Intertrochanteric Fracture
Intertrochanteric fractures are extracapsular fractures of the proximal femur that occur between the greater and lesser trochanter. There is an area of low bone mineral density known as the ward triangle bordered by the primary compressive trabeculae, principal tensile trabeculae and secondary compressive trabeculae (between the neck and lateral cortex adjacent to the trochanter on imaging). This area is prone to fracture, especially in individuals with osteoporosis.
Intertrochanteric fractures are easier to heal and less likely to result in avascular necrosis compared to femoral neck fractures. They are common in the elderly, usually following falls from standing height. Treatment is usually operative.
Intertrochanteric fractures account for 50% of proximal femur fractures. The average age is 80 years old. It affects women more than men.
Evans classification of intertrochanteric fracture (based on post-reduction stability)
| Classification | Description |
|---|---|
| Stable | Stable since the posteromedial cortex intact. It is able to resist compressive load |
| Unstable | Unstable due to significant comminution of posteromedial cortex |
| Reverse obliquity | Unstable since the femoral shaft is displaced medially by the adductors |
Boyd and Griffin classification of intertrochanteric fracture (based on the degree of displacement and comminution)
| Classification | Description |
|---|---|
| Type I | Non-displaced fracture along the intertrochanteric line |
| Type II | Displaced or comminuted along the intertrochanteric line |
| Type III | Comminuted intertrochanteric fracture with subtrochanteric extension |
| Type IV | Reverse obliquity with extension into subtrochanteric region |
Tronzo classification (based on fracture stability and pattern)
| Classification | Description |
|---|---|
| Type I | Incomplete fracture involving the greater trochanter. Stable |
| Type II | Non-comminuted fracture with intact posterior wall and small lesser trochanter fragment. Stable |
| Type III | Comminuted posterior wall with telescoping of the fragments (neck spike and shaft) and a large lesser trochanter fragment. Unstable |
| Type IV | Comminuted posterior wall without telescoping. The neck spike is displaced outside the shaft. Most of the posterior wall is lost medially. Unstable |
| Type V | Reverse oblique fracture with medial displacement of the shaft. Very unstable |
- Risk factors
- Proximal humerus fracture
- Osteoporosis
- Advanced age
- Comorbidities e.g. dementia, parkinsons
- High dependency with activities of daily living
- Mechanism of injury
- Low-energy e.g. fall from standing height in osteoporotic patients
- High-energy trauma in young patients
- Associated conditions
- Osteoporosis
- Signs and symptoms
- Severe pain along the entire hip region
- Deformity (similar to hip fracture): external rotation and limb shortening
- Inability to bear weight
- Pain with log roll and axial load
- Unable to perform active straight leg raise
- Investigations
- X-ray (AP pelvis, AP hip, cross table lateral and full length femur): to compare contralateral hip, assess neck shaft angle and define fracture pattern
- CT scan: to assess for occult fractures
- MRI: for occult fractures
- Bone scan: for occult fractures if MRI is contraindicated
- Indications for non-operative treatment
- Non-ambulatory patient
- High-risk of peri-operative mortality
- Skin breakdown at surgical site
- Incomplete fracture
- Indications for operative treatment
- Stable or unstable fracture in fit patients
- Severly comminuted fractures (arthroplasty)
- Pre-existing severe degenerative hip disease (arthroplasty)
- Severe osteoporosis (arthroplasty)
- Non-operative treatment
- Non-weight bearing + early mobilization (bed to chair)
- Protected weight bearing
- Operative treatment
- Closed reduction and intramedullary nail fixation
- Open reduction and internal fixation (ORIF)
- Sliding hip screw
- Proximal femur locking plate
- Arthroplasty
- Prognosis
- Correlates to how quickly safe surgery is performed
- Mortality decreases if surgery is performed within 48 hours
- Complications
- Deep venous thrombosis (DVT) occurs in 80% of patients
- Dehydration, ulcers or dehydration due to delayed presentation
- Implant failure
- Non-union and malunion
- Post-operative anaemia and transfusion
