Intertrochanteric Fracture Fixation Using a Sliding Hip Screw or Cephalomedullary Nail
Alexandra K. Schwartz, MD
Dr. Schwartz or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Synthes and serves as a paid consultant to or is an employee of Zimmer.
This chapter is adapted from Schwartz AK, Sherman CL: Intertrochanteric fracture fixation using a sliding hip screw or cephalomedullary nail, in Flatow E, Colvin AC, eds: Atlas of Essential Orthopaedic Procedures. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2013, pp 401-405.
PATIENT SELECTION
Approximately 340,000 patients sustain hip fractures in the United States each year. Intertrochanteric fractures are extracapsular hip fractures that occur primarily in elderly patients or patients with osteopenia or osteoporosis.
Indications
Surgical treatment is the standard of care for hip fractures, except for patients with comorbidities precluding surgery. Nonsurgical treatment may be fraught with complications, including fracture displacement, pain, inability to transfer, decubitus ulcers, pulmonary complications, urinary tract infections, and deep vein thrombosis (DVT). Patients treated nonsurgically require active treatment with early mobilization and particular caution in avoiding the aforementioned complications. A recent study analyzed a database of all hip fractures from Medicare claims in a 5-year period and found that approximately 6.2% of patients with hip fractures were treated nonsurgically.1
Contraindications
Surgery is contradicted primarily in the elderly, demented patient who was nonambulatory before the fracture and who has minimal pain. Rarely, a patient will be unable to undergo surgery because of severe medical comorbidities.
PREOPERATIVE IMAGING
Good-quality plain radiographs are needed to assess the fracture pattern accurately and thereby make an accurate diagnosis. Failure to identify the fracture completely may lead to use of an inappropriate implant and, ultimately, failure of fixation. Preoperative images should include an AP view of the pelvis and AP and lateral views of the affected hip. A traction/internal rotation AP view of the hip (best obtained with gentle manual traction and 15° of internal rotation applied) is very helpful in delineating the fracture pattern (Figure 1).
The AP view of the pelvis is helpful because it demonstrates the native anatomy on the contralateral side, provided the contralateral hip has not sustained a fracture and is free of other pathologies. Knowledge of normal anatomy will assist in choosing the correct angle device as well as allowing for comparison when achieving a reduction. A cross-table lateral is the preferred lateral view and is more comfortable for the patient than a frog-leg lateral. In approximately 2% to 10% of patients with a painful hip due to fracture after trauma, radiographic findings are negative. If the findings are negative but there is a high clinical suspicion for a fracture, further imaging is warranted. CT is readily available and is often used. MRI is another alternative, although it is not always immediately available and is more expensive. Lubovsky et al2 compared CT and MRI for the diagnosis of occult hip fractures. CT led to misdiagnosis in four of the six hips studied. MRI provided complete anatomic characterization of the fracture in the seven hips studied, eliminating the need for repeat or additional imaging. Patients who underwent CT scans and further imaging had a workup time of 56 hours, whereas those with MRI had a time to diagnosis of 32 hours. If an MRI is unable to be obtained because of a pacemaker or other contraindications, a bone scan may be used. Bone scans may not show positive results until up to 72 hours postinjury, however, which can lead to a delay in diagnosis and treatment. In addition, a bone scan may not accurately depict the fracture pattern.
PROCEDURE
Simple standard obliquity intertrochanteric fractures (on the Evans classification system) can be treated with either a sliding hip screw (SHS) or a cephalomedullary nail (CMN). Despite regional variations and surgeon preferences, the SHS is still the standard treatment because the CMN continues to have concern for peri-implant fracture
at the tip of the nail. While some studies show decreased blood loss and operative time with nails,3 other studies did not find differences in blood loss, surgical time, or recovery.4 Reverse obliquity fractures, intertrochanteric fractures with lateral wall involvement, transverse intertrochanteric fractures, and fractures with subtrochanteric extension should be treated with an intramedullary nail, not an SHS because of unacceptable rates of failure due to excessive collapse (Figure 2). Recent literature has shown that there is up to a 19.5% incidence of lateral wall fracture when using an SHS. Lateral wall thickness is a reliable predictor of intraoperative lateral wall fracture if the thickness is < 21 mm.5
at the tip of the nail. While some studies show decreased blood loss and operative time with nails,3 other studies did not find differences in blood loss, surgical time, or recovery.4 Reverse obliquity fractures, intertrochanteric fractures with lateral wall involvement, transverse intertrochanteric fractures, and fractures with subtrochanteric extension should be treated with an intramedullary nail, not an SHS because of unacceptable rates of failure due to excessive collapse (Figure 2). Recent literature has shown that there is up to a 19.5% incidence of lateral wall fracture when using an SHS. Lateral wall thickness is a reliable predictor of intraoperative lateral wall fracture if the thickness is < 21 mm.5
 FIGURE 1 Radiographs demonstrate a comminuted proximal femur fracture. A, AP view of the hip. B, AP view obtained with the lower extremity in manual traction and internal rotation. The alignment of the hip with traction allows for better understanding of the fracture pattern and its behavior with closed reduction. |
 FIGURE 2 AP radiograph of the hip demonstrates an intertrochanteric fracture treated with a sliding hip screw. Excessive collapse has occurred because of a previously unrecognized lateral wall fracture. |
A recent prospective randomized controlled trial comparing intramedullary versus extramedullary fixation of unstable (AO/OTA 31-A2) intertrochanteric fractures found that although there was statistically significant more shortening of the femoral neck in SHS than intramedullary nail (1.0 versus 0.2 cm), this did not correlate with worse clinical function as measured by the lower extremity measure (LEM), timed 2-minute walk test, timed up and go test, or functional independence measure (FIM).6
Room Setup/Patient Positioning
After preoperative briefing, the patient is carefully positioned supine on either a radiolucent table or a fracture table. The use of a fracture table is preferred for displaced intertrochanteric fractures, regardless of the implant chosen. The fracture table allows easy biplanar imaging without moving the fractured extremity, and it facilitates obtaining and maintaining an appropriate reduction. Obtaining fracture reduction before placement of either type of implant is critical. Boot traction rather than skeletal traction is usually adequate. Both feet and ankles are padded carefully to avoid pressure on bony prominences. Additional padding may be placed in the heel of the boot and over the dorsum of the feet. The legs are scissored with the surgical leg flexed and the contralateral leg extended. Care is taken to avoid hyperextension and excessive traction on the unaffected leg to avoid stretching of the femoral nerve. Placing the nonsurgical leg in a well-leg holder has been reported to cause compartment syndrome and is therefore not recommended.7 A well-padded perineal post is placed. All bony prominences are carefully padded, the genitals are checked, and the patient is secured on the operating table. Lower extremity compressive devices are
placed on both lower extremities. The arm on the surgical side is placed across the patient’s chest with a pillow between the chest and arm. A foam pad is placed around the elbow to protect the olecranon. A towel is then placed over the adducted and internally rotated arm, and wide silk tape is used to secure the arm to the fracture table. This allows for improved imaging as well as appropriate access to the proximal femur for placement of a CMN (Figure 3).
placed on both lower extremities. The arm on the surgical side is placed across the patient’s chest with a pillow between the chest and arm. A foam pad is placed around the elbow to protect the olecranon. A towel is then placed over the adducted and internally rotated arm, and wide silk tape is used to secure the arm to the fracture table. This allows for improved imaging as well as appropriate access to the proximal femur for placement of a CMN (Figure 3).
 FIGURE 3 Photograph demonstrates typical setup and patient positioning on a fracture table for surgical fixation of an intertrochanteric fracture using an intramedullary nail. Note the proximal and posterior extent of draping required for intramedullary nail fixation and the intraoperative use of a compression device on bilateral lower extremities.
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