MANUAL MINORS
An intertrochanteric fracture is a fracture of the proximal femur that occurs between the greater and lesser trochanters, two bony prominences located at the upper part of the femur.
It is a common injury in older adults, especially those with osteoporosis, and typically results from falls from standing height.
Unlike intracapsular femoral neck fractures, intertrochanteric fractures have a lower risk of avascular necrosis, as they do not directly compromise the blood supply to the femoral head.
Diagnosis
The diagnosis is suspected in patients, typically elderly, who present with severe hip and groin pain after a fall, accompanied by an inability to walk or bear weight on the affected leg. The limb is often shortened and externally rotated.
It is confirmed via X-rays of the pelvis and hip in anteroposterior and lateral views. In complex or unclear cases, a computed tomography (CT) scan may be performed for more detailed assessment.
Differential Diagnosis
Condition | Key Characteristics |
|---|---|
Femoral neck fracture | Groin pain, risk of avascular necrosis, shortened limb, and external rotation |
Hip dislocation | Obvious deformity, acute pain, leg in internal or external rotation, typically following high-energy trauma |
Hip contusion | Pain, but no visible fracture on X-rays |
Advanced hip osteoarthritis | Chronic, progressive pain, without acute trauma |
Emergency Management
Initial Assessment (ABC): Ensure the patient’s haemodynamic stability, particularly in elderly individuals who may have associated comorbidities.
Immobilisation: Immobilise the affected limb to prevent further displacement and reduce pain. Use splints or immobilisation devices.
Pain control: Administer analgesics such as NSAIDs or opioids to manage acute pain.
Diagnostic Imaging: Request pelvis and hip X-rays to confirm the fracture and determine the exact location and degree of displacement. In complex fractures, consider a CT scan.
Preoperative Stabilisation: In elderly patients, optimise medical conditions before surgery. Patients should be cardiovascularly stabilised if they present with dehydration or anaemia.
Antithrombotic Prophylaxis: Initiate measures to prevent deep vein thrombosis, such as low molecular weight heparin or compression devices.
Definitive Treatment
Definitive treatment for intertrochanteric fractures is usually surgical, as conservative management is associated with higher complication rates, such as thrombosis, pressure ulcers, or functional loss:
Open Reduction and Internal Fixation (ORIF): This is the treatment of choice for most intertrochanteric fractures. Devices used include:
Intramedullary nails or cephalomedullary nails: These are inserted into the femoral medullary canal and provide stability, being the most common option.
Dynamic Hip Screw (DHS): A sliding screw is fixed to the femoral head, and a plate stabilises the proximal femur.
External Fixation: This is an option for patients at high surgical risk or with local infections, though it is less commonly used.
Arthroplasty: In some complex cases, or if there is significant joint damage, hip arthroplasty may be considered, but it is not the first option in intertrochanteric fractures.
Postoperative rehabilitation is essential to avoid complications and restore mobility. Early mobilisation is crucial, with patients typically starting assisted walking within 24-48 hours post-surgery, depending on the stability of the fixation. Physiotherapy is vital to recover joint and muscle function.
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