This document discusses intertrochanteric fractures, including definition, epidemiology, classification systems, treatment options, and complications. It provides an overview of fracture anatomy, mechanisms of injury, evaluation with x-rays, and classifications including Boyd & Griffin, Evans, and AO. Treatment options discussed include non-operative management, internal fixation with devices like the dynamic hip screw and intramedullary nails, and prosthetic replacement. Post-operative rehabilitation and complications of treatment are also summarized.

1. Intertrochanteric Fractures
and its management with
DHS/PFN/Arthroplasty.
Dr. Kota Aditya
M.S.(Ortho)
Fellow in Ilizarov Surgery
Fellow in Sports Medicine
Associate Professor,
Department of
Orthopaedics,
ASRAM Medical College
Phone
+919949897152
Email
mimsaditya@gmail.com

2. Intertrochanteric Fracture
DEFINITION:-
• It is a fracture of proximal
femur, involving either
the greater or the lesser
trochanter or both.

3. EPIDEMIOLOGY
• Intertrochanteric fractures account
for nearly 50% of all fractures of the
proximal femur.
• Age of incidence: 66 - 76 years.
• Male:Female ratio – 1:2 to 1:8
(postmenopausal metabolic changes in bone.)
• Factors associated with IT fractures include:
▫ advancing age,
▫ increased number of comorbidities,
▫ prolonged bed ridden patients (parkinson’s disease etc.)
▫ osteoporosis-related fractures.

4. ANATOMY
• Intertrochanteric fractures
occur between the greater and
lesser trochanters of proximal
femur, occasionally extending
into the subtrochanteric
region.
• Extracapsular fractures - occur
in cancellous bone - has
abundant blood supply.
(nonunion and osteonecrosis
are rare)

5. MECHANISM:
In Elder individuals:-
• 90% of intertochanteric fractures
result from a simple fall.
In Young individuals:-
• Following high-energy injury
such as a motor vehicle accident
or fall from a height.
Most fractures result from a
direct impact to the greater
trochanteric area.

6. Pathoanatomy
• The distal fragment rides up
• Femoral neck shaft angle is
reduced.
• Deforming muscle forces
produce shortening, external
rotation, and varus position
of the limb.
• Abductors - pulls the greater
trochanter laterally and
proximally.
• Iliopsoas pulls the distal
fragment into flexion
• Fracture stability is
determined by the presence
of posteromedial bony
contact, which acts as a
buttress against fracture
collapse.

7. CLINICAL EVALUATION
 There is a history of fall or road traffic accident.
 Pain and swelling in the region of upper thigh.
 Inability to move the limb.
 Displacements lead to shortening, varus and
external rotation of the limb
 Tenderness over greater trochanter.
 Ecchymosis may be seen after 2 days of injury

8. RADIOGRAPHIC EVALUATION
ANTEROPOSTERIOR (AP) VIEW

9. Cross table lateral view

10. AP view with traction

11. Boyd and Griffin
Type 1:
• Fractures that extend along the
intertrochanteric line from the greater to
the lesser trochanter.
• Reduction - simple
Type 2:
• Comminuted fractures, Main fracture being
along intertrochanteric line, multiple
fractures in the cortex.
• Reduction - difficult due to comminution.
• A particularly deceptive form is the fracture
in which an anteroposterior linear
intertrochanteric fracture occurs, as in type
1, but with an additional fracture in the
coronal plane, which can be seen on the
lateral radiograph..
Type 3:
• Fractures that are basically
subtrochanteric with at least one
fracture passing across the proximal
end of the shaft just distal to or at the
lesser trochanter. Varying degrees of
comminution are associated.
• More difficult to reduce and result in
more complications at operation and
during convalescence.
Type 4:
• Fractures of the trochanteric region
and the proximal shaft, with fracture in
at least two planes, fracture in the
sagittal planeis difficult to see on
routine anteroposterior radiographs.
• If open reduction and internal fixation
are used, two-plane fixation is required
because of the spiral, oblique, or
butterfly fracture of the shaft

12. Boyd and Griffin
Type 1:
• Fractures that extend along the
intertrochan-teric line from the greater to
the lesser trochanter.
• Reduction - simple
Type 2:
• Comminuted fractures, Main fracture
being along intertrochanteric line,
multiple fractures in the cortex.
• Reduction - difficult due to comminution.
• A particularly deceptive form is the
fracture in which an anteroposterior linear
intertrochanteric fracture occurs, as in
type 1, but with an additional fracture in
the coronal plane, which can be seen on
the lateral radiograph..
Type 3:
• Fractures that are basically
subtrochanteric with at least one
fracture passing across the
proximal end of the shaft just
distal to or at the lesser trochanter.
• Varying degrees of comminution
are associated.
• More difficult to reduce and
• Results in more complications
intra and post operative period.
Type 4:
• Fractures of the trochanteric
region and the proximal shaft, with
fracture in at least two planes,
• Fracture in the sagittal plane is
difficult to see on routine
anteroposterior radiographs.
• If open reduction and internal
fixation are used, two-plane
fixation is required because of the
spiral, oblique, or butterfly fracture
of the shaft

13. Evans classification
Type I: Undisplaced 2-fragment
fracture
Type II: Displaced 2-fragment
fracture
Type III: 3-fragment fracture
without posterolateral
support, owing to
displacement of greater
trochanter fragment
Type IV: 3-fragment fracture
without medial support,
owing to displaced lesser
trochanter or femoral arch
fragment
Type V: 4-fragment fracture
without posterolateral and
medial support (combination
of Type III and Type IV)
R: Reversed obliquity fracture

14. Unstable intertrochanteric fractures
(fractures collapse despite axial reduction)
• 1. Comminuted fracture of the posterior medial
portion.
• 2. Reverse oblique fracture.
• 3. Transverse fracture.
• 4. A large posterior medial fragment.
• 5. Subtrochanteric extension.
Evans EM. J Bone Joint Surg Br. 1949; 31:190-203.
Kyle et al. J Bone Joint Surg Am. 1979; 61(2):216-21.

15. AO Classification Group 1
• Simple (two part)with
a single extension into
the medial cortex.
• The lateral cortex of
the greater trochanter
remains intact.
• The subgrouping further
defines the geometry of
the fracture line.
• All group 1 fractures are
inherently stable.
31-A1 Peritrochanteric simple
A1.1 Along intertrochanteric line
A1.2 Through greater trochanter
A1.3 Below lesser trochanter

16. AO Classification Group 2
• Fractures are multifragmentary.
• Fracture line begins anywhere
on the greater trochanter and
extends medially in more
than 2 places.
• This creates a third fracture
fragment that includes the
lesser trochanter.
• The lateral cortex remains intact.
• With the exception of a trivial
lesser trochanteric fragment,
fractures in this group are
unstable.
• The subgrouping for group 2
fractures defines the number and
geometry of the fragments.
31-A2 Peritrochanteric multifragmentary
31-A2.1 With one intermediate fragment
31-A2.2 With several intermediate
fragments
31-A2.3 Extending more than 1 cm below
lesser trochanter

17. AO Classification Group 3
• Both medial and lateral
cortices of the proximal
femur fractured.
• The subgroups describe
fracture direction and
comminution.
• The Reverse obliquity
fracture is in the group
A3.1
31-A3 Intertrochanteric
31-A3.1 Simple oblique
31-A3.2 Simple transverse
31-A3.3 Multifragmentary

18. AO Classification
31

19. Treatment

20. Nonoperative Treatment
Pin traction / Skin traction
Indications:
• comfortable nonambulatory patients
▫ (parkinsons disease, hemiplegic patients)
• patients with brief life expectancies
The mortality rate is higher in non
operative group
• 34.6% for fractures treated by traction
Vs.
• 17.5% for fractures treated by internal
fixation.
(Horowitz et al. 1960)

21. • Goal : Stable fixation of
the fracture fragments.
• Standard treatment:
▫ Rigid internal fixation of
intertrochanteric fractures
▫ early mobilization.
• Medical complications are
fewer and less serious than
nonoperative treatment.
• Variables that determine
strength of the ORIF:
(1) bone quality,
(2) fragment geometry,
(3) reduction,
(4) implant design,
(5) implant placement.
Operative treatment
Surgeon controlled

22. Which implant to
choose ???

23. DYNAMIC HIP SCREW
• This is the most commonly used device
for both stable > unstable fracture
patterns.
• It is available in plate angles from 120 to
150 degrees.
• Important technical aspects of screw
insertion are
▫ (1) central position in the femoral head
> posteroinferior position
(avoid anterosuperior screw placement)
▫ (2) placement within 1 cm of
subchondral bone to provide secure
fixation and

24. The Tip-Apex Distance (Baumgaertner et al.)
• It determines lag screw position
within the femoral head.
• It is the sum of the distances (mm)
from :
Tip of the lag screw
to
the apex of the femoral head
on both the AP and lateral
radiographic views
(after controlling magnification) .
• The sum should be <25 mm to
minimize the risk of lag screw
cutout and varus angulation.
Apex: Defined as the point where a
line parallel to, and in the middle of the
femoral neck intersects the joint.

25. Baumgaertner, Curtin, Lindskog, Keggi JBJS (A) ‘95

26. DYNAMIC HIP SCREW
Contraindications:
• In reverse obliquity
fractures
▫ 56% failure rate
• Lack of integrity of lateral
femoral wall
▫ associated with increased
sliding displacement
(collapse)

27. DYNAMIC HIP SCREW
• At surgery, the surgeon must be
prepared to deal with residual varus
angulation, posterior sag, or malrotation.
• A 4% to 12% incidence of loss of fixation is reported,
most commonly with unstable fracture patterns.
Most failures are attributable to
• screw placement
• failure to achieve posteromedial cortical continuity

28. INTRAMEDULLARY IMPLANTS
• Modern intramedullary techniques were developed
by Küntscher in Germany during the 1940s.

29. a) First Generation Nails
• K Nail
• Grosse Kempf Nail
b) Second Generation Nails
• Russel Taylor Nail
• Delta Nail
c) Third Generation Nails
• Trigen Nail
• Universal Femoral Nail (Synthes)
INTRAMEDULLARY IMPLANTS

30. INTRAMEDULLARY HIP SCREW
• This implant combines the features of a
dynamic hip screw (DHS) and an
intramedullary nail(IMN).
Advantages are both technical and mechanical:
• limited fracture exposure,
• decreased blood loss, and
• less tissue damage than an DHS.
• Lower bending moment than the DHS owing
to their intramedullary location.

31. INTRAMEDULLARY HIP SCREW
• The intramedullary hip screws show
no benefit over DHS in stable fracture
patterns.
• Indicated in intertrochanteric fractures with
subtrochanteric extension and in reverse obliquity
fractures.
Disadvantage
• Increased risk of stress fractures at tip of prosthesis as
implant creates stress riser in proximal femur.

32. • The femoral head is divided
into 9 sectors by 2 parallel
lines
• The lag screws are inserted in
the centro-inferior part of the
femoral head.
• Measurement of lateral slide
of the lag screw by comparing
(a) immediate postoperative
and
(b) final anteroposterior
radiographs.

33. PFNA - Proximal Femoral Nail Antirotation

34. Prosthetic Replacement
Indicated in :
• Failed internal fixation
• Unsuitable candidates for repeat internal
fixation.
A Calcar Replacement Hemiarthroplasty
is needed because of the level of the
fracture.
Primary prosthetic replacement for
comminuted, unstable intertrochanteric
fractures has yielded up to 94% good
functional results.
Journal of Orthopaedic Surgery 2006;14(3):240-4

35. Prosthetic Replacement
Disadvantages :
• Morbidity due to long operative procedure,
• Internal fixation problems with greater trochanteric
reattachment, and
• Risk of postoperative prosthetic dislocation.
Journal of Orthopaedic Surgery 2006;14(3):240-4

36. Total hip arthroplasty following failed
fixation of proximal hip fractures
(a) AP radiograph of 70 year old patient showing intertrochanteric fracture of right hip.
(b) Fracture was fixed with Proximal femoral nail.
(c) Fracture collapse with screw back out three months after the surgery.
(d) PFN was removed and cemented total hip arthoplasty was performed and trochanteric
wiring was done.
(e) Patient had dislocation of his hip two weeks after replacement surgery which was
managed conservatively
Srivastav S, Mittal V, Agarwal S - Indian J Orthop (2008)

37. External Fixation
• This is not commonly considered
• Indicated in patients unfit for
surgery
• Postoperative complications are
common
▫ pin loosening
▫ infection
▫ varus collapse
• Recent studies have reported
better results using
hydroxyapatite-coated pins.
Mitkovic's dynamic external fixator

38. Special Considerations
With use of an DHS,
• Large posteromedial fragments in younger individuals
should receive fixation with cerclage wires or a lag screw to
restore the posteromedial buttress.
• Greater trochanteric displacement should be fixed utilizing
tension band techniques.
Reverse obliquity fractures are best treated with an IM nail
with a supplemental antirotation screw or pin during
implant insertion.
Ipsilateral fractures of the femoral shaft, although more
common in association with femoral neck fractures, should
be ruled out when the injury is caused by high-energy
trauma.

39. Rehabilitation
• Early patient mobilization with weight bearing as
tolerated ambulation is indicated.

40. Hemi arthroplasty for failed internal fixation
of intertrochanteric fractures - Case 1
• A. Preoperative failed ORIF with
DHS of a reverse obliquity
fracture.
•
• B.Postoperative reconstruction
with Calcar Replacing Bipolar
Hemi-arthroplasty through a
trochanteric slide technique.

41. Case 2
• A. Preoperative failed ORIF
with screw cutout. The
acetabular joint space is well
preserved.
• B. Postoperative radiograph
demonstrating a cemented
calcar-replacing bipolar
hemi-arthroplasty.

42. Total Hip Arthroplasty for failed internal fixation
of intertrochanteric fractures - Case-3
• (A) A 59-year-old man suffering from a
stable intertrochanteric fracture.
• (B) Fixation using a compression hip screw.
• (C) The intertrochanteric fracture healed,
but it was complicated by avascular necrosis
of the femoral head. The acetabulum also
was eroded by the exposed tip of the lag
screw.
• (D) A hybrid total hip arthroplasty was
performed.
• The greater trochanter was cracked during
the broaching of the medullary canal and
was repaired with a cable-grip device.
The Journal of Arthroplasty, Volume 19, Issue 3, April 2004.

43. COMPLICATIONS
Loss of fixation:
• Eccentric placement of the lag screw within the femoral
head.
• Improper reaming may creates a second channel.
• Inability to obtain a stable reduction.
• Excessive fracture collapse such that the sliding capacity
of the device is exceeded.
• Inadequate screw-barrel engagement, which prevents
sliding.
• Severe osteopenia, which precludes secure fixation.

44. COMPLICATIONS
• Nonunion
• Malrotation deformity
• Osteonecrosis of the femoral head: rare
• Lag screw-sideplate separation.
• Lag screw migration into the pelvis.
• Lag screw backing out of the femoral head.
• Impingement of the distal aspect of IM nail on the
anterior femoral cortex due to mismatch of the nail
curvature and femoral bow.

45. Ten tips for hips:
• Protocol driven, fast-track
admission through
casualty
• Multidisciplinary care of
the comorbidities
• Surgery is the best
analgesic
• Surgical repair within 48
hours of hospital
admission
• Damage-limiting surgery and
anaesthesia by appropriately
experienced surgeons and
anaesthetists
• High quality communication
between clinicians and
allied health professionals
• Early mobilisation
• Pre-operative discharge
planning
• Falls prevention
• Continuous audit and
targeted research

46. Summary:
We should be able to minimize the morbidity
associated with an intertrochanteric fracture by:
• Recognizing the fracture pattern.
• Choosing the appropriate fixation device.
• Performing accurate reduction.
• Ideal implant placement.
• Being conscious of implant COSTS .
(Haidukewych GJ. J.Bone Joint Surg Am. 2009 Mar 1;91(3):712-9)

47. Thus, we must adopt an
“attitude of zero tolerance” for
inadequate fracture reduction and fixation
to provide high-quality
yet cost-effective care for the patient.

48. Future !!!

49. References
• Old Slideshare PPTs
• AO Manual
• Journal references have already been mentioned in
slides

50. Thank You
Dr. Kota Aditya
Ph +91-9949897152
mimsaditya@gmail.com