Hip Intertrochanteric Fractures

Intertrochanteric fractures are extracapsular fractures of the proximal femur occurring between the greater and lesser trochanters. These injuries are particularly common in elderly patients and represent a major cause of morbidity worldwide.

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Epidemiology

Intertrochanteric hip fx account for ~50% of all proximal femur fractures.

• ~150,000 cases annually in the United States
• Incidence:
  • 63 per 100,000 in elderly females
  • 34 per 100,000 in elderly males
• Female-to-male ratio: 2:1 to 8:1
• Strong association with osteoporosis and postmenopausal bone loss

Key Risk Factors

• Advanced age
• Multiple comorbidities
• Reduced independence in activities of daily living
• History of fragility fractures

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Anatomy

Intertrochanteric fractures occur in the cancellous bone-rich region between the trochanters, often extending into the subtrochanteric region.

Important Biomechanics

• Abundant blood supply → low risk of nonunion and osteonecrosis
• Muscle forces deform fracture fragments:
  • Abductors → lateral/proximal displacement of greater trochanter
  • Iliopsoas → medial/proximal displacement of lesser trochanter
  • Hip muscles → proximal migration of distal fragment

Stability Determinant

• Posteromedial cortex integrity
  • Intact → Stable fracture
  • Comminuted → Unstable fracture

See Also: Hip Joint Anatomy

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Mechanism of Injury

Elderly Patients (90%)

• Low-energy trauma
• Typically simple fall onto the greater trochanter

Younger Patients

• High-energy trauma:
  • Motor vehicle accidents
  • Falls from height

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Clinical Presentation

Patients typically present with:

• Severe hip pain
• Inability to bear weight
• Shortened, externally rotated limb

Important Clinical Considerations

Delayed presentation is common, increasing risk of:

• Dehydration
• Malnutrition
• Venous thromboembolism (VTE)
• Pressure ulcers
• Hemodynamic instability (due to blood loss into thigh)

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Radiographic Evaluation

Standard Imaging

• AP pelvis
• AP and cross-table lateral hip views

Additional Imaging

• Internal rotation view → better fracture visualization
• MRI → gold standard for occult fractures
• CT/Bone scan → if MRI contraindicated

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Intertrochanteric Fracture Classification

Evans Classification

Based on stability and reducibility:

• Stable fractures
  • Intact posteromedial cortex
• Unstable fractures
  • Comminution or loss of medial support
  • Reverse oblique pattern

AO/OTA Classification

• A1 → Stable
• A2, A3 → Unstable

In practice, many clinicians simplify classification into stable vs unstable Intertrochanteric fracture, which has direct treatment implications.

Special Fracture Patterns

1. Basicervical Fractures

• Located at femoral neck base
• Behave like intertrochanteric fractures
• Higher risk of osteonecrosis

2. Reverse Oblique Fractures

• Oblique fracture line (medial → proximal, lateral → distal)
• Strong tendency for medial shaft displacement
• Treated like subtrochanteric fractures

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Treatment of Intertrochanteric Fractures

Nonoperative Management

Reserved for:

• Medically unfit patients
• Non-ambulatory patients with minimal pain

Key principle:

• Early mobilization (bed-to-chair) to prevent complications

Operative Management (Standard of Care)

Goal: Stable fixation allowing early weight-bearing

Timing

• Surgery should be performed as soon as medically stable

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Intertrochanteric Fracture Surgery Options

1. Sliding Hip Screw (SHS)

• Traditional gold standard
• Effective for stable fractures

Key Technical Point

• Tip–apex distance < 25 mm reduces risk of screw cutout

Limitations

• Higher failure in unstable fractures
• More collapse and shortening

2. Cephalomedullary Nail (CMN)

• Intramedullary device
• Biomechanically superior in unstable patterns

Advantages

• Less soft tissue damage
• Reduced bending stress
• Better for:
  • Reverse oblique fractures
  • Subtrochanteric extension

3. Prosthetic Replacement

• Indicated when:
  • Fixation fails
  • Severe comminution

Considerations

• Higher surgical morbidity
• Risk of dislocation

4. External Fixation

• Rarely used
• Reserved for select cases
• Associated with:
  • Pin loosening
  • Infection

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Rehabilitation

• Early mobilization is critical
• Weight-bearing as tolerated
• Prevent complications:
  • Pneumonia
  • VTE
  • Muscle wasting

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Complications

1. Loss of Fixation (Most Common)

• Incidence: up to 20% in unstable fractures

Causes:

• Poor screw positioning
• Varus collapse
• Severe osteoporosis

2. Nonunion (<2%)

• Rare due to good blood supply
• Consider:
  • Revision fixation
  • Bone grafting
  • Arthroplasty in elderly

3. Malrotation

• Causes gait dysfunction
• May require corrective osteotomy

4. Implant-Specific Complications

• Z-effect (dual screw nails)
• Nail tip impingement
• Screw cutout

5. Osteonecrosis

• Rare compared to femoral neck fractures

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Key Clinical Pearls

• Stability (posteromedial cortex) determines treatment strategy
• Early surgery improves outcomes
• Tip–apex distance is critical for fixation success
• CMN preferred for unstable fracture patterns
• Early mobilization reduces mortality

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References & More

1. Attum B, Pilson H. Intertrochanteric Femur Fracture. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from: Pubmed
2. Kürüm H, Tosun HB, Aydemir F, Ayas O, Orhan K, Key S. Intertrochanteric Femoral Fractures: A Comparative Analysis of Clinical and Radiographic Outcomes Between Talon Intramedullary Nail and Intertan Nail. Cureus. 2023 Dec 21;15(12):e50877. doi: 10.7759/cureus.50877. PMID: 38259364; PMCID: PMC10801105. Pubmed
3. Egol KA. Handbook of fractures. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2019.