at the inferior aspect of the femoral neck; this
• (a)increases the pull out strength of the lag
screw from the femoral head and neck fragment,
• (b) provides better rotational stability of the
femoral head around the lag screw.
Talon compression hip screw
• A laboratory study
comparing use of the
Talon hip screw system
reported that use of the
prongs increased the
peak compressive forces
generated by Talon device
only when the lag screw
was inserted in the
inferior aspect of the
femoral neck and head
Trochanteric stabilizing plates
• The trochanteric stabilizing plate and the
lateral buttress plate are modular components
that buttress the greater trochanter.These
plates are placed over a four-hole sideplate
and are used to prevent excessive slide (and
resulting deformity) in unstable fracture
patterns. These devices prevent telescoping of
the lag screw within the plate barrel when the
proximal head and neck fragment abuts the
lateral buttress plate.
Can be used for screw fixation of the greate
trochanter or for insertion of an anti-rotation screw
• Clinical studies suggest
that these lateral
support plates are most
useful with unstable
fractures with a
deficient lateral cortical
The Medoff plate- biaxial sliding hip
• It has a standard lag screw component for
compression along the femoral neck. In place
of the standard femoral sideplate, however, it
utilizes a coupled pair of sliding components
that enable the fracture to impact parallel to
the longitudinal axis of the femur.
• A locking set screw may be used to prevent
independent sliding of the lag screw within the
plate barrel; if the locking set screw is applied,
the plate can only slide axially on the femoral
shaft (uniaxial dynamization). If, however, the
surgeon applies the implant without placement
of the locking set screw, sliding may occur along
both the femoral neck and the femoral shaft
(biaxial dynamization). For most intertrochanteric
fractures, biaxial dynamization is suggested.
Two lag screws these two lag
screw components provide
greater rotational stability of
Use of the PCCP was
associated with shorter
operative times, less blood
loss, and need for fewer
number of blood transfusions.
No differences were found
with respect to fracture union
or functional outcomes, a
learning curve exists with
large variations in operative
time compared with a
standard sliding hip screw.
Percutanious compression plate
• When sliding hip screw for stabilsation of I/T
#, there has been dissatisfaction with the
resultant deformity associated with use of this
type of device to stabilize unstable
fracture(subtrochentric and reverse oblique)
patterns. Excessive sliding of the lag screw
within the plate barrel results in limb
shortening and medialization (7 time more
failure rate) of the distal fragment.
Dissatisfaction with use of a sliding hip screw in unstable fracture
patterns led to the development of intramedullary hip screw
• (a) an intramedullary fixation device, because of its
location, theoretically provides more efficient load
transfer than does a sliding hip screw.
• (b) the shorter lever arm of the intramedullary device
can be expected to decrease tensile strain on the
implant, thereby decreasing the risk of implant failure.
• (c) because the intramedullary fixation device
incorporates a sliding hip screw, the advantage of
controlled fracture impaction is maintained,
• shorter operative time and less soft-tissue dissection
than a sliding hip screw.
proximal femoral nail (PFN)
• The PFN nail has been shown to prevent the fractures
of the femoral shaft by having a smaller distal shaft
diameter which reduces stress concentration at the tip.
• Due to its position close to the weight-bearing axis
the stress generated on the intramedullary implants is
• PFN implant also acts as a buttress in preventing the
medialisation of the shaft. The entry portal of the PFN
through the trochanter limits the surgical insult to the
tendinous hip abductor musculature only , unlike those
nails which require entry through the pyriformis fossa
The main principle of this type of fixation is based on
a sliding screw in the femoral neck-head fragment,
attached to an intramedullary naiL