Fixation of Trochanteric Fractures

Indications

Intertrochanteric Femoral Fractures, ct of a pertrochanteric fracture
CT of a pertrochanteric fracture. Image by Mikael Häggström, M.D. Author info – Reusing images- Conflicts of interest: None Mikael Häggström, M.D., Wikimedia Commons, CC0.
  • Stable intertrochanteric fractures with a sliding hip screw
  • Unstable patterns, reverse obliquity and subtrochanteric extension with a cephalomedullary nail
  • AO 31A1 fractures are stable, A2 and A3 are unstable
  • Lateral wall thickness under about 20 mm predicts failure with a sliding hip screw

Position

  • Supine on a traction table, contralateral leg in a well leg holder or scissor position
  • Image intensifier between the legs
  • Pad the perineal post to avoid pudendal nerve injury

Operative Steps

  1. Closed reduction with traction and internal rotation, confirmed in AP and lateral views
  2. Guide wire centre-centre in the head on both views
  3. Tip apex distance under 25 mm to reduce cut out (Baumgaertner)
  4. Ream, insert lag screw, then side plate or nail
  5. Compress with the screw before locking
  6. Distal locking for long nails or length unstable fractures
  7. Reduce before reaming, open reduction with clamps if closed reduction fails
  8. Avoid varus and posterior sag of the neck
  9. Check rotation against the other leg

Postoperative Care

  • Weight bear as tolerated
  • Check for varus collapse at 6 weeks
  • Orthogeriatric care and delirium screening
  • Osteoporosis treatment

Complications

  • Cut out, most common mechanical failure
  • Varus malunion and excess shortening
  • Periprosthetic fracture at the nail tip
  • Lateral thigh pain from prominent hardware
  • Infection
  • Medial perforation of the lag screw (Z effect) with two screw nails

Related Pages

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