Intertrochanteric Hip Fracture

Summary

An intertrochanteric hip fracture is a break in the upper part of the thigh bone (femur), between two bony bumps called the greater and lesser trochanters (Figure 1). These bumps are important because they are where muscles attach to help move the hip. This area has a good blood supply, which means it usually heals better than fractures that happen inside the hip joint, like femoral neck fractures. Because it’s outside the joint (called extracapsular), there is a lower risk of complications like bone death (avascular necrosis) or failure to heal (non-union). Intertrochanteric hip fractures can be stable (the bone pieces stay in place) or unstable (the bone breaks into several pieces or shifts easily). Most of the time this type of fracture happens in older adults after a simple fall. In younger people, they’re usually caused by more serious trauma, like a car accident. If not treated, these fractures can lead to serious problems, including long-term disability or even death. Most people need surgery to fix the break, using either a dynamic hip screw or a trochanteric femoral nail.

Clinical Presentation

Intertrochanteric hip fractures are more common in women than men. Older adults—especially those with weak bones (osteoporosis) and a history of falls—are most at risk. People with this kind of hip fracture are usually older and report a recent fall, even from standing height. They usually can’t stand or walk on the injured leg.

Physical Exam

On examination, there will be significant pain in the hip region and swelling over the area of the greater trochanter when compared to the unaffected hip. There may also be bruising over the area that was impacted when the initial fall occurred. The affected leg will often appear shortened and rotated outward (externally rotated). In rare cases where the nerves in the area have been impacted as a result of the fracture, there may be numbness and tingling or a loss of some sensation in various areas around the hip and thigh.

Imaging

X-rays are the most valuable form of imaging when diagnosing a hip fracture. X-rays will provide a clear image of the bones and will reveal the location of the fracture line. They will also reveal whether or not the fracture is in multiple pieces. X-rays can be used to evaluate the stability of the fracture, and therefore which surgery is appropriate for treatment.

A CT or MRI scan may be ordered if the x-rays do not show a fracture, but suspicion of a fracture is still high given the nature of the injury and findings on physical exam. CT and MRI can reveal stress or hairline fractures, which are incomplete fractures where there is no clear fracture line seen on plain x-ray.

Treatment

In general, surgery to stabilize the fracture is the recommended treatment option to ensure the best possible recovery after an intertrochanteric hip fracture. However, very rarely in higher risk patients and/or patients who were not able to walk prior to the injury (non-ambulatory), surgery may not be an option. Patients will be in bed and non-mobile prior to surgery.

Operative Treatment of Intertrochanteric Hip Fractures

There are two surgical procedures that are typically used in the treatment of intertrochanteric hip fractures: a dynamic hip screw or a trochanteric femoral nail. The type of procedure performed depends on the nature of the fracture as well as the individual characteristics of the patient. These procedures require that the fractured bones be appropriately realigned prior to inserting the surgical hardware. This is achieved by placing the patient in traction on a special operating table (fracture table) and checking the fracture position with a special portable x-ray machine (fluoroscopy).

Dynamic Hip Screw 

A dynamic hip screw is a good procedure to treat stable intertrochanteric hip fractures. A strong screw is placed across the fracture site into the femoral head –the ”ball” part of the hip joint. This is done using fluoroscopy. A strong metal plate is placed along the outside of the thigh bone and secured with screws. The hip screw is then able to slide along the groove at the top of the plate that when loaded creates a continuous dynamic force across the fracture site. This force promotes faster healing of the fracture. This device is sometimes referred to as a “sliding hip screw”.

Trochanteric Femoral Nail

Trochanteric femoral nail placement is suitable for either stable or unstable fractures (figure 2). It involves placing a short or long nail through the center of the femur and then positioning a “hip screw” across the fracture site into the femoral head. In stable fractures, the hip screw may be allowed to slide to compress the fracture site. In unstable fractures, the screw may be locked to prevent the fracture from collapsing.

A third procedure, total hip replacement, is used rarely -specifically in cases of severe bone fragmentation (comminution). It can also be used in persons who have preexisting osteoarthritis or fractures that have failed to heal using the two surgical procedures discussed above.

Edited by Stephen Pinney MD May 29th 2025