Summary Intertrochanteric Fractures are common extracapsular fractures of the proximal femur at the level of the greater and lesser trochanter that are most commonly seen following ground-level falls in the elderly population. Diagnosis is made with orthogonal radiographs of the hip. MRI is most helpful to evaluate occult hip fractures. Treatment is generally operative with sliding hip screw versus cephalomedullary nail depending on fracture stability. Epidemiology Incidence account for ~50% of hip fractures 150,000 intertrochanteric fractures per year in US 500 per 100,000 population per year for elderly female 200 per 100,000 population per year for elderly male Demographics age average ~80 years old login to view 1 more bullet female: male ratio between 2:1 and 8:1 Risk factors proximal humerus fractures increase risk of hip fracture for 1 year osteoporosis advancing age increased number of comorbidities increased dependency with ADLs Etiology Pathophysiology mechanism elderly login to view 1 more bullet young login to view 1 more bullet Associated conditions osteoporosis recurrent falls dementia parkinsons unsteady gait visual impairment medications Anatomy Osteology neck shaft angle 130 +/- 7 degrees anteversion 10 +/- 7 degrees intertrochanteric area exists between greater and lesser trochanters calcar femorale vertical wall of dense bone that extends from posteromedial aspect of femoral shaft to posterior portion of femoral neck level of involvement helps determine stable versus unstable fracture patterns radius of curvature of femur average 114-120 cm factors that decrease radius of curvature (increased bowing) login to view 3 more bullets Muscles deforming forces on proximal segment flexion login to view 4 more bullets external rotation login to view 5 more bullets abduction login to view 4 more bullets deforming forces on distal segment adduction and shortening login to view 4 more bullets overall varus alignment Blood supply rich collateral circulation reduces risk of nonunion trochanteric anastomosis login to view 4 more bullets transverse branch of LFCA and MFCA periosteum and surrounding muscles Biomechanics Ward's triangle area of lowest BMD in femoral neck bordered by 3 main compressive/tensile trabeculae login to view 8 more bullets Classification Stability most commonly used and reliable classification two types stable login to view 4 more bullets unstable login to view 14 more bullets AO/OTA Classification 31A -A1 peritrochanteric simple two part intact lateral cortex 31A-A2 pertrochanteric with separate posteromedial fragment intact lateral cortex 31A-A3 fracture extends through lateral and medial cortex Evans classification (based on post-reduction stability) Stable fracture posteromedial cortex intact or minimal comminution able to resist compressive loads Unstable fracture greater comminution of posteromedial cortex can be converted to a stable pattern if medial cortical opposition obtained Reverse obliquity unstable due to medial displacement of femoral shaft due to adductors Presentation History mechanism of injury low-energy most common in elderly higher-energy may be associated with other injuries pre-injury functional status predictor of postoperative functional status antecedent hip pain presence of OA or pathological fracture history of anticoagulation factors into surgical timing list of comorbidites (ASA classification) Symptoms acute onset of hip pain inability to ambulate Physical Exam inspection shortened, externally rotated lower extremity palpation tenderness over greater trochanter motion pain with log roll and axial load unable to perform active straight leg raise assess thigh compartments neurovascular assessment Imaging Radiographs recommended views AP pelvis AP hip cross table lateral full length femur optional traction internal-rotation view login to view 1 more bullet findings AP pelvis login to view 1 more bullet AP hip login to view 1 more bullet cross-table lateral login to view 1 more bullet full length femur login to view 5 more bullets CT indication second line imaging to evaluate for occult fracture login to view 1 more bullet views thin, 1-2 mm slice cuts diagnostic accuracy sensitivity 86% specificity 98% MRI indication occult hip fracture login to view 1 more bullet isolated greater trochanteric fracture to evaluate for intertrochanteric extension findings bone marrow edema STIR or fat-suppressed T2 line of decreased intensity on T1 coronal view corresponding with signal on T2 and STIR diagnostic accuracy sensitivity login to view 2 more bullets Bone scan indication contraindication to MRI login to view 4 more bullets diagnosis accuracy variable with sensitivity up to 98% Treatment Nonoperative protected weight bearing indications login to view 4 more bullets techniques login to view 1 more bullet outcomes login to view 4 more bullets Operative closed reduction and intramedullary nail fixation (IMN) indications login to view 12 more bullets technique login to view 3 more bullets outcomes login to view 5 more bullets open reduction and internal fixation (ORIF) indications login to view 2 more bullets techniques login to view 3 more bullets outcomes login to view 1 more bullet arthroplasty indications (rare) login to view 4 more bullets Techniques Closed reduction with intramedullary fixation (IMN) indications pros vs. ORIF login to view 6 more bullets cons vs. ORIF login to view 3 more bullets approach supine on fracture table lateral decubitus on radiolucent table technique short vs long CMN login to view 20 more bullets lag screw versus helical blade login to view 8 more bullets complication lag screw or helical blade cutout login to view 3 more bullets anterior perforation of femur perimplant fracture Open reduction and internal fixation (ORIF) techniques sliding hip compression screw login to view 17 more bullets proximal femoral locking plate login to view 12 more bullets Arthroplasty technique long stem with calcar-replacing prosthesis often needed must attempt fixation of greater trochanter to shaft pros possible early return to unrestricted weight bearing not reliant on internal fixation in osteoporotic bone cons increased blood loss and OR time increased cost may require prosthesis that some surgeons are less familiar with Complications Implant failure and cutout incidence occurs in 4-20% usually occurs within first 4 months risk factors older age osteoporosis fracture type quality of reduction tip-apex distance (TAD) login to view 4 more bullets treatment young login to view 1 more bullet elderly or articular injury from screw cutout login to view 1 more bullet Nonunion and malunion incidence <2% login to view 1 more bullet varus malreduction can occur with excessively lateral starting point (>3mm) login to view 1 more bullet diagnosis hip pain with persistent radiolucent defect at fracture site 4-7 months after surgery CT scan may help confirm diagnosis rule out infection treatment valgus intertrochanteric osteotomy + bone grafting arthroplasty login to view 1 more bullet Peri-implant fracture incidence 1-3% at 1 year no significant difference between short and long CMN short CMN typically fracture just distal to tip of nail long CMN typically fracture more around the rod (as opposed to the tip) risk factors distal interlocking screw protective against fracture treatment short CMN login to view 2 more bullets long CMN login to view 2 more bullets Anterior perforation of the distal femur incidence mostly seen with insertion of long CMN decreased with improvements in nail radius of curvature to better match patient anatomy risk factors mismatch of the radius of curvature of the femur (shorter) and implant (longer) posterior starting point on the greater trochanter Postoperative anemia and transfusions blood transfusion >30% postoperative transfusion rate AAOS moderate recommendation login to view 1 more bullet transexamic acid (TXA) AAOS strong recommendation for use decrease EBL decrease postoperative blood transfusion Prognosis General considerations Anesthesia type (spinal vs. general) No difference in postoperative delirium, mortality and ambulatory function at 60 days Mortality 15-30% mortality risk in the first year following fracture 84.4% at one year with nonoperative treatment Factors that increase mortality male gender (25-30% mortality) vs female (20% mortality) higher in intertrochanteric fracture (vs femoral neck fracture) operative delay of >2 days age >85 years 2 or more pre-existing medical conditions ASA classification (ASA III and IV increases mortality) Factors that decrease mortality Surgery within 48 hours decreases 1 year mortality AAOS moderate recommendation for hip fracture surgery within 24-48 hours of admission early medical optimization and co-management with medical hospitalists or geriatricians AAOS strong recommendation for use of interdisciplinary care teams In the absence of clear risk factors for valvular disease, arrhythmias, worsening heart failure, or coronary artery stenosis, an echocardiogram is unlikely to change peri-operative complications and has been shown to delay time to surgical fixation Loss of independence community-dwelling ambulators at 1-year 41% maintain pre-injury ambulatory status 40% more dependent on assistive devices 12% became household ambulators 8% became nonfunctional ambulators One-third general rule 1/3 regain function 1/3 lose one level of independence 1/3 mortality rate