Intertrochanteric hip fractures with a regular fracture
pattern can be either stable or unstable. The obliquity of the
intertrochanteric fracture is different than in the reverse oblique fracture
pattern. Stable intertrochanteric fracture is stable and most studies show that
there is equal outcome between the sliding hip screw and the intramedullary
nail for a stable fracture pattern (the sliding hip screw is cheaper). A
construct with two screws is as good as a construct with three of four screws.
A displaced fracture is probably a high energy fracture, but it is not
comminuted. If this fracture does not align with traction on the fracture
table, then you need to do open reduction, and if the fracture appears stable
after open reduction, it is easier when you are there to do compression hip
screw. The best treatment for a reverse oblique fracture is cephalomedullary
nail. A sliding hip screw may fail if used for reverse oblique hip fractures.
Unstable fractures are best treated with a cephalomedullary nail. A fracture of
the hip above a retrograde nail will require reduction and internal fixation
with a compression hip screw. An antegrade nail for this hip fracture will not
work unless you remove the retrograde nail which can be a much bigger operation
than using a compression hip screw. A thin or incompetent lateral wall
increases the chances of intraoperative lateral wall blow out. This
intraoperative complication increases the chances of postoperative failure of
the hardware and the need for reoperation. If the lateral wall thickness is
less than 20 mm, then the hip fracture should not be treated with a compression
hip screw. The integrity of the lateral wall is a predictor for fracture
pattern stability, and it is an x-ray sign that guides the implant choice.
