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Intertrochanteric fracture

109 citationsUpdated Sep 2026

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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, particularly heart failure and dementia, rather than fracture type or reduction quality [3]. Only the highest-volume hospitals showed an inpatient mortality benefit for Medicare patients with intertrochanteric hip fractures [154]. 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 is biomechanically superior [59]. However, there remains conflicting evidence to guide the choice of implant for intertrochanteric fractures [32].

Treatment selection depends on fracture stability and patient comorbidity. 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]. A national register-based study indicates a lower reoperation rate for intramedullary nails than sliding hip screws for unstable trochanteric and subtrochanteric fractures, but not for stable fractures or individual fracture types [63]. 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].

Arthroplasty is associated with superior results to internal fixation in patients older than 80 years with comminuted intertrochanteric fractures and severe osteoporosis [10]. This indication is validated 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]. 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]. Total hip replacement is a difficult operation for complications of intertrochanteric fractures, and preoperative planning is paramount for success [34]. External fixation is the method of choice for high-risk geriatric patients with intertrochanteric fracture [36]. Good outcomes cannot be achieved with traction alone for femoral intertrochanteric fractures [44]. The clinical and radiographic results of the salvage treatment for the failed fixation of intertrochanteric fracture were satisfactory [7]. 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]. 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].

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]. The femoral head forms two-thirds of a sphere, with a small central depression from which the ligamentum teres extends to connect to the acetabular notch [82].

The femoral neck-shaft angle 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, 89]. Normal version, defined as the head-neck angle in the frontal plane, averages 15 to 20° [82], while the mean anteversion of the femoral neck is 10° ± 7° [92] and approximately 14 degrees in relation to femoral condyles, with a range of 1–40 degrees [88, 89]. At the junction of the neck and shaft are the greater and lesser trochanters, connected by the intertrochanteric line anteriorly and the intertrochanteric crest posteriorly [82]. The acetabulum is normally anteverted 15 degrees and obliquely oriented in the coronal plane 45 degrees caudally, with the posterosuperior articular surface thickened to accommodate weight bearing [88, 89]. The inferior surface of the acetabulum contains the acetabular (cotyloid) notch, which is bound by the transverse acetabular ligament [88, 89].

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, which accounts for longer healing time after a fracture [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, whilst 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, with secondary compressive and tensile trabecular groups also present [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, and 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 capsule attaches anteriorly and posteriorly along the periphery of the acetabulum outside the labrum, and inferiorly to the acetabular labrum [83]. On the femur, the capsule is attached anteriorly along the intertrochanteric crest [83]. Posteriorly, the capsule attaches only partially, such that the basicervical region of the femoral neck and the intertrochanteric region of the femur are not intracapsular [83]. The hip joint capsule extends anteriorly to the intertrochanteric crest but posteriorly only partially across the femoral neck, leaving the basicervical and intertrochanteric crest regions extracapsular [79, 80]. The capsule is tight in extension and internal rotation, and relaxed in flexion and external rotation [79, 80].

The iliofemoral ligament is Y-shaped and is the thickest and strongest of the three main ligaments supporting the hip [82]. Also known as the Y ligament of Bigelow, it originates at the anterior inferior iliac spine (AIIS) and inserts at the intertrochanteric line in an inverted Y manner [83, 79, 80]. The medial portion connects the AIIS to the anterior intertrochanteric line, while the lateral portion originates slightly superior to the medial arm and attaches to the anterior greater trochanter [82]. The iliofemoral ligament functions to limit external rotation [82], and in isolation, 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 ligament extends from the ischial margin of the acetabulum to the greater trochanter of the femur, providing support posteriorly and restricting internal rotation motion [82]. The pubofemoral ligament extends from the obturator crest of the pubic bone to the femoral neck, acting to limit abduction of the joint [82]. The ischiofemoral and pubofemoral ligaments are weaker but provide additional stability [79, 80]. Deep fibers from all three ligaments merge to form the zona orbicularis, which circumvents the femoral neck [82].

The ligamentum teres originates in the cotyloid fossa and attaches on the fovea of the femoral head [83]. It arises from the apex of the cotyloid notch and attaches to the fovea of the femoral head, transmitting an arterial branch of the posterior division of the obturator artery to the femoral head, which is less significant in adults [79, 80]. The sacrospinous and sacrotuberous ligaments create the boundaries of the greater and lesser sciatic foramina [83]. The sacrospinous ligament creates the upper border of the lesser sciatic foramen and the lower border of the greater sciatic foramen, while the sacrotuberous ligament creates the inferior border of the lesser sciatic foramen [83]. The piriformis muscle and the sciatic nerve exit from the greater sciatic foramen, and the short external rotator muscles exit from the lesser sciatic foramen [83].

Muscles

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, which function together to maintain and abduct the femur during the stance phase of gait [90]. The gluteus medius has three different components: anterior, middle, and posterior [90]. A Trendelenburg lurch is an attempt by the body to compensate for abductor weakness by bringing the center of gravity closer to the hip center, forcing the patient to lean toward the affected side [90].

The adductor muscles of the hip include the adductor brevis, the adductor longus, the adductors magnus, the pectineus, and the 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 piriformis forms the reference structure for the posterior part of the hip [90]. The most consistent internal rotators of the hip joint are the gluteus medius and tensor fascia latae muscles [90].

The iliopsoas muscle has a large origin along the iliac crest, the iliac fossa, the sacra ala, the iliolumbar ligaments, and the sacroiliac ligaments [90]. It also has origins along the bodies of the T12 through L4 thoracic lumbar vertebra, the transverse process of the first through fifth lumbar vertebra, and the intervertebral disks [90]. The rectus femoris crosses the hip joint and the knee joint; its straight head originates from the AIIS, whereas the reflected head originates from the supra-acetabular tubercle at the superior-anterior edge of the acetabulum [90]. The sartorius muscle originates on the ASIS, crosses the hip and knee joints, and inserts on the medial aspect of the tibia and the pes anserine complex [90]. The tensor fasciae latae muscle originates laterally on the anterolateral edge of the iliac crest, with an action to flex, abduct, and rotate the hip [90]. The gluteus maximus originates from the sacrum, the coccyx, and the sacrotuberous ligaments, while the hamstring muscles originate on the ischial tuberosity [90]. The obturator internus muscle originates from the inner component of the obturator foramen and emerges through the lesser sciatic foramen [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, the internal pudendal artery, the nerve to the obturator internus, the posterior femoral cutaneous nerve, the sciatic nerve, the inferior gluteal nerve, the inferior gluteal artery, and the nerve to the quadratus femoris all 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]. Most often, the sciatic nerve passes below the piriformis and is situated on top of the short external rotators [90].

Vascular Anatomy

The medial femoral circumflex artery is the main blood supply to the femoral head, terminating 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, and the superior and inferior gluteal arteries also contribute branches to this ring [92]. The ascending cervical arteries originate from the extracapsular arterial ring and are divided into four distinct groups based on their anatomic relationship to the femoral neck: lateral, medial, posterior, and anterior [92]. The lateral group of ascending branches is the main blood supply to the femoral head [92]. These 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 but does not provide sufficient blood supply to maintain the viability of the femoral head [92].

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 to the femoral head [95]. In adulthood, the major blood supply to the femoral head is from the medial femoral circumflex and lateral epiphyseal arteries [95].

The common femoral artery arises from the external iliac artery as it passes underneath the inguinal ligament, passing anterior and medial to the hip capsule [95]. The common femoral vein is a continuation of the external iliac vein [95]. The common femoral vessels are the most commonly reported extrapelvic vascular structures that are injured during total hip arthroplasty, with the most common mechanism of injury being errant retractor placement anterior to the acetabulum [95]. The profundus or deep femoral artery arises from the lateral aspect of the common femoral artery approximately 3.5 cm below the inguinal ligament and travels between the pectineus and adductor longus muscles [95]. The lateral circumflex artery arises from the lateral side of the proximal profundus femoris artery [95]. The medial circumflex artery most commonly comes from the posteromedial profundus femoris artery but may also come directly from the femoral artery; it traverses between the pectineus and psoas muscles and appears at the upper border of the quadratus femoris [95].

The superior gluteal vessels are branches of the posterior division of the internal iliac artery and are closest to the hip as they exit from the sciatic notch [95]. Superior gluteal artery injury can occur with the placement of screws in the region of the sciatic notch [95]. The inferior gluteal vessels and internal vessels are branches of the anterior division of the internal iliac artery, exiting the pelvis between the piriformis and coccygeus muscles [95]. These vessels can be injured by screws in the posterior column that are at least 5 mm past the bony margin [95].

Fracture Pathophysiology

Intertrochanteric fractures are considered extracapsular fractures [92]. Callus formation is common in intertrochanteric fracture patterns, and nonunion is rare because of the absence of synovial fluid and the presence of an abundant blood supply [92]. Intertrochanteric femur fractures account for approximately 50% of all proximal femur fractures [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, although these differences 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]. 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.

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 as 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].

Evans-Jensen: 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].

Other Considerations: A proposed classification based on the integrity of the lateral femoral wall (intact, partial, or complete) suggests that Group B and C fractures are unstable and cannot be treated with a sliding hip screw [110]. Grouped basicervical and related trochanteric fracture types share a common instability denominator and should be treated alike [145]. The practicality of a new fracture classification system and the definition of basicervical trochanteric fracture have been discussed in the context of the reverse wedge effect [157]. A novel classification system based on the lateral view of 3D-CT is proposed for predicting the reducibility of intertrochanteric fractures [153]. A 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 intertrochanteric fractures [148]. Unsupervised clustering using a Hausdorff distance–based K-means approach can achieve identification of the type of intertrochanteric fractures with clinical significance [43]. Fracture classification was the main determinant for the use of the trochanteric stabilizing plate in a study of 20,902 fractures from the Norwegian hip fracture register [147]. Additional studies are required to establish a classification system with clear treatment recommendations for unstable intertrochanteric fractures [2].

Clinical Presentation

Epidemiology and Demographics

Intertrochanteric fractures constitute 40% to 50% of all hip fractures [123]. These injuries 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]. In contrast, femoral neck fractures are associated with more generalized low bone density involving the proximal femur globally, whereas intertrochanteric fractures show regional reduction at the greater trochanter [12].

Diagnostic Imaging and Classification

Unsupervised clustering of morphological fracture lines can achieve identification of the type of intertrochanteric fractures with clinical significance [43]. 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]. 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].

Associated Injuries and Complications

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 [58]. The risk of the development of avascular necrosis (AVN) of the femoral head is relatively high for unstable intertrochanteric fractures [22]. 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].

Prognostic Factors and Outcomes

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]. Displaced trochanter fragments lead to poor outcome in pertrochanteric fractures [28]. 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]. A hip fracture has a dramatic impact on the patients' health-related quality of life (HRQoL), and the deterioration in HRQoL sustained also one year after the fracture [31]. Long-term functional outcomes in geriatric hip fracture patients are frustrating, but early geriatric intervention may lead to better function [27]. 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]. Systemic immune-inflammation index can be utilized in clinical practice to identify those at high risk of postoperative delirium in older intertrochanteric fracture patients [122].

Investigations

Plain radiography: Conventional radiographs remain critical for the initial imaging evaluation of the hip and are used to diagnose fractures [41]. A complete hip series 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 are integral to fracture assessment and can be supplemented with CT to investigate suspected occult fractures, define fracture morphology, and assist in preoperative planning [41]. Additionally, radiographs allow for the serial assessment of hardware positioning and the evaluation of symptomatic hardware following open reduction and internal fixation [41].

CT: Computed tomography overcomes the limitations of radiography by providing a three-dimensional assessment of bony morphology and, to some degree, soft-tissue abnormalities [84]. CT is particularly helpful in fracture evaluation when radiographs are negative or when further defining fracture morphology in patients requiring surgical reduction [84]. CT scans effectively examine cortical and cancellous bone and can generate three-dimensional reconstructions of the hip for surgical planning [99]. Analysis using 3D CT reconstructions reveals a high incidence of coronal fragments in intertrochanteric femur fractures [67].

MRI: The soft-tissue contrast of MRI is superior to other imaging modalities for assessing both intra-articular and extra-articular hip pathology [84]. For patients suspected of having soft tissue or intra-articular pathology, MRI is the modality of choice due to its superior sensitivity and specificity [99].

Other Considerations: A thorough understanding of normal anatomy and biomechanics is necessary to identify pathology and determine the appropriate course of treatment [40]. A comprehensive clinical examination is required to establish a differential diagnosis, as many hip conditions present with similar symptoms [40]. The Nottingham Hip Fracture Score (NHFS) discriminates survival at all timepoints with similar accuracy to validating studies in the hip fracture cohort [39].

Surveillance and Complication Detection: Adverse fracture-implant motions were detected with high resolution in stable trochanteric hip fractures treated with intramedullary nails [77]. Close clinical and radiographic surveillance is advised for patients with unstable hip fracture patterns who undergo osteosynthesis using a TFNA implant [215]. Arterial injuries associated with hip fractures may present late as pseudoaneurysms; greater awareness should lead to earlier detection and effective treatment [58].

Treatment

Non-Operative

Conservative management of unstable intertrochanteric fractures is well tolerated by Chinese patients but requires a good standard of nursing care [160]. The authors successfully managed two cases of intertrochanteric fracture below Birmingham Hip Resurfacing using non-operative methods [62].

Operative

Indications: Appropriate identification of associated medical comorbidities, medical and orthopaedic comanagement, and prompt surgical treatment may minimize the risks of complications, morbidity, and mortality while improving outcomes [108]. Outcome after intertrochanteric hip fracture depends on the patient’s preinjury functional levels and medical comorbidities [108]. The American Academy of Orthopaedic Surgeons 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 [17]. In the AAOS Appropriate Use Criteria, 52% of treatment items are rated as rarely appropriate and 76% of rehabilitation items are rated as appropriate [17].

Surgical Approach / Technique: The percutaneous reduction with double screwdrivers group presented better clinical effects for managing irreducible extracapsular hip fractures than the limited open reduction group [69]. Minimally invasive treatment is feasible for most patients with old femoral fractures of the trochanter and femoral shaft [191]. Treatment with a proximal femur locking compression plate can provide good-to-excellent healing for pertrochanteric fractures, with a limited occurrence of complications [140]. 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].

Implant Selection: 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 is biomechanically superior [59]. The AMBI remains the gold standard for fractures of the trochanteric region [16]. For unstable trochanteric femoral fractures, one of the sliding hip screw systems provides a safe and simple alternative [53]. Either a midshaft intramedullary dynamic hip screw or a caudal dynamic hip screw in the treatment of intertrochanteric fractures is an effective, simple and safe method [112]. In older patients with intertrochanteric fractures, the InterTAN nail proved among the most effective in reducing nonmechanical major post-surgery complications, but had the highest risk of intraoperative complications [52]. Hip fractures treated with intramedullary nails have merits with lower rate of blood loss, femoral neck shortening and non-union; 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 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]. Equivalent mortality was observed after operation with sliding hip screw or intramedullary nail for trochanteric AO/OTA A1 and A2 fractures reported in the Norwegian Hip Fracture Register from 2008 to 2020 [170].

Nail Length and Configuration: Caution should be used before the greater use of very short (< 200 mm) intramedullary nails for the treatment of trochanteric hip fractures [119]. No measurable differences have been observed in the union or complication rates of modern short nails and long nails, although long nails are associated with longer surgical times and more blood loss [167]. Long 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 the characteristics of the fracture and on 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]. A superior locking nail can safely be used to manage complex trochanteric fractures, as there are small differences in axial fracture movement which are clinically insignificant [200]. 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]. PFNA-II has the advantages of a simple operation, few complications, and clinical efficacy for the treatment of intertrochanteric fractures [136].

Arthroplasty: For the severe osteoporotic elderly with unstable fractures, bipolar hemiarthroplasty is an effective method to treat the unstable intertrochanteric fractures [114]. Both PFNA and cementless bipolar hemiarthroplasty are safe and effective treatments for femoral intertrochanteric fracture in elderly patients [133]. 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].

Adjuncts: Intravenous tranexamic acid administration in treating geriatric intertrochanteric femoral fractures with intramedullary nailing is supported by robust evidence for efficacy and safety [120]. This prospective randomized controlled trial aims to evaluate the clinical effect of an evidence-based ERAS pathway integrated with Chinese and western medicine on perioperative outcomes in intertrochanteric fracture patients undergoing intramedullary fixation and provide reliable evidence-based data [132].

Setting of Care: The use of multidisciplinary teams, which include primary care providers, geriatricians, internists, social workers, physiatrists, and care managers, can help to lower the cost of treating hip fractures by decreasing complications and hospital lengths of stay [108]. 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].

Other Considerations: One-year mortality rates after intertrochanteric hip fracture are between 10% and 30% [108]. 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]. 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].

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]. A hip fracture has a dramatic impact on patients' health-related quality of life, and the deterioration in health-related quality of life is sustained one year after the fracture [31].

Perioperative Blood Loss

Intertrochanteric fractures in elderly patients undergoing intramedullary fixation surgery are associated with significant perioperative hidden blood loss and anemia [60]. Extramedullary fixation of stable intertrochanteric fractures significantly reduces perioperative blood loss compared to intramedullary fixation [9].

Mechanical and Implant-Related Complications

The InterTAN nail has the highest risk of intraoperative complications among implants for fixation of intertrochanteric femoral fractures in older patients [52]. 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]. The risk of the development of avascular necrosis of the femoral head is relatively high for unstable intertrochanteric fractures [22]. In conversion to hip arthroplasty after failed intertrochanteric fracture fixation, intraoperative femoral fracture occurred in 12% of patients treated with intramedullary hip screws compared to 1% of patients treated with extramedullary fixation devices [65]. In conversion to hip arthroplasty after failed intertrochanteric fracture fixation, late periprosthetic fracture occurred in 6% of patients treated with extramedullary fixation devices compared to 0% of patients treated with intramedullary hip screws [65]. The overall complication rate for conversion hip arthroplasty after intertrochanteric fracture fixation was 21% for extramedullary fixation devices and 27% for intramedullary hip screws [65]. Increased intraoperative blood loss, operating time, and requirement of a long femoral stem should be considered when performing cementless total hip arthroplasty following failed internal fixation for intertrochanteric fractures [131].

Secondary Fractures

Although subchondral positioning of the hip screw might diminish the incidence of femoral neck fractures after internal fixation of trochanteric fractures, adequate management of systemic osteoporosis should be targeted as a main factor of prevention [15]. In cases of femoral neck fractures after removal of hardware in healed trochanteric fractures, the fracture was spontaneous (with no trauma) in 87.5% of reported cases [188]. In cases of femoral neck fractures after 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].

Functional Outcomes

Salvage treatment for the failed fixation of intertrochanteric fracture yielded satisfactory clinical and radiographic results [7]. 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]. Five-year survivorship free of revision for conversion hip arthroplasty after intertrochanteric fracture fixation was 95% in the extramedullary fixation group and 94% in the intramedullary hip screw group [65].

Recovery

Functional Outcomes and Quality of Life: A hip fracture exerts a dramatic impact on patient health-related quality of life (HRQoL), with deterioration persisting one year post-fracture [31]. Although hip pain is not a major issue, walking ability and activities of daily living (ADL) function show obvious deterioration [25]. The comparatively low rate of revision surgery confirms that the cephalomedullary nail constitutes a safe treatment [25]. Geriatric intertrochanteric fracture patients with Parkinson’s disease (PD) exhibit significantly lower survival rates, worse hip joint function, a higher rate of internal fixation failure, worse ADLs, and higher depressive emotional tendencies compared to patients without PD [130]. Despite modern treatment, patient-reported outcomes for lower limb long bone shaft fractures do not return to normal at one year [222]. This evidence highlights the frustrating long-term outcome for geriatric hip fracture patients, suggesting that early geriatric intervention may lead to better function [27].

Gait and Rehabilitation: 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 to achieve the same functional gain as patients with stable fractures [152].

Mortality and Survival: Low serum albumin and advanced age are independent risk factors for long-term mortality in elderly patients with intertrochanteric fractures [54]. The Nottingham Hip Fracture Score (NHFS) discriminates survival at all timepoints with similar accuracy to validating studies in the hip fracture cohort [39].

Complications and Complications of Treatment: 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]. The most common complication in extracapsular femoral neck (EFD) patients was late periprosthetic fracture (6% vs 0% in intramedullary hip screw [IMHS]; P = .29), while intraoperative femoral fracture was more common in IMHS patients (12% vs 1% in EFD; P = .02) [65]. Delayed union after subtrochanteric femur fracture occurs frequently [220].

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)
• [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)
• [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)
• [L3] They can be utilized in clinical practice to identify those at high risk of POD in older intertrochanteric fracture patients. [122] (10.1186/s13018-024-04699-8)
• [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)
• [L2] This prospective randomized controlled trial aims to evaluate the clinical effect of an evidence-based ERAS pathway integrated with Chinese and western medicine on perioperative outcomes in intertrochanteric fracture patients undergoing intramedullary fixation and provide reliable evidence-based data. [132] (10.1186/s13018-020-01586-w)
• [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)
• [L3] Fracture classification was the main determinant for TSP use. [147] (10.1186/s13018-020-02163-x)
• [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)
• [L5] The practicality of the new fracture classification system, the definition of basicervical trochanteric fracture, and the mechanisms underlying the reverse wedge effect have been deeply discussed. [157] (10.1186/s12891-021-04388-1)
• [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)
• [L5] [167] (10.5435/jaaos-d-15-00325)
• [L3] [170] (10.1302/0301-620x.106b6.bjj-2023-1219.r1)
• [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)
• [L4] The authors advise close clinical and radiographic surveillance of patients with unstable hip fracture patterns who undergo osteosynthesis with use of a TFNA implant. [215] (10.2106/jbjs.18.00997)
• [L3] Delayed union after subtrochanteric femur fracture occurs frequently. [220] (10.1186/s12891-019-2775-x)
• [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

• Total hip replacement
• Hip resurfacing
• Avascular necrosis of the femoral head

References

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