Sliding Hip Screw or Nail for the Intertrochanteric Fracture
An intertrochanteric fracture is one of the most common fractures of old age, and an implant or screw placement that does not hold means collapse, a second operation and lost independence.
Key terminology
- Intertrochanteric fracture
- This hip fracture runs between the greater and lesser trochanters, outside the joint capsule (extracapsular). The leg typically lies shortened and externally rotated.
- Lesser trochanter
- This bony knob sits on the posteromedial upper femur, where the iliopsoas inserts. When it breaks off, the medial buttress of the fracture is lost.
- Unstable intertrochanteric fracture
- This fracture has lost its posteromedial support or lateral wall, or extends toward the subtrochanteric region. It tends to collapse into varus after fixation.
- Reverse obliquity fracture
- This fracture line runs from proximal medial to distal lateral, opposite the usual intertrochanteric line. Its shaft tends to drift medially away from the head.
- Sliding hip screw
- This implant puts a large lag screw up the femoral neck through a barrel on a plate fixed to the lateral shaft. The screw slides in the barrel so the fracture compresses as the patient bears weight.
- Cephalomedullary nail
- This implant is a rod down the femoral canal with a screw or blade passed up into the femoral head. It sits inside the bone, closer to the line of weight bearing than a side plate.
- Tip-apex distance (TAD)
- This measurement adds the distance from the lag screw tip to the apex of the femoral head on the AP and lateral films. A smaller number means a deeper, more central screw.
- Cutout
- This failure happens when the lag screw migrates up and out through the femoral head. It usually needs revision surgery, often to a hip replacement.
Takeaways
- An intertrochanteric fracture lies outside the hip capsule and is fixed rather than replaced. The fracture runs between the greater and lesser trochanters in well-vascularized bone below the capsule. The blood supply to the femoral head is usually spared, so it heals reliably with internal fixation (vs a displaced femoral neck fracture, which often needs arthroplasty). Nearly half of US hip fractures are intertrochanteric (StatPearls NBK493161).
- Stability depends on the posteromedial cortex and the lateral femoral wall. A broken-off lesser trochanter removes the medial buttress and lets the fracture collapse into varus. The lateral wall is the cortex just below the greater trochanter. With a sliding hip screw, reoperation within 6 months ran 3% with an intact lateral wall vs 22% with a broken one, and 74% of wall fractures happened during surgery (Palm et al, J Bone Joint Surg Am 2007;89:470-475, PMID 17332094; Gotfried, Clin Orthop Relat Res 2004;425:82-86, PMID 15292791).
- A reverse obliquity fracture is the classic weak spot for the sliding hip screw. The line runs from proximal medial to distal lateral (AO/OTA 31-A3), so sliding can push the shaft medially instead of compressing the fracture. In a Mayo series, 9 of 16 sliding hip screws failed. Pooled A3 trials found healing complications near 9% with both a nail and a sliding hip screw, and far more with static plates (Haidukewych et al, J Bone Joint Surg Am 2001;83:643-650, PMID 11379732; Parker et al, Injury 2018;49:1319-1323, PMID 29804880).
- A tip-apex distance over 25 mm predicts lag screw cutout. TAD adds the distance from the screw tip to the apex of the head on the AP and lateral films. None of 120 screws with TAD ≤25 mm cut out, and mean TAD was 38 mm in cutouts. A meta-analysis of nails found TAD >25 mm had an odds ratio of 3.72 for cutout (Baumgaertner et al, J Bone Joint Surg Am 1995;77:1058-1064, PMID 7608228; Ng et al, Eur J Orthop Surg Traumatol 2022;32:1617-1625, PMID 34665292).
- Pooled trials show nails and sliding hip screws give about the same survival and function. A Cochrane review of 76 studies (10,979 patients) found 12-month mortality RR 0.99 (moderate certainty) and an imprecise reoperation RR of 1.15. Nails lowered superficial infection (RR 0.71) and nonunion (RR 0.55). Nails also caused 1 extra implant-related femur fracture per 67 patients (Lewis et al, Cochrane Database Syst Rev 2022;1:CD000093, PMID 35080771).
- US surgeons switched to nails faster than the evidence moved. Among young surgeons sitting the ABOS oral boards, nail use for intertrochanteric fractures rose from 3% in 1999 to 67% in 2006. Plate patients had slightly less pain and deformity, and nail patients had more procedure-related complications (particularly fracture). The authors noted the shift came despite a lack of supporting evidence (Anglen and Weinstein, J Bone Joint Surg Am 2008;90:700-707, PMID 18381305).
- AAOS and NICE disagree on the implant for the unstable intertrochanteric fracture. AAOS 2021 accepts either a sliding hip screw or a cephalomedullary nail for a stable fracture and recommends a nail for unstable, subtrochanteric and reverse obliquity fractures. NICE CG124 recommends a sliding hip screw for trochanteric fractures above and including the lesser trochanter (AO A1 and A2) and keeps the nail for subtrochanteric fractures (AAOS CPG Management of Hip Fractures in Older Adults 2021; NICE CG124 guideline 2011).
- Registry data favor a nail for unstable patterns, and the largest RCT found no difference by pattern. In Norway, simple 2-part fractures had more reoperations after a nail (4.2% vs 2.4% at 1 year), and unstable fractures had fewer (HRR 0.82). Parker's 1000-patient RCT found no reoperation difference for any fracture type (Matre et al, Clin Orthop Relat Res 2013;471:1379-1386, PMID 23224796; Grønhaug et al, Bone Joint J 2022;104-B:274-282, PMID 35094569; Parker, Injury 2017;48:2762-2767, PMID 29102044).