Intertrochanteric fractures are extracapsular hip fractures between the base of the neck and the lesser trochanter, making up about half of hip fractures in older people. Stable patterns are fixed with a sliding hip screw, while unstable and reverse oblique patterns are fixed with a cephalomedullary nail.
Definition
- fractures from the extracapsular part of the neck to a point 5 cm distal to the lesser trochanter
Incidence
- About half of hip fractures are extracapsular
- Patients older on average than those with femoral neck fractures
- Women more affected than men
- Incidence rising with an ageing population
Aetiology
- Low energy fall from standing in osteoporotic elderly patients
- High energy trauma in younger patients
- Risk factors include osteoporosis, female sex, age, falls risk, low BMI and steroid use
- Previous fragility fracture
- Pathological fracture from metastasis
Anatomy
- Extracapsular, between the greater and lesser trochanters
- Rich cancellous blood supply, so union is reliable and AVN rare
- Calcar femorale is dense posteromedial bone that resists compression
- Lateral wall thickness under 20.5 mm predicts sliding hip screw failure (Hsu)
- Neck shaft angle about 130 degrees
- Leg shortens and externally rotates from muscle pull
Classification
Boyd and Griffin Classification of Intertrochanteric Fractures
| Type | Description |
|---|---|
| 1 | Simple fracture that extends along the intertrochanteric line from the greater to the lesser trochanter |
| 2 | Comminuted fractures, the main fracture being along the intertrochanteric line, but with multiple fractures in the cortex |
| 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. (reverse subtrochanteric) |
| 4 | Fractures of the trochanteric region and the proximal shaft, with fracture in at least two planes, one of which usually is the sagittal plane and may be difficult to see on routine anteroposterior radiographs |
Evans Classification of Intertrochanteric Fractures Based on Direction of Fracture
| Type | Description |
|---|---|
| I | Fracture line extends upward and outward from the lesser trochanter . Further subdivided . Stable . Unstable . Stability restored by anatomical reduction . Stability unrestored by anatomical reduction |
| II | reverse obliquity fracture, the major fracture line extends outward and downward from the lesser trochanter |
AO Classification of Trochanteric Fractures
| Group | Description |
|---|---|
| A1 | uncomminuted |
| A2 | increasing comminution |
| A3 | subtrochanteric extensions or reverse obliquity |
Pathology
- Stability depends on posteromedial cortical support and lateral wall integrity
- Unstable patterns include posteromedial comminution, reverse obliquity and subtrochanteric extension
- Lateral wall fracture converts a stable pattern to unstable
- Reverse obliquity fractures displace medially with a sliding hip screw
History
- Fall with inability to weight bear
- Groin or lateral hip pain
- Cause of fall, including syncope or stroke
- Premorbid mobility, residence and cognition
- Comorbidities and anticoagulant use
- Prodromal pain suggesting pathological fracture
Examination
- Shortened and externally rotated leg, often more rotated than in intracapsular fractures
- Bruising over the greater trochanter
- Pain on hip movement
- Distal neurovascular status
- Pressure areas
- Associated injuries, including distal radius, proximal humerus and head
- Cognitive screen
Investigations
- FBC, UEC, coagulation and group and hold
- ECG and chest X-ray
- Delirium screen
- CT or MRI when X-rays are negative and suspicion is high
X-rays
- AP pelvis with AP and lateral hip
- Full length femur to exclude distal lesions and plan nail length
- Traction internal rotation view to define the pattern
- Assess lateral wall, posteromedial comminution and reverse obliquity
- Tip apex distance under 25 mm postop (Baumgaertner)
Treatment
Non-operative
Broken Gamma Nail
Operative
- Surgery within 48 hours (ANZ Hip Fracture Care Standard)
- Stable patterns treated with sliding hip screw or cephalomedullary nail
- Unstable, reverse obliquity and subtrochanteric extension treated with cephalomedullary nail
- Closed reduction on a traction table before fixation
- Lag screw centre centre or inferior and deep, tip apex distance under 25 mm
- Arthroplasty reserved for failed fixation or severe arthritis
- Weight bear as tolerated postop
Complications
- Lag screw cut out, the most common mechanical failure, linked to tip apex distance
- Excess collapse with shortening and medialisation of the shaft
- Peri-implant fracture at the tip of a short nail
- Anterior cortex perforation with a long nail
- Varus malunion
- Nonunion uncommon
- Delirium, pneumonia, VTE and pressure injuries
Prognosis
- One year mortality around 25%
- Many do not regain prior mobility or independence
- Union rates over 95%
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.