7/18/21 Newsletter: Unstable Intertrochanteric Femur Fractures

Ortho Trauma Survival Guide


Trauma Bay Management: High energy trauma

The trauma bay can be intimidating. It helps to have a systematic approach down so you don’t miss steps and you can create order out of the chaos. These are the things we focus on when we’re in the trauma bay.

Systematic Process in Order of priority:

  • Pelvis binder? (Place if able to close down volume of pelvis)

  • Fracture finding and exam (call out xrays and imaging you need if someone is standing by)

  • Irrigation, note what is injured, CT if concerned for traumatic arthrotomy

  • Prioritize and execute plan while setting up supplies

  • Reduction, Splinting, and Traction

    • Any dislocated joint from carpals to tarsals should be reduced (except spine)

  • Notes:

    • Ideally if stable you get all imaging done prior to all procedures (avoid multiple sedations)

    • Important: Take pictures of all open injuries, any rule out nec fasc, bad cellulitis, and video patients that have bad injuries with concern for nerve damage, moving their extremities around so the attendings believe you and you have ammo to support your physical exam

Ortho Forge Discussion Highlights

Highlights from the Ortho Forge Community on Discord. Here is an adaptation from one of our case discussions.

New topic: ~80 female, ground level fall. How would you describe this frx?

This is an AP view of a left hip in a skeletally mature individual demonstrating an unstable intertrochanteric femur fracture with reverse obliquity and posterior medial calcar involvement. 

What are the four factors of instability for intertrochanteric femur frxs?

1. Reverse obliquity

AP of a right hip in a skeletally mature individual with a right comminuted unstable intertrochanteric femur fracture. There is reverse obliquity (fracture extending from the medial proximal to distal lateral) as well as subtrochanteric extension (the fracture line extending distal to the base of the lesser trochanter).

2. Posteromedial calcar involvement

AP of a left hip in a skeletally mature individual with an unstable intertrochanteric femur fracture, it has standard obliquity with posteromedial calcar involvement.


A fracture of the lesser trochanter by itself does not always involve the calcar, but it should make you suspicious. 

If there is a fracture that involves the base of the lesser troch that extends into part of the femoral shaft as seen in the xray above, then this in my mind would be considered to involve the calcar and be in the unstable category. Some Attendings would still use a short nail for this fracture.

3. Thin lateral wall or lateral wall involvement

AP of the right hip showing a standard obliquity right intertrochanteric femur fracture with a thin lateral wall. There is a very thin wall of bone on the lateral side of the femur as well as a lesser trochanteric piece. 

Thin lateral walls are not strong enough to support a sliding hip screw, so a cephalomedullary nail (long or short depending on who you talk to) would be the right answer.

Avoid sliding hip screws with thin lateral wall intertrochanteric femur fractures. 

4. Intertroch with subtroch extension.

AP of a left hip showing an intetrochanteric (IT) femur fracture with subtrochanteric extension.

In pure subtrochanteric femur fractures (unlike this one) the lesser trochanter is still connected to the proximal fracture fragment causing it to flex from the iliopsoas muscle attachment to the lesser trochanter and externally rotate from the short external rotator muscles (piriformis, superior and inferior gemelli, obturator internus, and quadratus femoris). In the fracture above, the lesser trochanter is attached to the distal fragment.

How are unstable IT femur fractures treated? 

Those are the main types of unstable intertrochanteri femur fractures. Unstable IT fractures are commonly treated with a long cephalomedullary nail. Stable IT fractures are commonly treated with short cephalomedullary nails and sometimes sliding hip screws.

If you have any questions about this connect with us on our Discord chat: https://discord.gg/pysgWhDkjR

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