HIP FRACTURES
high-energy trauma.6 A typical fracture follows a fall onto the
The management of
intertrochanteric hip
fractures: an update
Sophia M Wakefield
Paul L Rodham
Peter V Giannoudis
Abstract
Intertrochanteric fractures are a common type of proximal femoral
fracture, and account for high morbidity and mortality. Early recogni-
tion and management of such fractures is important, with surgery
preferably undertaken within 48 hours. The choice of surgical strategy
remains variable between centres and individual surgeons; in part
because evidence to support a specific strategy has been weak.
Herein, we provide the latest evidence on the management of these
fractures.
Keywords Dynamic hip screw; intramedullary nail; outcomes
Introduction
Hip fractures are common injuries associated with significant
morbidity and mortality.1 Approximately 76,000 hip fractures
were reported in the UK in 2021.2 This was a rise from 61,500
in 2013 and is likely to represent an ageing population.2 The
estimated costs (including medical and social care) are around
£2 billion a year in the UK.3 The treatment of such fractures
requires a coordinated, multidisciplinary approach from sur-
geons, anaesthetists, ortho-geriatricians, and the wider rehabili-
tation team.4 At present, approximately one-quarter of patients
with hip fractures are admitted from institutional care, and
10e20% of those admitted from home ultimately move to insti-
tutional care.4
Intertrochanteric hip fractures are the most frequent type of
hip fracture and are most common in older patients, secondary
to osteoporosis.5 These fractures may also be associated with
other osteoporotic fractures, either preceding the hip fracture or
occurring at the same time. In older patients, these injuries tend
to occur following low-energy mechanisms, contrasting with the
younger population where they tend to occur as the result of a
Sophia M Wakefield MBBS Foundation doctor, Academic
Department of Trauma and Orthopaedics, School of Medicine,
University of Leeds, UK. Conflicts of interest: none declared.
Paul L Rodham MBBS MRes MRCS Specialist Registrar ST6, Academic
Department of Trauma and Orthopaedics, School of Medicine,
University of Leeds, UK. Conflicts of interest: none declared.
Peter V Giannoudis MD PhD FACS FRCS Professor, Academic
Department of Trauma and Orthopaedics, School of Medicine,
University of Leeds and NIHR Leeds Biomedical Research Centre,
Chapel Allerton Hospital, UK. Conflicts of interest: none declared.
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lateral aspect of the greater trochanter. Risk of fracture is
correlated with the degree of protective overlying adipose and
muscle tissue which absorb and dissipate energy and reaction
times.7
Hip fractures confer a high mortality risk with up to one-third
of patients dying within 1 year, and one in ten dying within 1
month.4 This high mortality is associated with the significant
frailty and complex co-morbidities seen within this patient pop-
ulation, as opposed to the fracture itself. Those that survive often
describe ongoing pain, reduced function and a poorer quality of
life.8 The management of these fractures is therefore multi-
faceted, ranging from meticulous surgical technique to careful
management of the pre- and postoperative medical and social
needs of the patient.
Classification of hip fractures
Hip fractures may be broadly divided into those which are
intracapsular and extracapsular (Figure 1).9,10 The former are
usually transcervical or subcapital, and the latter are either
intertrochanteric (also known as pertrochanteric), or sub-
trochanteric. The commonest type of fracture is the inter-
trochanteric fracture, which accounts for approximately half of
all femoral neck fractures.9
Many classification systems for describing intertrochanteric
fractures exist. An early and widely used classification system
was presented by Evans in 1949.11 This system was based on the
stability of the fracture following reduction, which was deter-
mined by fracture geometry, degree of comminution, and integ-
rity of the posteromedial cortex. Since then, several other
classification systems have been proposed, but there is no uni-
versal consensus.12,13 In 1996, the Arbeitsgemeinschaft fu €r
Osteosynthesefragen (AO) and Orthopaedic Trauma Association
(OTA) combined to propose a new universal system using
common definitions, intending to improve the reliability of
classification in clinical practice and research.14 This classifica-
tion was updated in 2018, to help improve the application of this
classification based on feedback from the clinical users.15 A key
emphasis of this classification is the importance of lateral wall
integrity as a determinant of stability, dividing fractures into
three groups of progressively increasing instability. These three
groups are further divided into nine subgroups (Figure 2).15 31A1
fractures are simple intertrochanteric fractures, occurring at the
proximal end of the femur in the trochanteric region. These
fractures are split into isolated trochanteric fractures which do
not cross the femoral neck (31A1.1), two-part fractures (31A1.2),
and fractures with more than two parts, but which still possess
an intact lateral wall of greater than 20.5 mm (31A1.3). 31A2
fractures are multi-fragmentary fractures, with an incompetent
lateral wall (20.5 mm), and comprise of subtypes: 31A2.1
(fractures with one intermediate fragment), 31A2.2 (fractures
with two intermediate fragments), and 31A2.3 (fractures with 2
intermediate fragments). Finally, the 31A3 subgroup classifies
reverse oblique intertrochanteric fractures, further divided into
simple oblique (31A3.1), simple transverse (31A3.2), and
wedge/multi-fragmentary (31A3.3) fractures.
It was hoped that the 2018 AO/OTA system would offer
greater reliability than that which was previously available.15
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 HIP FRACTURES

However, whilst it does for the group classifications, this reli-

Figure 1 Diagram of the hip joint, demonstrating the location of
intertrochanteric fractures (in red), in relation to other types of hip
fracture. Reproduced from reference 10 with permission from BMJ
Publishing Group.
ability appears reduced concerning its sub-groups. Chan et al.
(2021) evaluated 150 posterioreanterior (PA) and lateral plain
radiographs of intertrochanteric fractures from three hospitals.16
Each film was classified by six orthopaedic surgeons using the
2018 AO/OTA classification; radiographs were then re-classified
after 3 months. The study found only moderate inter-observer
reliability at group level, with this falling to fair when sub-
group classifications were made. These findings are consistent
with other studies including Davidson et al. (2023) who
compared the 2018 classification with the original 1983 classifi-
cation, demonstrating reduced reliability with the new classifi-
cation.17e19 This further questions the discriminatory capacity of
the AO/OTA classification using X-rays and suggests that it re-
quires further evaluation.
In addition to plain radiographs, other imaging modalities,
such as computed tomography (CT) and magnetic resonance
imaging (MRI), have been considered for fracture assessment.
These have the advantage of being potentially more reliable in
delineating fracture patterns and discerning areas of comminu-
tion that may confer instability. Raj et al. (2021) evaluated the
role of CT scans with three-dimensional (3-D) reconstructions.20
They demonstrated that CT scans improve intra- and inter-
observer agreement of the AO/OTA classification when
compared to X-ray, with the CT scan changing the classification
in one-third of cases. The study found that X-rays underestimated
the integrity of the lateral cortex and as a result, fracture stability.

Figure 2 The updated classification system of intertrochanteric fractures, according to the modified 2018 AO/OTA Classification.15 This classi-
fication system divides intertrochanteric fractures into three main groups, with a further division into eight subgroups. Data from reference 15.

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 HIP FRACTURES
The authors concluded that CT provided the most benefit with
AO/OTA 31A2 fracture types where both stability and lateral wall
integrity are most difficult to assess. A study by Wada et al.
(2020) also demonstrated higher reliability of CT over X-rays in
grading fractures using the same system.21
Haj-Mirzaian et al. (2020) recently published a systematic
review and meta-analysis to evaluate the use of CT and MRI for
radiographically occult hip fractures in elderly patients.22 Studies
were included if patients were clinically suspected to have a hip
fracture, but there was no radiographic evidence of a surgical hip
fracture (including the absence of any definite fracture or only
the presence of an isolated greater trochanter (GT) fracture). The
results demonstrated that 39% of patients with normal X-rays
had an MRI-detected fracture. It also highlighted a very high rate
(92%) of intertrochanteric extension in patients who had sus-
tained an isolated GT fracture. In a comparison with MRI as the
gold standard, CT had a sensitivity of 79% and a specificity of
71%. In a further meta-analysis, Wilson et al. (2020) similarly
evaluated the diagnostic accuracy of limited MRI protocols,
establishing that a protocol utilizing coronal T-1 weighted and
short tau inversion recovery (STIR) sequences was 100% sensi-
tive when compared to more comprehensive protocols.23 These
shorter sequences were more time-efficient and better tolerated
by patients.
Immediate assessment of hip fractures
It is important to stabilize the patient as soon as possible, with
the aim of performing surgery within 36 hours.4 Older patients
are at increased risk if they have pre-existing cognitive impair-
ment, or acute delirium following fracture.24 A 4 A’s rapid
assessment test (4AT) for delirium and cognitive impairment
has been advocated as a bedside screening tool for this pur-
pose.25 Pre-existing co-morbidities need to be identified and
optimized, including early discussion with the anaesthetic team
to avoid delays to theatre. Surgical teams should aim to identify
reversible risk factors including anaemia, anticoagulation, vol-
ume depletion, electrolyte imbalances, uncontrolled diabetes,
uncontrolled heart failure, correctable cardiac arrhythmia or
ischaemia, acute chest infection and exacerbations of chronic
chest conditions.26e28
Although the surgical team are responsible for the care of the
patient, the involvement of a wider multidisciplinary team
(MDT) from the point of admission is crucial. Wu et al. (2023)
conducted a randomized control trial (RCT), comparing MDT
management with standard treatment, demonstrating faster
weight-bearing, shorter length of hospital stay, and better pain
scores in patients managed through an MDT approach.29
To examine factors predictive perioperative complications,
Babagoli et al. (2023) undertook a retrospective cohort study on
310 patients following intertrochanteric fracture.30 A multi-
variate analysis showed that neutrophilia was the primary
determinate for in-hospital mortality, whilst age and blood
transfusion were the main determinants for long-term mortality.
Preoperative dehydration was the primary variable associated
with postoperative complications.
Pain is a prominent feature of hip fracture presentation and
therefore it is recommended that immediate and continuous
analgesia is given to patients, including those with cognitive
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impairment.31 Analgesia needs to be sufficient to enable move-
ments necessary for investigations (e.g. being able to tolerate
passive external rotation of the leg) and nursing care. Analgesics
normally include paracetamol, nerve blocks, with opiate usage at
as low a dose as possible.32 Non-steroid anti-inflammatory drugs
(NSAIDs) can be utilized; however, their usage should not sur-
pass 2 weeks due to the risk of delayed bone healing.33 Patients
are normally offered the choice of spinal or general anaesthesia
after being presented with the risks and benefits of each. At
present, there is no evidence to suggest that one is superior to the
other in terms of mortality or chest complications.34 All pro-
cedures should result in full weight-bearing from the first
postoperative day.35
Surgical management
The most common approach for surgical management of an
intertrochanteric fracture involves the use of either a dynamic
hip screw (DHS) or intramedullary nail (IMN).36 The choice of
surgical approach to managing intertrochanteric fractures is often
variable and dependent on the clinician. Broadly, the choice of
screw or nail is dependent on the fracture type, with the AO/OTA
fracture classification proving useful to guide stability. For those
rare patients who are not suitable for surgery, traction can pro-
vide good pain relief with early mobilization when pain allows.
These patients are typically left with a shortened limb.37
A recent cohort study of 46,243 patients from the Swedish
Fracture Register demonstrated wide variations in implant
choice, which the authors thought was surprising given the
availability of current evidence.38 It was suggested that clear
national guidelines would improve the consistency of practice
across the country.
Dynamic hip screw
The dynamic hip screw (DHS) is also known as the sliding hip
screw or compression hip screw.36 Following reduction, the
fracture is internally fixed by the application of a lag screw into
the femoral neck, which is secured laterally by a plate that is
applied onto the lateral femoral cortex (Figure 3). The lag screw
can slide within the barrel of the plate along the longitudinal axis
of the femoral neck, permitting compression of the fracture, and
hence aiding bone healing.39 Core to the success of a DHS is the
tip-apex distance (TAD). This measure is defined as the sum of
the distance from the tip of the femoral lag screw to the apex of
the femoral head on anterior-posterior (AP) and lateral radio-
graphic views. When the TAD is greater than 2.5 cm, the risk of
failure secondary to cut-out of the lag screw increases.40
Intramedullary nail
Intramedullary nails (IMNs) are devices which confer strength
and stability to the bone as a result of their on-axis position and
inherent load-sharing properties.41 They are inserted into the
medullary canal and secured with screws at both the proximal
and distal ends (Figure 4). Before insertion, the canal can be
reamed to facilitate siting of a larger diameter nail which results
in increased bending and torsional stiffness.42 In clinical use
there are varying types of IMNs with differing options of length,
diameter and composition.43 Recent debate has often surrounded
the use of long nails, which span the full length of the femur,
compared to short nails that end at the femoral isthmus. Short
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 HIP FRACTURES

Figure 3 A 57-year-old female with a history of osteopenia had a fall from standing height, sustaining an isolated left neck of femur fracture. (a) This
image demonstrates a stable 31A1.1 fracture. The patient therefore underwent fixation with a dynamic hip screw, with the postoperative X-ray
images demonstrated in b, c and d demonstrating a well-healed fracture at 4 months postoperatively, with no loss of position or peri-implant
complication.

nails (Figure 5) offer the benefit of faster surgical times as the nail
is all jig-based, however, there were initial concerns with the risk
of peri-implant fractures.
Zhang et al. (2017) conducted a meta-analysis comparing the
outcomes of short intramedullary nails (SINs) and long intra-
medullary nails (LINs).44 A total of 2431 patients (mean age 74.83
years) were included in the analysis, with 1498 LIN and 940 SIN
cases. The findings demonstrated longer surgical times, higher
intraoperative blood loss, and a higher transfusion rate in the LIN
group. Notably, there were no significant differences in the length
of hospital stay, peri-implant fractures, re-operation rate, 1-year
mortality, Harris hip score or overall complication rates. More

Figure 4 A previously fit and healthy 63-year-old female presented following a fall from standing height, sustaining a left neck of femur fracture (a
and b). Initially, this fracture was presumed to possess an intact lateral wall (31A1.3), and therefore a dynamic hip screw was preoperatively chosen
as the fixation method of choice. However, when placed on traction, it became evident that there was a transverse element of the fracture which
extended through the lateral wall, and thus defined as a 31.A3.2 fracture (c and d). As a result, the operating surgeon treated this fracture with a
long intramedullary nail (e, f and g).

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 HIP FRACTURES

Figure 5 A 71-year-old female with a past medical history of osteoporosis, Crohn’s disease, diabetes mellitus and ischaemic heart disease
presented following a fall from standing height, and having sustained a left neck of femur fracture (a and b). At presentation to hospital, radiographs
demonstrate a fracture extending into the greater trochanter (31A2.2). As this fracture pattern is often ambiguous with regards to stability, the
operating surgeon elected to perform a short intramedullary nail (c, d and e). Radiographs taken at 5 months postoperatively demonstrate a healed
fracture, with no loss of position (f and g).

recently, Elbaz et al. (2023) evaluated the outcome of 137 patients
undergoing short nails (Gamma-3 Proximal Femoral Nails e PFN)
and 66 patients who underwent long nails (Trochanteric Fixation
Nail Advanced e TFNA) for treatment of intertrochanteric hip
fractures.45 They noted no significant difference between
complication rates and outcomes between the two groups,
although the longer TFNA nail had a lower rate of cut-out.
Dynamic hip screw versus intramedullary nailing
There has been significant debate over the relative advantages of a
DHS over an IMN. It has been reported that the use of IMN fixation
has significantly increased over the past two decades, despite the
evidence for this strategy being uncertain.46 Grønhaug et al. (2022)
assessed data from 17,341 patients with trochanteric or sub-
trochanteric fractures treated with DHS or IMN, within the Nor-
wegian Hip Fracture Register over the period 2013e2019.47 They
found a significantly lower re-operation rate for IMNs, when
compared with DHS for unstable trochanteric (31A2 and 31A3) and
subtrochanteric fractures; there was however, no difference
recorded in the re-operation rate for stable (31A1) fractures. They
concluded that the 1-year mortality for unstable and stable fractures
was significantly lower in those treated with IMNs. More recently,
Lopez-Hualda et al. (2023) undertook a retrospective review of
clinical outcomes, complications and mortality of patients under-
going DHS and TFNA.48 They found that TFNA use was associated
with a higher success rate in achieving full weight-bearing at hos-
pital discharge, reduced postoperative complications (including
infection, mechanical failure and cut-out), and lower mortality
levels. It was suggested that TFNA was the preferred choice for
unstable intertrochanteric fractures.
A recent meta-analysis by Wessels et al. (2022) described no
significant differences in peri- and postoperative outcomes be-
tween both DHS and IMN, regardless of the AO/OTA subtype.49
However, there was a trend towards improved functional scores
and patient-reported outcomes, favouring the IMN technique, for
31A1 and 31A2 subtypes; no statistical conclusions were re-
ported for 31A3 fractures due to a lack of data. Yu et al. (2023)
conducted a meta-analysis of thirty RCTs, demonstrating reduced
rates of blood loss, femoral neck shortening and non-union when
utilizing an IMN.50
Alessio-Mazzola et al. (2022) conducted a retrospective re-
view of DHS and IMN fixation in the treatment of 31A1 inter-
trochanteric fractures.51 Eighty-five patients were included (44
treated with DHS; 41 with IMN), in which there were no signif-
icant differences observed in the clinical, functional and radio-
graphic outcomes; nor mortality. Despite greater operative costs,
there was a significantly reduced operative time with IMN fixa-
tion. However, treatment with the DHS demonstrated reduced
intraoperative fluoroscopy and postoperative transfusion re-
quirements. This study therefore recommended the use of DHS in
preference to IMN for this fracture type. Furthermore the recent
INSITE study, a large, multi-centre RCT including 850 patients,
similarly demonstrated no difference in health-related quality of
life at 1-year follow-up when comparing DHS with IMN in 31A1
and 31A2 fractures, suggesting that the higher-associated costs of
IMN fixation may not be warranted.52
Trochanteric stabilizing plate
The trochanteric stabilizing plate (TSP) can be utilized in com-
bination with the DHS in an attempt to recreate a lateral buttress,

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 HIP FRACTURES
usually in the case of complex and unstable fractures.53 There are
however no universal guidelines as to when to use them. A
recent scoping review by Alm et al. (2021) attempted to clarify
when and how to apply the TSP.54 The authors found a wide
heterogeneity of study methods, with the rate of complications
and re-operations for the DHS with the TSP being similar to that
previously reported with both DHS and IMN alone. They were
therefore unable to make firm recommendations of the appro-
priate use of the TSP.
Li et al. (2023) have recently examined lateral wall thickness
as a predictor of instability.55 This study utilized computational
models created from CT images of a healthy male subject, to
construct an intertrochanteric (31A2) fracture with various
thicknesses of the lateral femoral wall and to assess the outcome
of fixation with a DHS, IMN or a proximal femoral locking
compression plate (P-FLCP). They concluded that the thickness
of the lateral wall should be considered when selecting an
appropriate internal fixation device; IMN devices experience
lower stress levels and a moderate bony displacement, in
contrast to DHS and locking plates. This study, however, did not
consider the biomechanical and biological features of normal
femoral anatomy and therefore it is recommended that further
biomechanical testing is performed to corroborate this result.
Postoperative considerations
Given that osteoporosis is a major risk factor for intertrochanteric
fractures, consideration should be given to optimizing its man-
agement during the acute admission.56 Bisphosphonates have
long been used for osteoclastic inhibition; these can be given
orally or intravenously.57 Intravenous bisphosphonates can be
delivered yearly, posing a significant benefit to the patient by
reducing the volume of tablet medications that they are required
to take. A recent study by Jalan et al. (2021) investigated the
optimal timing of bisphosphonate administration for inter-
trochanteric fractures and fracture healing, particularly given
that there have been previous concerns that very early
bisphosphonate treatment may have a deleterious effect on
fracture healing in the context of surgery.58 The timing of infu-
sion did not appear to significantly impact on fracture healing,
suggesting that early use of bisphosphonates may be a safe op-
tion before patient discharge.
Tranexamic acid (TXA) has been used to reduce intraoperative
blood loss following hip fracture.59 It is a competitive inhibitor of
tissue plasminogen activator that blocks the lysine-binding sites
of plasminogen and has the effect of inhibiting fibrin clot break-
down.60 In a recent RCT of 100 participants, patients were ran-
domized to either a proximal femoral nail anti-rotation (PFNA)
group with the administration of intravenous TXA, or a PFNA
group with no additional interventions.61 The results of this study
demonstrated that the use of TXA significantly reduced the risk of
introperative, total and hidden blood loss, and the need for an
additional allogenic transfusion without increasing the compli-
cation rate for this procedure. This has been further corroborated
in a meta-analysis of 1194 patients by Agius et al. (2022).62
Ongoing MDT care in the postoperative phase is also imper-
ative, focusing on facilitating weight-bearing through pre-
emptive analgesia which aims to reduce overall complication
rates. In a recent Cochrane review by Handoll et al. (2021), MDT
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rehabilitation resulted in fewer in-hospital deaths, and better
mobility at 1-year post-injury. Whilst there was significant het-
erogeneity within the study populations compared, the authors
were able to conclude that there is a moderate probability that
MDT rehabilitation results in fewer poorer outcomes.63
Conclusions
Intertrochanteric fractures of the hip are common fractures, and
pose a significant risk of mortality in elderly patients. Patients
should be promptly reviewed and optimised for theatre, with
fixation performed ideally on the next day’s operating list. Whilst
IMNs have been increasingly considered the treatment of choice
particularly for fractures with subtrochanteric extensions, the
current literature does not support their use over the DHS, at
least for simple fracture patterns. Postoperatively, an MDT
approach is key to optimizing long-term patient outcomes. A
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