Intertrochanteric hip fractures with lateral wall fractures should be treated with an intramedullary device as opposed to a sliding hip screw, as the intact lateral wall provides a buttress for the proximal fragment facilitating fracture impaction as well as rotational and varus stability.
Palm et al showed that 22% of patients with a fractured lateral femoral wall underwent reoperation for collapse of fracture compared to 3% with an intact lateral femoral wall. Interestingly, 74% of the lateral proximal femoral wall fractures were iatrogenic during the procedure itself.
Gotfried et al reported on 24 patients with postoperative intertrochanteric hip fracture collapse and noted that this complication followed fracture of the lateral wall in every instance and resulted in protracted period of disability until fracture healing. They recommend care when drilling at the base of the lateral wall intraoperatively.
The referenced article by Lindskog et al reviews the diagnosis, treatment, as well as biomechanical reviews of treatment options for unstable intertrochanteric hip fractures.
Answer 1, 2, and 3: No difference in collapse has been shown between long or short intramedullary device and a sliding hip screw in stable intertrochanteric hip fractures.
Answer 4: Early postoperative weight bearing is the goal after repair, and no differences have been shown in collapse rates with different weight bearing protocols.
Palm H, Jacobsen S, Sonne-Holm S, Gebuhr P; Hip Fracture Study Group. Integrity of the lateral femoral wall in intertrochanteric hip fractures: an important predictor of a reoperation. J Bone Joint Surg Am. 2007 Mar;89(3):470-5.
PMID:17332094 (Link to Abstract)
Gotfried Y. The lateral trochanteric wall: a key element in the reconstruction of unstable pertrochanteric hip fractures. Clin Orthop Relat Res. 2004 Aug;(425):82-6.
PMID:15292791 (Link to Abstract)
Lindskog DM, Baumgaertner MR. Unstable intertrochanteric hip fractures in the elderly. J Am Acad Orthop Surg. 2004 May-Jun;12(3):179-90.
PMID:15161171 (Link to Abstract)