Intertrochanteric Fracture Fixation Using a Sliding Hip Screw or Cephalomedullary Nail

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.


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.


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.