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Intertrochanteric fracture

105 citationsUpdated Sep 2026

Overview

Intertrochanteric fractures are analyzed from standpoints of epidemiology, classification, treatment, and results [1]. Mortality following these injuries is largely determined by patient-related systemic factors, specifically heart failure and dementia, rather than fracture type or reduction quality [3]. While the cephalomedullary nail has emerged as the preferred construct in the United States, with the majority of surgeons believing it is easier to use, associated with improved outcomes, or biomechanically superior [59], conflicting evidence remains to guide the choice of implant [32]. A national register-based study indicates a lower reoperation rate for intramedullary nails than sliding hip screws for unstable trochanteric and subtrochanteric fractures, but no difference in reoperation rate between the two for stable fractures [63].

Treatment selection is heavily influenced by patient age and fracture stability. Arthroplasty is indicated for unstable trochanteric fractures in patients over 75 years [48] and is associated with superior results to internal fixation in patients older than 80 years with comminuted intertrochanteric fractures and severe osteoporosis [10]. For this demographic, arthroplasty shows better and earlier clinical results and lower mechanical complication rates compared to nailing [48]. Conversely, extramedullary fixation of stable intertrochanteric fractures significantly reduces perioperative blood loss compared to intramedullary fixation while affording similar functional outcomes and times to union [9]. Extramedullary implants are recommended for consideration in stable intertrochanteric fractures, especially in patients who are anemic or at high risk for hospital readmission [46].

Prognostic factors and care pathways further define management. Intertrochanteric fractures with ≥10 mm of lesser trochanter displacement were associated with poorer short-term functional and patient performance outcomes compared with patients with less displacement, although these differences diminished over time [4]. However, the integrity of the lesser trochanter has no significant influence on the surgical outcome of intramedullary nail internal fixation [156]. The implementation of an evidence-based algorithm for the treatment of intertrochanteric fractures reduced costs while maintaining quality of care and resulted in a lower rate of complications and re-admissions [66]. Only the highest-volume hospitals showed an inpatient mortality benefit for Medicare patients with intertrochanteric hip fractures [154]. Additional studies are required to specify the influence of fracture characteristics on complication rate and function for unstable intertrochanteric fractures and to establish a classification system with clear treatment recommendations [2].

Anatomy & Pathophysiology

Bony Anatomy

The hip is a multiaxial joint formed by the articulation between the pelvis and femur, connecting the axial skeleton and the lower extremity [82]. The hemipelvis comprises the ilium, ischium, and pubis, which unite at the triradiate cartilage within the concave acetabulum [82]. The acetabulum consists of an articular crescent-moon–shaped lunate surface and a nonarticular central fossa that serves as the attachment point for the ligamentum teres [82]. It is normally anteverted 15 degrees and obliquely oriented in the coronal plane 45 degrees caudally [88]. The posterosuperior articular surface is thickened to accommodate weight bearing, while the inferior surface contains the acetabular (cotyloid) notch, which is bound by the transverse acetabular ligament [88].

The femoral head forms two-thirds of a sphere, with a small depression at its center from which the ligamentum teres extends to connect to the acetabular notch [82]. The neck-shaft angle of the femur averages 125° [82], with a mean adult value of 130° ± 7° [92] and an average of 127 degrees that begins at 141 degrees in the fetus [88]. Normal version, defined as the head-neck angle in the frontal plane, averages 15 to 20° [82], with a mean anteversion of 10° ± 7° [92]. The femoral neck is normally anteverted approximately 14 degrees in relation to femoral condyles, with a range of 1–40 degrees [88]. At the junction of the femoral neck and shaft are the greater and lesser trochanters, which are connected by the intertrochanteric line anteriorly and the intertrochanteric crest posteriorly [82].

The subtrochanteric region extends distally from the lesser trochanter for a distance of 5 cm [213]. This area is characterized by predominantly cortical bone and poor vascularity [213]. The concentration of stresses in the subtrochanteric region has been estimated to be up to 1200 lb/sq inch, the highest of the human skeleton [213]. In this region, the medial side is subject to high compressive stresses, while high tensile stresses are exerted on the lateral side [213]. The region of the proximal femur 3–10 cm below the lesser trochanter is eccentrically loaded, with compressive medial forces considerably greater than lateral tensile forces [213].

Trabecular Architecture

The two prime trabecular groups of the proximal femur are the principal tensile group and the principal compressive group [92]. Secondary compressive and tensile trabecular groups also exist in the proximal femur [92]. These trabecular bone patterns are the result of bone’s response to stress, expressed as Wolff’s law [92]. The weakest area in the femoral neck is located in the Ward triangle [92]. The calcar femorale is a medial area of dense trabecular bone that transfers stress from the femoral shaft to the inferior portion of the femoral neck [92]. Fractures of the proximal femur follow the path of least resistance [92]. The amount of energy absorbed by the bone determines the degree of comminution [92]. The calcar femorale can redistribute stresses, and its destruction can lead to an increase in posterior medial stress [208].

Ligaments and Capsule

The hip is surrounded by a dense fibrous capsule extending from the periphery of the acetabulum to the intertrochanteric line of the femoral neck [82]. The capsule enhances joint stability by preventing translation of the femoral head in the acetabulum [82]. The hip joint capsule extends anteriorly to the intertrochanteric crest but posteriorly only partially across the femoral neck [79]. Consequently, the basicervical and intertrochanteric crest regions are extracapsular [79]. The hip capsule is tight in extension and internal rotation, and relaxed in flexion and external rotation [79].

The iliofemoral ligament, also known as the Y ligament of Bigelow, is the strongest ligament in the body [79]. It attaches the anterior inferior iliac spine (AIIS) to the intertrochanteric line in an inverted Y manner [79]. The iliofemoral ligament functions to limit external rotation, while its lateral arm limits extension of the joint [82]. It becomes taut in full extension, preventing anterior dislocation and hyperextension of the hip [83]. The twisted orientation of the hip ligaments provides a screw mechanism for the hip in full extension [83]. The ischiofemoral and pubofemoral ligaments are weaker than the iliofemoral ligament but provide additional stability [79]. The ischiofemoral ligament provides support posteriorly and restricts internal rotation motion [82], while the pubofemoral ligament acts to limit abduction of the joint [82]. Deep fibers from the iliofemoral, ischiofemoral, and pubofemoral ligaments merge to form the zona orbicularis, which circumvents the femoral neck [82]. The ligamentum teres arises from the apex of the cotyloid notch and attaches to the fovea of the femoral head [79]. It transmits an arterial branch of the posterior division of the obturator artery to the femoral head, which is less significant in adults [79].

Vascular Anatomy

The medial femoral circumflex artery is the main blood supply to the femoral head [92]. It terminates in the posterior aspect of the extracapsular arterial ring [92]. The lateral femoral circumflex artery gives rise to the anterior aspect of the arterial ring [92]. The superior and inferior gluteal arteries also contribute branches to the extracapsular arterial ring [92]. The ascending cervical arteries originate from the extracapsular arterial ring and are divided into four distinct groups: lateral, medial, posterior, and anterior [92]. The lateral group of ascending branches is the main blood supply to the femoral head [92]. The ascending branches give off multiple perforator vessels to the femoral neck and terminate in the subsynovial arterial ring located at the margin of the articular surface of the femoral head [92]. The lateral epiphyseal artery penetrates the femoral head and is believed to be the dominant blood supply to the femoral head from this system [92]. Fractures that disrupt the ascending blood flow to the lateral epiphyseal vessel have an increased risk of osteonecrosis [92].

The artery of the ligamentum teres arises from either the obturator or medial femoral circumflex artery and does not provide sufficient blood supply to maintain the viability of the femoral head [92]. In adulthood, the major blood supply to the femoral head is from the medial femoral circumflex and lateral epiphyseal arteries [95]. From birth to approximately 4 years of age, the major blood supply to the femoral head comes from the medial and lateral femoral circumflex arteries, with major contributions from the artery of the ligamentum teres [95]. From the age of 4 years to adulthood, the posterosuperior and posteroinferior retinacular arteries from the medial circumflex artery are the major blood supply [95].

Muscular Anatomy

The primary hip flexor muscles are the iliopsoas, rectus femoris, and sartorius muscles [90]. The gluteus maximus and hamstring muscles are the most important hip joint extensors [90]. The abductors of the hip are predominantly the gluteus medius and minimus muscles [90]. The gluteus medius and minimus muscles function together to maintain and abduct the femur during the stance phase of gait [90]. The adductor muscles of the hip include the adductor brevis, adductor longus, adductors magnus, pectineus, and gracilis [90]. The external rotators of the hip include the obturator internus and externus, superior and inferior gemelli, quadratus femoris, and piriformis muscles [90].

The iliopsoas muscle has a large origin along the iliac crest, iliac fossa, sacra ala, iliolumbar ligaments, and sacroiliac ligaments [90]. The iliopsoas muscle/tendon traverses a groove between the iliopectineal eminence and AIIS [88]. The iliopsoas tendon traverses the anteromedial aspect of the hip joint before inserting into the lesser trochanter [87]. The rectus femoris crosses the hip joint and the knee joint, with the straight head originating from the AIIS and the reflected head from the supra-acetabular tubercle [90]. The piriformis muscle originates from the greater sciatic foramen and inserts onto the greater trochanter [90]. The superior gluteal nerve and artery exit the pelvis above the piriformis muscle [90]. The pudendal nerve, internal pudendal artery, nerve to the obturator internus, posterior femoral cutaneous nerve, sciatic nerve, inferior gluteal nerve, inferior gluteal artery, and nerve to the quadratus femoris exit the pelvis below the piriformis [90]. In 10% of cases, the common peroneal component of the sciatic nerve can pass through the division in the piriformis [90].

Fracture Pathophysiology

Intertrochanteric fractures are considered extracapsular fractures [92]. Callus formation is common in intertrochanteric fracture patterns [92]. Nonunion is rare in intertrochanteric fractures because of the absence of synovial fluid and the presence of an abundant blood supply [92]. The mechanism of injury determines the character of intertrochanteric fractures in young adults [6]. Intertrochanteric fractures with ≥10 mm of lesser trochanter displacement were associated with some poorer short-term functional and patient performance outcomes compared with patients with less displacement [4]. Differences in functional outcomes associated with lesser trochanter displacement diminished over time [4]. The risk of driving the femoral head into the acetabulum must be anticipated in intertrochanteric fractures with ipsilateral central fracture of the acetabulum, even when the acetabular fracture is only slightly displaced [38]. Adverse fracture-implant motions were detected in stable trochanteric hip fractures treated with intramedullary nails with high resolution [77]. The subtrochanteric region is subject to deforming forces of flexion and external rotation from the iliopsoas, abduction from the gluteus medius, and adduction and shortening of the shaft from the hamstrings and adductors [213].

Classification

AO/OTA: The AO classification system is more reliable for measuring intertrochanteric fractures of the proximal femur than the Evans, Kyle, and Boyd systems [109]. It describes trochanteric femur fractures as stable with a fixed trochanter minor (A1.1–A2.1) and unstable with a fractured or dislocated trochanter minor (A2.2–A2.3) or reversed fracture line (A3.1–A3.3) [146]. Specifically, AO/OTA type 31 A1 and A2.1 are considered stable fracture patterns, whereas AO/OTA type A2.2, 2.3, and A3 are considered unstable [45].

Lateral Femoral Wall Integrity: A proposed classification based on the integrity of the lateral femoral wall categorizes fractures as intact, partial, or complete [110]. In this system, Group B and C fractures are considered unstable and cannot be treated with a sliding hip screw [110].

Iliofemoral Ligament Relationship: A new classification focusing on the relationship between the attachment of the iliofemoral ligament and the course of the fracture line serves as a useful communication tool for medical professionals in the diagnosis of intertrochanteric fractures [148].

Other Considerations: The pathogenesis of combined subcapital and intertrochanteric fractures is unclear and may differ in each case [11]. Intertrochanteric fractures are characterized by a disproportionately reduced greater trochanteric bone mineral density with relative preservation of other regions, rather than uniformly low composite hip density [12]. There is a high incidence of coronal fragments in intertrochanteric femur fractures when analyzed with 3D CT reconstructions [67]. The grouped fractures of basicervical and related trochanteric types share a common instability denominator and should be treated alike [145]. Unsupervised clustering using a Hausdorff distance–based K-means approach can achieve identification of the type of intertrochanteric fractures with clinical significance [43]. A novel classification system based on the lateral view of 3D-CT is proposed for predicting the reducibility of intertrochanteric fractures [153]. The AO/OTA and Evans-Jensen classification systems have limited utility in predicting the difficulty of achieving closed reduction intraoperatively due to their reliance on anteroposterior radiographs [153].

Clinical Presentation

Epidemiology and Demographics

Intertrochanteric fractures constitute 40% to 50% of all hip fractures [123]. Unlike femoral neck fractures, which are associated with generalized low bone density involving the proximal femur globally, intertrochanteric fractures demonstrate regional reduction in bone density [12].

Radiographic and Diagnostic Features

Insufficiency femoral intertrochanteric fractures associated with greater trochanteric avulsion fractures are often overlooked on standard radiographs but can be successfully identified and treated by internal fixation using MRI [24]. MRI evaluation of apparently isolated greater trochanter fractures is useful to diagnose the extent of occult fracture and determine the treatment strategy [50]. Greater trochanter fractures that do not cross > 50% of the intertrochanteric line and do not have a fracture angle between 35 and 42 degrees do not require further imaging as they will not have complete intertrochanteric extension [56]. Unsupervised clustering can achieve identification of the type of intertrochanteric fractures with clinical significance [43].

Frax Classification: * Stable patterns: AO/OTA type 31 A1 and A2.1 [45]. * Unstable patterns: AO/OTA type A2.2, 2.3 and A3 [45].

Complications and Associated Injuries

Vascular injury after an intertrochanteric fracture should be suspected from the appearance and position of the lesser trochanteric fragment and the presence of progressive anaemia after fixation [33]. Arterial injuries associated with hip fractures may present late as pseudoaneurysms, and greater awareness should lead to earlier detection and effective treatment [58]. The risk of the development of AVN of the femoral head is relatively high for unstable intertrochanteric fractures [22].

Secondary Fracture Risk: A high grade of osteoporosis is the most important predisposing factor in the spontaneous development of a subcapital femoral neck fracture after a healed intertrochanteric hip fracture [19]. Although subchondral positioning of the hip screw might diminish the incidence, adequate management of systemic osteoporosis should be targeted as a main factor of prevention for femoral neck fractures after internal fixation of trochanteric fractures [15].

Perioperative Blood Loss: Intertrochanteric fractures in elderly patients undergoing intramedullary fixation surgery were associated with significant perioperative hidden blood loss and anemia [60]. Elderly patients with unstable intertrochanteric fractures treated by intramedullary fixations have a significant amount of perioperative hidden blood loss, which is much greater than observed intra-operatively [61].

Malalignment and Fragment Displacement: 25.7% of patients undergoing internal fixation for trochanteric fractures experienced torsional malalignment, with unstable fractures and delayed operative time identified as major risk factors [35]. Displaced trochanter fragments lead to poor outcome in pertrochanteric fractures [28]. Intertrochanteric fractures with ≥10 mm of lesser trochanter displacement were associated with some poorer short-term functional and patient performance outcomes compared with patients with less displacement, although these differences diminished over time [4].

Prognosis and Outcomes

Mortality following intertrochanteric femoral fractures is largely determined by patient-related systemic factors, particularly heart failure and dementia, rather than fracture type or reduction quality [3]. Having three or more comorbid systemic diseases has been detected as the major determinant of 1-year mortality after primary cemented calcar-replacement bipolar hemiarthroplasty performed for unstable intertrochanteric fracture in elderly patients [29]. A hip fracture has a dramatic impact on the patients' HRQoL, and the deterioration in HRQoL sustained also one year after the fracture [31]. This paper shows the frustrating long-term outcome of geriatric hip fracture patients but it also suggests that an early geriatric intervention may lead to better function [27].

Investigations

Plain radiography: Conventional radiographs remain critical in the initial imaging evaluation of the hip and can be used to diagnose fractures [41]. A complete hip series usually consists of an anterior-posterior (AP) pelvis, a centered AP hip, a lateral view (frog-leg, cross-table, Dunn 45° or 90°), and a false-profile (Lequesne) view [41]. Radiographs remain integral to the assessment of fractures and can be supplemented with CT to further investigate suspected occult fractures, define fracture morphology, and assist in preoperative planning [41]. Additionally, radiographs can serially assess hardware positioning and evaluate symptomatic hardware related to open reduction and internal fixation [41].

CT: Computed tomography overcomes the limitations of radiography by providing three-dimensional assessment of bony morphology and, to some degree, assessment of soft-tissue abnormalities [84]. CT is helpful in fracture evaluation, particularly in the setting of negative radiographs, or for further defining fracture morphology in patients requiring surgical reduction [84]. CT scans are effective for examining cortical and cancellous bone and can be used to create three-dimensional reconstructions of the hip for use in surgical planning [99].

MRI: Magnetic resonance imaging is the modality of choice for patients suspected of soft tissue or intra-articular pathology, given its superior sensitivity and specificity [99].

Other Considerations: The Nottingham Hip Fracture Score (NHFS) was able to discriminate survival at all timepoints with similar accuracy to the validating studies in the hip fracture cohort [39].

Treatment

General Principles and Outcomes

One-year mortality rates following intertrochanteric hip fracture range between 10% and 30% [108]. Patient outcomes depend heavily on preinjury functional levels and medical comorbidities [108]. Appropriate identification of associated medical comorbidities, combined with medical and orthopaedic co-management and prompt surgical treatment, minimizes risks of complications, morbidity, and mortality while improving outcomes [108]. Multidisciplinary teams comprising primary care providers, geriatricians, internists, social workers, physiatrists, and care managers help lower treatment costs by decreasing complications and hospital lengths of stay [108]. Under orthopaedic and geriatric co-management, clinicians should prioritize attention to age and chronic disease in patients with femoral intertrochanteric fractures and provide anti-osteoporosis treatment when permitted [209]. A validated, condition-specific hip fracture score is required to improve outcome measurement and comparison across studies regarding the effect of displaced lesser trochanter fractures on patient outcomes [8].

Non-Operative

Conservative management of unstable intertrochanteric fractures is well tolerated by Chinese patients but requires a high standard of nursing care [160]. Minimally invasive treatment is feasible for most patients with old femoral fractures of the trochanter and femoral shaft [191]. In specific cases, such as intertrochanteric fractures below a Birmingham Hip Resurfacing, non-operative methods have been successfully used [62].

Operative

Indications: Surgery is indicated for the majority of intertrochanteric fractures, with the goal of delivering patient-appropriate care in a timely manner [108]. Arthroplasty is a validated indication for unstable trochanteric fractures in patients over 75 years, provided the procedure is performed by experienced operators [48]. For severe osteoporotic elderly patients with unstable fractures, bipolar hemiarthroplasty is an effective treatment method [114].

Surgical Approach / Technique: The cephalomedullary nail has emerged as the preferred construct for intertrochanteric femur fractures, with the majority of surgeons believing it is easier to use, associated with improved outcomes, or biomechanically superior [59]. For unstable trochanteric femoral fractures, one of the sliding hip screw systems provides a safe and simple alternative to intramedullary fixation [53]. The PRDS group presented better clinical effects for managing irreducible extracapsular hip fractures than the LOR group [69]. Managing bilateral intertrochanteric fractures in the elderly with severe trauma is challenging, but a coordinated multidisciplinary approach and one-stage bilateral internal fixation can lead to effective treatment outcomes and favorable prognoses [5].

Implant Selection: Implant choice should be based on fracture pattern, cost, and the surgeon’s familiarity [108]. The AMBI remains the gold standard for fractures of the trochanteric region [16]. Extramedullary fixation of stable intertrochanteric fractures significantly reduces perioperative blood loss but affords similar functional outcomes and times to union compared to intramedullary fixation [9]. Consequently, extramedullary implants are recommended for stable intertrochanteric fractures, especially in patients who are anemic or at high risk for hospital readmission [46]. Either a MIDHS or a CDHS is an effective, simple, and safe method for treating intertrochanteric fractures [112]. The Long IMHS is an effective device for sub-trochanteric and proximal femoral fractures, achieving a high rate of union with a low complication rate [30]. PFNA-II offers the advantages of a simple operation, few complications, and clinical efficacy [136]. Treatment with a PFLCP can provide good-to-excellent healing for pertrochanteric fractures with limited complications [140]. A superior locking nail can safely manage complex trochanteric fractures, as small differences in axial fracture movement are clinically insignificant [200].

Intramedullary nails have merits including lower rates of blood loss, femoral neck shortening, and non-union, but carry a shortcoming of increased risk of femoral fractures [189]. Total failure rates and re-operation rates were greater with intramedullary nails compared to sliding hip screws, with no evidence for a reduced failure rate with intramedullary nails in unstable trochanteric fractures [137]. Routine use of intramedullary hip-screws cannot be recommended for all intertrochanteric femoral fractures, although the device is a promising alternative for unstable fractures due to decreased shortening and the possibility of early weight-bearing [138]. In older patients, the InterTAN nail proved among the most effective in reducing nonmechanical major post-surgery complications but had the highest risk of intraoperative complications [52]. Caution should be used before the greater use of very short (< 200 mm) intramedullary nails for trochanteric hip fractures [119]. No measurable differences have been observed in the union or complication rates of modern short and long intramedullary nails, although long nails are associated with longer surgical times and more blood loss [167]. Long intramedullary nails are suited better for managing 31-A2.3 to 31-A3.3 fracture types [167]. The choice of nail length should be based on the surgeon’s assessment of fracture characteristics and surgeon preference, not simply on historical perception of fracture risk [167]. Failure of hip fracture surgery is more likely related to poor reduction and implant placement rather than implant size or design, with very few exceptions [167]. Based on evidence from randomised trials, the use of fixed nail plates for surgical fixation of A3 trochanteric hip fractures cannot be justified [55]. Routine distal locking is unnecessary for trochanteric fractures and should be used only where there is a subtrochanteric extension of the fractures [163].

Arthroplasty: While both bipolar hemiarthroplasty and closed reduction and internal fixation are effective treatments for unstable intertrochanteric fractures, bipolar hemiarthroplasty offers a clinically meaningful advantage in early-to-mid-term gait recovery [51]. Both PFNA and cementless bipolar hemiarthroplasty are safe and effective treatments for femoral intertrochanteric fracture in elderly patients [133]. Arthroplasty in unstable trochanteric fractures in patients over 75 years shows better and earlier clinical results with lower mechanical complication rates compared to nailing [48].

Adjuncts: Intravenous TXA administration is supported by robust evidence for efficacy and safety in treating geriatric intertrochanteric femoral fractures with intramedullary nailing [120].

Setting of Care: The treatment of intertrochanteric fractures of elderly patients with a modified external fixator provides significant advantages such as minimal operative and anaesthetic risks, no blood loss, early weight-bearing, short hospitalisation time, and rapid union time [72].

Salvage and Complications: The clinical and radiographic results of salvage treatment for failed fixation of intertrochanteric fracture were satisfactory [7]. Additional studies are required to specify the influence of fracture characteristics on complication rate and function and to establish a classification system with clear treatment recommendations for unstable intertrochanteric fractures [2].

Complications

Mortality and Systemic Factors: Having three or more comorbid systemic diseases is a major determinant of 1-year mortality after primary cemented calcar-replacement bipolar hemiarthroplasty for unstable intertrochanteric fracture in elderly patients [29]. Low serum albumin and advanced age are independent risk factors for long-term mortality in elderly patients with intertrochanteric fractures [54]. Different anaesthesia methods do not affect the incidence of adverse events such as death within 30 days after surgery in oldest-old patients (aged 90 years and older) with intertrochanteric fractures [57].

Perioperative Blood Loss: Intertrochanteric fractures in elderly patients undergoing intramedullary fixation surgery are associated with significant perioperative hidden blood loss and anemia [60].

Mechanical and Implant-Related Complications: The risk of the development of avascular necrosis (AVN) of the femoral head is relatively high for unstable intertrochanteric fractures treated with gamma-nailing [22]. There is a 12.5% increase in the risk of 30-day mortality associated with the use of an intramedullary nail compared with a sliding hip screw in the treatment of trochanteric fractures of the hip [142].

Secondary Fractures and Late Complications: Although subchondral positioning of the hip screw might diminish the incidence of femoral neck fractures after internal fixation, adequate management of systemic osteoporosis should be targeted as a main factor of prevention [15]. In reported cases of femoral neck fractures following removal of hardware in healed trochanteric fractures, the mean interval from implant removal to fracture was 18 days, with a range of 2 to 120 days [188]. The fracture was spontaneous (no trauma) in 87.5% of cases and mild trauma in 12.5% [188]. The fracture site was subcapital in 95.55% of cases and transcervical in 4.44% [188].

Functional Outcomes and Quality of Life: A hip fracture has a dramatic impact on patients' health-related quality of life (HRQoL), and the deterioration in HRQoL is sustained one year after the fracture [31]. Although pain at the hip was not a major problem after subtrochanteric fracture treatment, there was an obvious deterioration in walking ability and activities of daily living (ADL) function [25]. Long-term functional outcomes in geriatric hip fracture patients are often frustrating, but early geriatric intervention may lead to better function [27].

Salvage and Revision Surgery: The most common complication in patients converted to hip arthroplasty after extramedullary fixation for intertrochanteric fractures was late periprosthetic fracture, occurring in 6% of cases compared to 0% in the intramedullary hip screw group [65]. Intraoperative femoral fracture occurred in 12% of patients converted to hip arthroplasty after intramedullary hip screw fixation for intertrochanteric fractures, compared to 1% in the extramedullary fixation group [65]. The overall complication rate for conversion hip arthroplasty after intertrochanteric fracture fixation was 21% for extramedullary devices and 27% for intramedullary hip screws [65]. Outcomes of cementless total hip arthroplasty following failed internal fixation for intertrochanteric fractures were satisfactory, though increased intraoperative blood loss, operating time, and requirement of a long femoral stem should be considered [131]. Total hip replacement is a difficult operation for complications of intertrochanteric fractures, and preoperative planning is paramount for success [34]. The short-term survivorship of conversion hip arthroplasty after surgical treatment of an intertrochanteric fracture is excellent regardless of the original fracture fixation method [65].

Other Considerations: The rate of revision surgery following cephalomedullary nail treatment for subtrochanteric fractures was comparatively low [25].

Recovery

Functional Outcomes and Quality of Life: Displaced trochanter fragments lead to poor outcome in pertrochanteric fractures treated by cephalomedullary nails [28]. Although pain at the hip was not a major problem, there was an obvious deterioration in walking ability and activities of daily living (ADL) function; however, the rate of revision surgery was comparatively low, confirming that the cephalomedullary nail constitutes a safe treatment [25]. While both bipolar hemiarthroplasty (BHA) and closed reduction internal fixation (CRIF) are effective treatments for unstable intertrochanteric fractures, BHA offers a clinically meaningful advantage in early-to-mid-term gait recovery [51]. Patients with unstable extracapsular hip fractures may require a prolonged rehabilitation period in order to achieve the same functional gain as patients with stable fractures [152]. Geriatric intertrochanteric fracture patients with Parkinson’s disease (PD) had significantly lower survival rates, worse hip joint function, a higher rate of internal fixation failure, worse activities of daily living, and higher depressive emotional tendency compared to patients without PD [130]. The presence of a Trendelenburg gait at last clinical follow-up was similar between groups (37% in the EFD group and 38% in the IMHS group) following conversion hip arthroplasty after surgical treatment of an intertrochanteric fracture [65].

Mortality and Systemic Determinants: Low serum albumin and advanced age were independent risk factors for long-term mortality in elderly patients with intertrochanteric fractures [54]. Different anaesthesia methods do not affect the incidence of adverse events such as death within 30 days after surgery in oldest-old patients with intertrochanteric fractures [57]. The Nottingham Hip Fracture Score (NHFS) was able to discriminate survival at all timepoints with similar accuracy to the validating studies in the hip fracture cohort [39].

Complications and Complications of Treatment: The most common complication was late periprosthetic fracture in the EFD patients (6% vs 0% in IMHS; P = .29) and intraoperative femoral fracture in the IMHS patients (12% vs 1% in EFD; P = .02) following conversion hip arthroplasty [65]. The overall complication rate was similar (21% for EFD vs 27% for IMHS; P = .51) between groups following conversion hip arthroplasty after surgical treatment of an intertrochanteric fracture [65]. Delayed union after subtrochanteric femur fracture occurs frequently [220]. Despite modern treatment, the patient-reported outcomes of lower limb long bone shaft fractures do not return to normal at one year [222].

Union and Salvage: Fracture union occurred in 82 per cent of patients treated with parallel Garden screws for intracapsular femoral fractures [221]. The short-term survivorship of conversion hip arthroplasty after surgical treatment of an intertrochanteric fracture is excellent regardless of original fracture fixation method [65]. Five-year survivorship free of revision was 95% in the EFD group and 94% in the IMHS group (P = 1.0) following conversion hip arthroplasty [65].

Key Evidence

• [L4] The review analyzes intertrochanteric fractures from standpoints of epidemiology, classification, treatment and results. [1] (10.1016/0020-1383(83)90093-1)
• [L5] Additional studies are required to specify the influence of fracture characteristics on complication rate and function and to establish a classification system with clear treatment recommendations for unstable intertrochanteric fractures. [2] (10.1007/s11999-013-2834-9)
• [L3] Mortality following intertrochanteric femoral fractures is largely determined by patient-related systemic factors, particularly heart failure and dementia, rather than fracture type or reduction quality. [3] (10.1186/s13018-026-06813-4)
• [L2] Intertrochanteric fractures with ≥10 mm of lesser trochanter displacement were associated with some poorer short-term functional and patient performance outcomes compared with patients with less displacement, although these differences diminished over time. [4] (10.1097/corr.0000000000003574)
• [Case_report] Managing bilateral intertrochanteric fractures in the elderly with severe trauma is challenging, but a coordinated multidisciplinary approach and one-stage bilateral internal fixation can lead to effective treatment outcomes and favorable prognoses. [5] (10.1186/s12891-024-07432-y)
• [L4] The mechanism of injury determines the character of intertrochanteric fractures in young adults. [6] (10.1007/s004020000190)
• [L3] The clinical and radiographic results of the salvage treatment for the failed fixation of intertrochanteric fracture were satisfactory. [7] (10.1016/j.injury.2019.12.004)
• [Paper] This CORR Insights® commentary discusses the controversy regarding the effect of displaced lesser trochanter fractures on patient outcomes and highlights the need for a validated, condition-specific hip fracture score to improve outcome measurement and comparison across studies. [8] (10.1097/corr.0000000000003630)
• [L1] Extramedullary fixation of stable intertrochanteric fractures significantly reduces perioperative blood loss but affords similar functional outcomes and times to union compared to intramedullary fixation. [9] (10.1186/s12891-016-1333-z)
• [L3] The results suggest that arthroplasty is associated with superior results to internal fixation in patients older than 80 years with comminuted intertrochanteric fractures and severe osteoporosis. [10] (10.1016/j.arth.2011.03.003)
• [L4] The pathogenesis of combined subcapital and intertrochanteric fractures is unclear and may differ in each case. [11] (10.1016/0020-1383(95)00173-5)
• [L3] Intertrochanteric fractures are characterized by a disproportionately reduced greater trochanteric bone mineral density with relative preservation of other regions, rather than uniformly low composite hip density, whereas femoral neck fractures are associated with more generalized low bone density involving the proximal femur globally. [12] (10.1186/s12891-026-09776-z)
• [L3] Despite differences in terms of demographic and injury characteristics, patients who sustain a subtrochanteric femur fracture can expect similar outcome profiles regardless of fracture type. [13] (10.2106/jbjs.23.00583)
• [L4] Although subchondral positioning of the hip screw might diminish the incidence, adequate management of systemic osteoporosis should be targeted as a main factor of prevention. [15] (10.1016/j.injury.2018.11.007)
• [L1] The AMBI remains the gold standard for fractures of the trochanteric region. [16] (10.1007/s00402-005-0021-5)
• [L5] The Appropriate Use Criteria for the Management of Hip Fractures in the Elderly provide a framework for clinicians to determine the appropriateness of various treatments and rehabilitation interventions based on specific patient scenarios, with 52% of treatment items rated as rarely appropriate and 76% of rehabilitation items rated as appropriate. [17] (10.2106/jbjs.16.00260)
• [L3] A high grade of osteoporosis is the most important predisposing factor in the spontaneous development of a subcapital femoral neck fracture after a healed intertrochanteric hip fracture. [19] (10.1007/s004020050408)
• [L4] The risk of the development of AVN of the femoral head is relatively high for unstable intertrochanteric fractures. [22] (10.1007/s004020100276)
• [L5] Insufficiency femoral intertrochanteric fractures associated with greater trochanteric avulsion fractures were often overlooked on radiographs but successfully identified and treated by internal fixation using MRI. [24] (10.1007/s00402-011-1358-6)
• [L3] Although pain at the hip was not a major problem there was an obvious deterioration in walking ability and ADL function, but the rate of revision surgery was comparatively low which confirms that the cephalomedullary nail constitutes a safe treatment. [25] (10.1016/j.injury.2008.09.010)
• [L3] This paper shows the frustrating long-term outcome of geriatric hip fracture patients but it also suggests that an early geriatric intervention may lead to better function. [27] (10.1007/s00402-011-1313-6)
• [L3] Displaced trochanter fragments lead to poor outcome in pertrochanteric fractures. [28] (10.1016/j.injury.2015.06.040)
• [L3] Having three or more comorbid systemic diseases has been detected as the major determinant of 1-year mortality after primary cemented calcar-replacement bipolar hemiarthroplasty performed for unstable intertrochanteric fracture in elderly patients. [29] (10.1016/j.arth.2017.04.042)
• [L4] The Long IMHS is an effective device for the treatment of sub-trochanteric and proximal femoral fractures with a high rate of union achieved and a low complication rate. [30] (10.1016/j.injury.2003.12.011)
• [L3] A hip fracture has a dramatic impact on the patients' HRQoL, and the deterioration in HRQoL sustained also one year after the fracture. [31] (10.1186/s12891-016-1111-y)
• [L4] There remains conflicting evidence to guide the choice of implant for intertrochanteric fractures. [32] (10.1302/0301-620x.99b1.bjj-2016-0134.r1)
• [L5] Vascular injury after an intertrochanteric fracture should be suspected from the appearance and position of the lesser trochanteric fragment and the presence of progressive anaemia after fixation. [33] (10.1016/0020-1383(93)90065-e)
• [L4] Total hip replacement is a difficult operation for complications of intertrochanteric fractures, and preoperative planning is paramount for success. [34] (10.1097/01.blo.0000150113.11866.48)
• [L3] 25.7% of patients undergoing internal fixation for trochanteric fractures experienced torsional malalignment, with unstable fractures and delayed operative time identified as major risk factors. [35] (10.1016/j.injury.2015.07.015)
• [L4] External fixation is the method of choice for high-risk geriatric patients with intertrochanteric fracture. [36] (10.1016/0020-1383(95)00172-7)
• [L4] The risk of driving the head into the acetabulum must be anticipated, even when the acetabular fracture is only slightly displaced. [38] (10.1016/s0020-1383(80)80053-2)
• [L3] NHFS was able to discriminate survival at all timepoints with similar accuracy to the validating studies in the hip fracture cohort. [39] (10.1302/0301-620x.107b11.bjj-2024-1635.r2)
• [L3] The unsupervised clustering can achieve identification of the type of intertrochanteric fractures with clinical significance. [43] (10.1016/j.injury.2019.03.032)
• [L3] Good outcomes cannot be achieved with traction alone for femoral intertrochanteric fractures. [44] (10.1016/j.injury.2019.10.087)
• [Paper] [45] (10.1007/s00402-017-2857-x)
• [L3] The authors recommend considering extramedullary implants for stable intertrochanteric fractures, especially in patients who are anemic or at high risk for hospital readmission. [46] (10.5435/jaaos-d-21-00657)
• [L3] The study validated the indication of arthroplasty in unstable trochanteric fractures in patients over 75 years, showing better and earlier clinical results with lower mechanical complication rates compared to nailing, provided the procedure is performed by experienced operators. [48] (10.1016/j.otsr.2011.06.009)
• [L3] MRI evaluation of apparently isolated greater trochanter fractures is useful to diagnose the extent of occult fracture and determine the treatment strategy. [50] (10.1016/j.injury.2018.03.017)
• [L3] While both BHA and CRIF are effective treatments for unstable intertrochanteric fractures, BHA offers a clinically meaningful advantage in early-to-mid-term gait recovery. [51] (10.1186/s13018-026-06961-7)
• [L1] In older patients with intertrochanteric fractures, InterTAN nail proved among the most effective in reducing nonmechanical major post-surgery complications, but had the highest risk of intraoperative complications. [52] (10.1186/s12891-025-09032-w)
• [L1] For these fractures one of the sliding hip screw systems provides a safe and simple alternative. [53] (10.1016/s0020-1383(03)00287-0)
• [L3] Low serum albumin and advanced age were independent risk factors for long-term mortality in elderly patients with intertrochanteric fractures. [54] (10.1186/s12891-022-05442-2)
• [L1] Based on the evidence to date from randomised trials, the use of fixed nail plates for surgical fixation of A3 trochanteric hip fractures cannot be justified. [55] (10.1016/j.injury.2018.05.017)
• [L4] Greater trochanter fractures that do not cross > 50% of the intertrochanteric line and do not have a fracture angle between 35 and 42 degrees do not require further imaging as they will not have complete intertrochanteric extension. [56] (10.1016/j.injury.2017.01.017)
• [L3] Different anaesthesia methods do not affect the incidence of adverse events such as death within 30 days after surgery in oldest-old patients with intertrochanteric fractures. [57] (10.1186/s12891-023-06973-y)
• [L4] Arterial injuries associated with hip fractures may present late as pseudoaneurysms, and greater awareness should lead to earlier detection and effective treatment. [58] (10.1007/s004020050372)
• [L5] Despite equivalent outcomes for most intertrochanteric femur fractures, the cephalomedullary nail has emerged as the preferred construct, with the majority of surgeons believing it is easier to use, associated with improved outcomes, or is biomechanically superior. [59] (10.1007/s11999-015-4469-5)
• [L3] Intertrochanteric fractures in elderly patients undergoing intramedullary fixation surgery were associated with significant perioperative hidden blood loss and anemia. [60] (10.1007/s00402-019-03311-7)
• [L3] Elderly patients with unstable intertrochanteric fractures treated by intramedullary fixations have a significant amount of perioperative hidden blood loss, which is much greater than observed intra-operatively. [61] (10.1016/j.injury.2017.06.017)
• [L4] The authors successfully managed two cases of intertrochanteric fracture below Birmingham Hip Resurfacing using non-operative methods. [62] (10.1016/j.injury.2008.10.040)
• [L2] This national register-based study indicates a lower reoperation rate for IMN than SHS for unstable trochanteric and subtrochanteric fractures, but not for stable fractures or individual fracture types. [63] (10.1302/0301-620x.104b2.bjj-2021-1078.r1)
• [L3] [65] (10.1016/j.arth.2017.06.032)
• [L3] The implementation of an evidence-based algorithm for the treatment of intertrochanteric fractures reduced costs while maintaining quality of care with a lower rate of complications and re-admissions. [66] (10.1302/0301-620x.96b9.34153)
• [L4] There is a high incidence of coronal fragments in intertrochanteric femur fractures when analyzed with 3D CT reconstructions. [67] (10.1016/j.injury.2016.12.015)
• [L3] The PRDS group presented better clinical effects for managing irreducible extracapsular hip fractures than the LOR group. [69] (10.1186/s12891-022-05390-x)
• [Paper] The treatment of intertrochanteric fractures of elderly patients with this modification provides significant advantages such as minimal operative and anaesthetic risks, no blood loss, early weight-bearing, short hospitalisation time and rapid union time. [72] (10.1016/j.injury.2004.10.013)
• [L3] Adverse fracture-implant motions were detected in stable trochanteric hip fractures treated with intramedullary nails with high resolution. [77] (10.1016/j.injury.2018.01.005)
• [L4] The AO classification system with groups can be used more reliably to measure intertrochanteric fractures of the proximal femur than Evans, Kyle, and Boyd classification systems. [109] (10.1016/j.injury.2005.02.005)
• [L5] The authors propose a new classification of intertrochanteric fractures based on the integrity of the lateral femoral wall (intact, partial, or complete), suggesting that Group B and C fractures are unstable and cannot be treated with SHS. [110] (10.1016/j.injury.2017.07.030)
• [L3] Either a MIDHS or a CDHS in the treatment of intertrochanteric fractures is an effective, simple and safe method. [112] (10.1007/s00264-006-0248-y)
• [Paper] For the severe osteoporotic elderly with unstable fractures, bipolar hemiarthroplasty is an effective method to treat the unstable intertrochanteric fractures. [114] (10.1016/j.injury.2020.01.010)
• [L1] Caution should be used before the greater use of very short (< 200 mm) intramedullary nails for the treatment of trochanteric hip fractures. [119] (10.1302/0301-620x.102b3.bjj-2019-0776.r3)
• [L1] Our meta-analysis provides robust evidence supporting the efficacy and safety of intravenous TXA administration in treating geriatric intertrochanteric femoral fractures with intramedullary nailing. [120] (10.1186/s12891-023-06725-y)
• [L5] [123] (10.1016/j.eats.2024.103317)
• [L3] Geriatric intertrochanteric fracture patients with PD had significantly lower survival rates, worse hip joint function, a higher rate of internal fixation failure, worse activities of daily living and higher depressive emotional tendency compared to patients without PD. [130] (10.1016/j.otsr.2019.11.022)
• [L3] Outcomes of cementless THA following failed internal fixation for femoral neck and intertrochanteric fractures were satisfactory; increased intraoperative blood loss, operating time, and requirement of long femoral stem should be considered in the latter type of fracture. [131] (10.1016/j.injury.2019.01.018)
• [L3] Both PFNA and CPH are safe and effective treatments for femoral intertrochanteric fracture in elderly patients. [133] (10.1186/s12891-019-2793-8)
• [L4] PFNA-II has the advantages of a simple operation, few complications, and clinical efficacy for the treatment of intertrochanteric fractures. [136] (10.1186/s13018-014-0112-5)
• [L1] However, total failure rates and re-operation rates were greater with IMN compared to SHS, with no evidence for a reduced failure rate with IMN in unstable trochanteric fractures. [137] (10.1007/s00264-005-0028-0)
• [L1] Routine use of intramedullary hip-screws cannot be recommended for the treatment of intertrochanteric femoral fractures, although the device is a promising alternative for unstable fractures due to decreased shortening and the possibility of early weight-bearing. [138] (10.2106/00004623-199805000-00002)
• [L4] Treatment with a PFLCP can provide good-to-excellent healing for pertrochanteric fractures, with a limited occurrence of complications. [140] (10.1016/j.injury.2011.01.030)
• [L2] There is a 12.5% increase in the risk of 30-day mortality associated with the use of an intramedullary nail compared with a sliding hip screw in the treatment of trochanteric fractures of the hip. [142] (10.1302/0301-620x.101b1.bjj-2018-0601.r2)
• [L4] Although both have similar functional outcomes according to Harris Hip Scores and PFNA is more preferable choice due to lower complication rate and less invasive nature, the hemiarthroplasty is still one of the best ways to treat unstable comminuted and/or severe osteoporosis of elderly intertrochanteric fracture. [144] (10.1016/s0020-1383(13)70073-1)
• [L4] The grouped fractures (basicervical and related trochanteric types) share a common instability denominator and should be treated alike. [145] (10.1007/s00264-009-0814-1)
• [L3] [146] (10.1016/j.injury.2010.07.499)
• [L4] The new classification focusing on the relationship between the attachment of the iliofemoral ligament and the course of the fracture line is a useful communication tool for medical professionals in the diagnosis of fractures. [148] (10.1016/j.injury.2016.05.015)
• [L3] Patients with unstable extracapsular hip fractures may require a prolonged rehabilitation period in order to achieve the same functional gain as patients with stable fractures. [152] (10.1016/j.injury.2018.05.023)
• [L4] [153] (10.1186/s13018-026-07044-3)
• [L2] Only the highest-volume hospitals showed an inpatient mortality benefit for Medicare patients with intertrochanteric hip fractures. [154] (10.2106/jbjs.h.01204)
• [L3] The integrity of the lesser trochanter has no significant influence on the surgical outcome of intramedullary nail internal fixation of femoral intertrochanteric fractures. [156] (10.1186/s12891-015-0492-7)
• [L1] Conservative management of unstable intertrochanteric fractures is well tolerated by Chinese patients but requires a good standard of nursing care. [160] (10.1016/0020-1383(81)90049-8)
• [L1] [163] (10.1016/j.injury.2016.07.038)
• [L5] [167] (10.5435/jaaos-d-15-00325)
• [L4] [188] (10.1016/j.injury.2017.11.031)
• [L1] Hip fractures treated with IMN have merits with lower rate of blood loss, femoral neck shortening and non-union; shortcoming of increased risk of femoral fractures. [189] (10.1186/s12891-023-06715-0)
• [L4] Minimally invasive treatment is feasible for most patients with old femoral fractures of the trochanter and femoral shaft. [191] (10.1016/j.injury.2019.03.002)
• [L5] There are small differences in axial fracture movement which are clinically insignificant, and a superior locking nail can safely be used to manage complex trochanteric fractures. [200] (10.1186/s13018-024-05079-y)
• [L5] The calcar femorale can redistribute stresses and the destruction of the calcar femorale can lead to an increase in posterior medial stress. [208] (10.1186/s12891-021-04324-3)
• [L2] Under the co-management of orthopedics and geriatrics, doctors should pay more attention to age and chronic disease in Chinese patients with femoral intertrochanteric fracture, and give anti-osteoporosis treatment if allowed. [209] (10.1186/s13018-021-02874-9)
• [L4] [213] (10.1016/s0020-1383(13)70017-2)
• [L3] Delayed union after subtrochanteric femur fracture occurs frequently. [220] (10.1186/s12891-019-2775-x)
• [L2] Fracture union occurred in 82 per cent of patients. [221] (10.1016/0020-1383(94)90131-7)
• [L3] Despite modern treatment, the patient-reported outcomes of lower limb long bone shaft fractures do not return to normal at one year. [222] (10.1016/j.injury.2014.06.025)

See Also

• Hip resurfacing
• Subtrochanteric fracture
• Total hip replacement

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