Hip iSAWE 18

Question

A 74 year old woman had an intertrochanteric fracture fixed with a cephalomedullary nail. Eight weeks later she has increasing hip pain.

Hip iSAWE 18, AP radiographs of the hip, before and after fixation
AP radiographs of the hip, before and after fixation. Image by Hellerhoff, Wikimedia Commons, CC BY-SA 4.0.
  1. Describe the series of radiographs.
  2. What are the risk factors for this complication?
  3. How would you manage it?

Answer

Radiographs

  • Intertrochanteric fracture fixed with a cephalomedullary nail
  • Later films show varus collapse and the lag screw cutting out of the femoral head superiorly

Risk factors

  • Tip apex distance over 25 mm (Baumgaertner)
  • Superior or anterior lag screw position
  • Varus or poor reduction
  • Unstable fracture pattern
  • Poor bone quality
  • Calcar referenced tip apex distance adds information

Management

  • Exclude infection with bloods and aspiration or tissue samples
  • Assess acetabular damage from the screw
  • Conversion to total hip arthroplasty in most elderly patients
  • Calcar replacing or long stem, with trochanteric fixation as needed
  • Revision fixation with valgus reduction in younger patients with good head stock
  • Higher dislocation and complication rates than primary THA

Related pages

Author Contributions

Orthofracs team

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.