Emergent Care / Stabilization:
Emergent care and stabilization of intertrochanteric (IT) fractures are vital for optimal patient outcomes. Patients should be evaluated for the cause of their hip fracture and for any unstable concomitant medical conditions. Patients should be medically optimized for conditions including stroke, unstable angina, pulmonary embolism, heart failure, and uncontrolled obstructive lung disease prior to interventions for their hip fracture. If patients are stable, they should proceed with surgery within 24 hours of hospitalization. If patients are medically unsafe to proceed with surgery within 24 hours, they should be medically optimized to proceed with surgery with a goal of 72 hours from admission. If stabilization of coexisting medical conditions is not reached within 72 hours, the surgery can be delayed further; however, this delay increases the risk of postoperative complications. 

• Thromboembolic prophylaxis should be provided to all patients with hip and IT femur fractures.
• Patients should be treated with antibiotic prophylaxis for infection prevention.
• Patients should be provided with analgesic treatment. Improper pain control can impair recovery of function and increase the risk of delirium. Pain relief options include nonopioid analgesics such as acetaminophen, nerve blocks, and opioids. Resources for opioid prescribing guidelines, as well as nonopioid alternatives, can be found here.
• Ensure the collection of appropriate radiographs and monitor hemoglobin / hematocrit.

Causes / typical injury mechanism:
In older adult patients, IT fractures typically occur due to low-energy falls / trauma, especially in patients with osteoporosis or other bone diseases. These patients should undergo bone density evaluation and potential treatment following their recovery from hip fracture. If the injury is due to a fall, the cause of the fall should be investigated and remediated, if applicable.

In younger patients, these fractures are often a result of high-energy trauma, or less commonly due to underlying pathology such as malignancy.

Classic history and presentation:
IT femur fractures are seen in patients with a history of trauma to the femur or hip. Older patients commonly present in the context of a mechanical, ground-level fall. These patients often have underlying osteoporosis or osteopenia. These fractures are less common in younger patients but present with a history of motor vehicle accident or other high-energy trauma.

On inspection, patients often present with acute-onset pain in the ipsilateral hip with an inability to bear weight; they may also present with overlying soft tissue swelling or ecchymosis. The pain will likely present in the anterior groin, thigh, or lateral buttock. The ipsilateral leg may have visible deformities such as shortening and external rotation. On physical examination, they will have severe pain with passive range of motion of the hip, particularly with provocative examinations, including log roll and axial load of the extremity. Distally, they should remain neurovascularly intact.

Prevalence:
There are about 150 000 IT fractures per year in the United States. This fracture pattern makes up about 50% of hip fractures.

• Age – Most common in individuals 65 years and older
• Sex / gender – 3:1 female-to-male ratio

Risk factors:

• Previous hip fracture
• Osteoporosis
• Malignancy
• Advancing age
• Body mass index (BMI) over 22

Other associated conditions include dementia, Parkinson disease, unsteady gait, use of walking aids, vertigo, visual impairment, antiepileptic medications, and other neurological conditions. 

Pathophysiology:
IT fractures are fractures present in the anatomic region between the greater trochanter and lesser trochanter of the proximal femur. In a true IT fracture, the fracture line crosses both cortices and passes above the lesser trochanter medially and below the crest of the vastus lateralis laterally. These are often referred to as transtrochanteric fractures. A variant of IT fractures are reverse oblique fractures, in which the fracture traverses proximally to medially from the IT region to the subtrochanteric region. The fracture patterns of IT femur fractures can be classified as below. Fracture pattern affects stability of the fracture after fixation and warrants fixation with different techniques.   

Grade / classification system:
Müller AO / Orthopedic Trauma Association (OTA) classification: the bone, bone segment, and type of fracture are organized alphanumerically.

• The femur is identified by the number 3.
• The fracture along the femur is localized to the proximal end segment with the number 1.
• The type of fracture is classified as trochanteric by the letter A and further classified as an IT fracture with the number 3.

Thus, IT fractures have the classification of 31A3.

This can be further broken down into subgroups:

• 31A3.1 represents simple oblique fractures.
• 31A3.2 represents simple transverse fractures.
• 31A3.3 represents wedge or multifragmentary fractures.

Fractures classified as simple pertrochanteric fractures (31A1) and multifragmentary pertrochanteric lateral wall incompetent fractures (31A2) are also often referred to as IT fractures as they occur in the trochanteric area. These fractures, however, have an intact lateral cortex. Reverse oblique fractures are designated as 31A3 with simple oblique fracture (31A3.1), simple transverse fracture (31A3.2), or wedge or multifragmentary fracture (31A3.3).

These fractures are also classified based on stability. Stable IT fractures are those with an intact posteromedial cortex, which indicates that, once reduced, they will be stable with medial compressive loads. Unstable fractures are those that will result in medial shaft displacement or collapse of the fracture into varus.

Unstable IT femur fractures are defined by:

• Posteromedial comminution.
• Reverse obliquity.
• Thin or incompetent lateral wall.
• Subtrochanteric extension.

Related topic: hip fracture