Intertrochanteric hip fractures are extracapsular fractures of the proximal femur occurring between the greater and lesser trochanters. They account for approximately half of all hip fractures, predominantly affect elderly women after low-energy falls, and carry a 30-day mortality of ~10% and 1-year mortality approaching 30%. [1-2] Surgical fixation — typically with a cephalomedullary nail (unstable patterns) or sliding hip screw (stable patterns) — within 24–48 hours is the standard of care. [1][3-4]
The following figure illustrates the anatomical classification of hip fractures, including the intertrochanteric region:
1. History
- Mechanism: Low-energy fall from standing height (elderly) vs. high-energy trauma (young patients) [2]
- Pain location: Anterior groin and lateral hip pain; inability to bear weight
- Timing: Acute onset with fall; ask about prodromal symptoms (syncope, dizziness, chest pain) to evaluate for a medical cause of the fall
- Progression: Immediate inability to ambulate; worsening pain with any hip movement
- Associated symptoms: Leg shortening, rotational deformity; ask about anticoagulant use, prior falls, and baseline ambulatory status
- Important negatives: Absence of back pain (lumbar pathology), absence of knee pain (referred pain), no history of malignancy (pathologic fracture)
2. Alarm Features
- Hemodynamic instability (occult hemorrhage — hip fractures can lose 500–1500 mL into the thigh) [2]
- Syncope or chest pain preceding the fall → evaluate for MI, PE, arrhythmia as the precipitating event [6-7]
- Open fracture or neurovascular compromise (rare but critical)
- Signs of compartment syndrome (severe thigh swelling, pain out of proportion)
- Concurrent head/cervical spine injury in high-energy mechanisms
- Perioperative myocardial infarction occurs in up to 35% of hip fracture patients (often asymptomatic) [8]
3. Medications
- ED pain management:
- Peripheral nerve block (fascia iliaca compartment block or PENG block) — strongly recommended as part of multimodal analgesia; reduces opioid use, delirium, and respiratory depression [3][9-10]
- Acetaminophen 1 g IV/PO
- Low-dose opioids (avoid excessive sedation in elderly)
- Avoid NSAIDs if renal impairment or surgical candidate
- Perioperative antibiotics: Cefazolin 1–2 g IV 1–2 hours preoperatively and for 24 hours postoperatively (vancomycin if cephalosporin allergy) [1]
- VTE prophylaxis: LMWH (enoxaparin), aspirin, or rivaroxaban — chemoprophylaxis is recommended over mechanical prophylaxis alone [1][3][11]
- Tranexamic acid (TXA): Recommended to reduce blood loss and transfusion need [3]
- Medications to hold/review: Anticoagulants (warfarin, DOACs) — balance surgical timing vs. reversal; metformin (hold perioperatively); antihypertensives contributing to falls [1][12]
- Contraindicated: Benzodiazepines as first-line for agitation/delirium postoperatively [13]
4. Diet
- Preoperative: NPO for surgical planning
- Postoperative nutritional supplementation: Oral nutritional supplements (high-protein, ≥1.2 g/kg/day protein) reduce infective complications by ~50%, pressure ulcers, and hospital length of stay [14-15]
- Calcium (800–1000 mg/day) and vitamin D (800–1000 IU/day) supplementation recommended for bone health [13][16]
- Malnutrition screening: Use MNA or serum albumin; malnutrition prevalence is high in this population and independently worsens outcomes [17]
- Hydration: Aggressive IV fluid resuscitation perioperatively; monitor for occult blood loss
5. Review of Systems
- Cardiovascular: Chest pain, palpitations, dyspnea (precipitating cardiac event?), orthopnea, lower extremity edema
- Neurologic: Syncope, presyncope, confusion/delirium (baseline cognitive status), focal weakness
- Pulmonary: Cough, dyspnea (PE risk, aspiration risk)
- GU: Urinary retention, incontinence (common postoperatively)
- GI: Constipation (opioid-related), nausea, appetite
- Musculoskeletal: Other fracture sites (wrist, spine, pelvis), baseline mobility and ambulatory aids
6. Collateral History and Family History
- Baseline functional status: Pre-fracture ambulatory level (independent, walker, wheelchair) — strongest predictor of postoperative functional recovery [18]
- Cognitive baseline: Dementia or cognitive impairment increases fall risk, delirium risk, and mortality [19]
- Living situation: Independent vs. assisted living vs. nursing facility — impacts disposition planning
- Family history: Osteoporosis, hip fracture, metabolic bone disease
- Social: Alcohol use (fall risk, bone density), smoking, home safety hazards
7. Risk Factors
- Nonmodifiable: Age >65 (risk doubles every 5 years after 50), female sex (3:1 ratio), prior fracture, metabolic bone disease, bony malignancy [1]
- Modifiable: Osteoporosis (T-score < −2.5), increased fall risk, low BMI (<18.5), physical inactivity, vitamin D deficiency [1]
- Medications increasing risk: Corticosteroids, PPIs, loop diuretics (decrease BMD); SSRIs, benzodiazepines, opioids, antihypertensives (increase fall risk) [1]
- Comorbidities worsening outcomes: Diabetes, cognitive impairment, COPD, CKD, coronary artery disease, heart failure [19-20]
- Lifestyle: Alcohol >27 g/day, smoking, high caffeine intake (>3 cups/day) — 1.5–2× increased fracture odds [1]
8. Differential Diagnosis
- Femoral neck fracture — intracapsular; different surgical management (arthroplasty vs. fixation); may appear similar clinically
- Subtrochanteric fracture — more distal; often requires long intramedullary nail
- Isolated greater trochanter fracture — often managed conservatively; lateral hip pain without shortening
- Pubic ramus fracture — groin pain, ambulatory difficulty; pelvic X-ray diagnostic
- Hip dislocation — typically high-energy; fixed flexion/internal rotation (posterior) or extension/external rotation (anterior)
- Pathologic fracture — suspect with minimal trauma, known malignancy, lytic lesions on imaging
- Occult fracture — normal X-ray but persistent pain; MRI is gold standard for detection (~15% of hip fractures are radiographically occult) [2][21]
- Lumbar radiculopathy or referred knee pain — can mimic hip pathology
9. Past Medical History
- Prior fractures (especially contralateral hip — 10% lifetime risk of second hip fracture)
- Osteoporosis diagnosis and treatment history (bisphosphonates, denosumab)
- Cardiac history (CAD, CHF, arrhythmias — impacts anesthesia risk and perioperative MI risk) [6][22]
- Diabetes, CKD, COPD — independently associated with early mortality [19]
- Anticoagulation status and indication
- Prior surgeries (especially hip/knee)
- Cognitive impairment or dementia
10. Physical Exam
- Vital signs: Tachycardia and hypotension may indicate occult hemorrhage; fever suggests infection or concurrent illness
- Inspection: Affected limb classically shortened and externally rotated; ecchymosis over the lateral hip/thigh is common with extracapsular fractures [2]
- Palpation: Tenderness over the greater trochanter and groin
- Range of motion: Severe pain with any passive hip rotation (log-roll test); do not force ROM
- Neurovascular: Assess distal pulses, sensation, and motor function (sciatic nerve injury rare but possible)
- Skin: Assess for pressure injuries (sacrum, heels) — especially if prolonged time on the ground
- Full trauma survey: Head, C-spine, chest, pelvis, and extremities in high-energy mechanisms
11. Lab Studies
- CBC: Baseline hemoglobin (transfusion threshold Hgb <8 g/dL in asymptomatic patients; higher if cardiac disease) [1][3]
- BMP/CMP: Renal function, electrolytes, glucose
- Coagulation studies: PT/INR (especially if on warfarin); important for surgical timing
- Type and screen/crossmatch
- Troponin: Perioperative MI occurs in up to 35–41% of patients; serial troponin monitoring recommended at admission and postoperatively [8][23]
- Urinalysis: UTI screening (common comorbidity)
- Albumin/prealbumin: Nutritional status assessment; low albumin is an independent risk factor for complications and mortality [14][17]
- Vitamin D, calcium, PTH: Osteoporosis workup (can be initiated inpatient or outpatient) [3]
12. Imaging
- First-line: AP pelvis and cross-table lateral hip radiographs — sufficient for diagnosis in most cases [1][21]
- Key findings: Fracture line traversing the intertrochanteric region; assess for comminution, lesser trochanter involvement, and reverse obliquity pattern (indicates instability)
- MRI: Gold standard if radiographs are negative but clinical suspicion remains high (~15% of fractures are occult) [1][13][21]
- CT: Alternative to MRI when MRI is contraindicated or unavailable; useful for surgical planning and assessing fracture pattern/comminution
- Imaging is unnecessary: Traction films are not recommended; preoperative traction should not be used [3]
13. Special Tests
- AO/OTA Classification: Categorizes trochanteric fractures as A1 (stable, simple pertrochanteric), A2 (unstable, multifragmentary), or A3 (intertrochanteric/reverse obliquity, unstable) — guides surgical implant selection [24-26]
- ASA Physical Status Classification: Preoperative risk stratification
- Nottingham Hip Fracture Score or similar: Predicts 30-day mortality
- DEXA scan: Ordered for outpatient osteoporosis evaluation (not acute) [3]
- Point-of-care ultrasound: Can be used to perform fascia iliaca or PENG blocks in the ED [10]
14. ECG
- Obtain on all patients: Baseline ECG is essential for preoperative evaluation and to assess for a cardiac precipitant of the fall [6]
- Key findings to evaluate:
- New arrhythmias (atrial fibrillation, heart block) — common in elderly hip fracture patients [27]
- ST changes suggesting acute coronary syndrome — perioperative MI is frequently silent [8]
- QTc prolongation (medication-related)
- Serial ECGs and troponins recommended perioperatively given the high incidence of myocardial injury (~35–41%) [8][23]
- Echocardiography: Consider preoperatively in patients with known cardiac disease or abnormal ECG; 75% of patients who developed cardiac events had abnormal preoperative TTE findings [22]
15. Assessment
- Intertrochanteric fractures are extracapsular — the blood supply to the femoral head is preserved, so avascular necrosis is not a concern (unlike femoral neck fractures) [4]
- Stability classification is the key determinant of surgical approach: stable (A1) vs. unstable (A2/A3) [2][4][24]
- Mortality: 30-day ~10%, 1-year ~24–30%; men have higher excess mortality than women [18][28]
- Functional outcomes: Only ~50% recover pre-fracture ADL function at 6 months; 25% recover instrumental ADLs [18]
- Complications: Delirium (most common postoperative complication), VTE, pneumonia, UTI, pressure ulcers, perioperative MI, surgical site infection [1][29]
- Atypical presentations: Nondisplaced fractures may present with ambulatory ability preserved and minimal deformity — maintain high clinical suspicion
16. Treatment Plan
- Initial stabilization (ED):
- Immobilize in position of comfort (pillows); no traction [3]
- Peripheral nerve block (fascia iliaca or PENG) as early as possible [3][9-10]
- IV fluids, pain management (multimodal), NPO for surgery
- Correct coagulopathy if applicable
- Surgical management:
- Stable fractures (A1): Sliding hip screw (SHS) [2][4]
- Unstable fractures (A2, A3, reverse obliquity): Cephalomedullary nail (CMN) — strong AAOS recommendation [3-4]
- Timing: Within 24–48 hours of admission; delays beyond 24 hours are associated with 38% increase in complications and 74% increase in mortality [1][3][30-31]
- Anesthesia: Spinal or general — no difference in mortality or ambulation at 60 days [1]
- Perioperative care:
- Cefazolin preoperatively + 24 hours postoperatively [1]
- TXA to reduce blood loss [3]
- VTE prophylaxis: LMWH, aspirin, or DOAC for ≥4 weeks [1][3][11]
- Transfusion threshold: Hgb <8 g/dL (asymptomatic) [1][13]
- Delirium prevention: Minimize opioids, avoid benzodiazepines, reorient frequently [13]
- Postoperative rehabilitation:
- Weight-bearing as tolerated immediately postoperatively [1][3]
- Early mobilization within 24 hours — improves mobility outcomes [1]
- PT/OT throughout hospitalization and post-discharge [13]
- Oral nutritional supplementation (high-protein) [13-14]
- Osteoporosis management:
- Vitamin D + calcium supplementation
- DEXA scan referral
- Consider bisphosphonate or denosumab initiation (typically 2 weeks post-surgery) [3][13]
17. Disposition
- All intertrochanteric hip fractures require hospital admission for surgical management [13]
- ICU admission criteria: Hemodynamic instability, active cardiac event, severe respiratory compromise, need for invasive monitoring
- Observation/floor: Most patients; multidisciplinary co-management with medicine/geriatrics is recommended [13][18]
- Discharge criteria: Pain controlled on oral medications, ambulating with PT, safe disposition plan, VTE prophylaxis arranged
- Discharge destination: Most patients require inpatient rehabilitation or skilled nursing facility; only ~25% of previously independent patients return directly home [18][32]
- Specialist consultation triggers: Orthopedic surgery (all cases), geriatrics/hospitalist co-management, cardiology (if active cardiac disease or perioperative MI), palliative care (if goals-of-care discussion needed)
18. Follow Up / Return Precautions
- Orthopedic follow-up: Typically 2 weeks (wound check, X-ray) and 6 weeks postoperatively
- Osteoporosis evaluation: DEXA scan and bone health clinic referral within 3 months [3]
- Fall prevention: Home safety assessment, PT for balance/strength, medication review to minimize fall-risk drugs, vision assessment [1]
- Return precautions (patient counseling):
- Return immediately for increasing pain, wound drainage/redness, fever, leg swelling (DVT), chest pain or shortness of breath (PE/MI), confusion
- Expected recovery: Most patients require 3–6 months for functional recovery; many will not return to pre-fracture baseline [18][28]
- Secondary fracture prevention: Lifelong osteoporosis treatment, calcium/vitamin D, exercise program, fall prevention strategies [1][13]
- Mortality awareness: Counsel families that 1-year mortality is ~24–30% even with optimal care; functional decline and loss of independence are common [18]
References
1. Hip Fractures: Diagnosis and Management. — Schroeder JD, Turner SP, Buck E. American Family Physician. 2022.
2. Ultra-Early Versus Early Surgery for Hip Fracture. — Viamont-Guerra MR, Guimarães R, Bridges C, Antonioli E, Lenza M. The Cochrane Database of Systematic Reviews. 2024.
3. AAOS Management of Hip Fractures in Older Adults Evidence-Based Clinical Practice Guideline. — Switzer JA, O'Connor MI. The Journal of the American Academy of Orthopaedic Surgeons. 2022.
4. Management of Acute Hip Fracture. — Bhandari M, Swiontkowski M. The New England Journal of Medicine. 2017.
5. Hip fracture and orthogeriatrics. — Christine Lafont, Thomas Krams Pathy's Principles and Practice of Geriatric Medicine 6e. 2022.
6. Cardiovascular Diseases, Prevention, and Management of Complications in Older Adults and Frail Patients Treated for Elective or Post-Traumatic Hip Orthopaedic Interventions: A Clinical Consensus Statement of the ESC Council for Cardiology Practice (CCP), the European Association of Preventive Cardiology (EAPC), the Association for Acute CardioVascular Care (ACVC), the Association of Cardiovascular Nursing & Allied Professions of the ESC (ACNAP), the ESC Working Group on Aorta and Peripheral Vascular Diseases (WG APVD), and the ESC Working Group on Thrombosis (WG T). — Guasti L, Fumagalli S, Afilalo J, et al. European Journal of Preventive Cardiology. 2025.
7. Immediate Risk for Cardiovascular Events in Hip Fracture Patients: A Population-Based Cohort Study. — Hsu WWQ, Sing CW, Li GHY, et al. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences. 2022.
8. Perioperative Myocardial Infarctions Are Common and Often Unrecognized in Patients Undergoing Hip Fracture Surgery. — Hietala P, Strandberg M, Strandberg N, Gullichsen E, Airaksinen KE. The Journal of Trauma and Acute Care Surgery. 2013.
9. Peripheral Nerve Blocks for Hip Fractures. — Liu YT, Tovar Hirashima E, Yadav K. The Journal of the American Medical Association. 2025.
10. Ultrasound Guidelines: Emergency, Point-of-Care, and Clinical Ultrasound Guidelines in Medicine. — American College of Emergency Physicians (2023). 2023.
11. Aspirin or Low-Molecular-Weight Heparin for Thromboprophylaxis after a Fracture. — Major Extremity Trauma Research Consortium (METRC), O'Toole RV, Stein DM, et al. The New England Journal of Medicine. 2023.
12. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. — Douketis JD, Spyropoulos AC, Murad MH, et al. Chest. 2022.
13. Best Practices In The Management Of Orthopaedic Trauma. — Matthew L. Davis MD FACS, Gregory J. Della Rocca MD PhD FACS, Megan Brenner MD MS RPVI FACS, et al American College of Surgeons (2015). 2015.
14. Effect of Oral Nutritional Supplementation on Outcomes in Older Adults With Hip Fractures and Factors Influencing Compliance. — Chen B, Zhang JH, Duckworth AD, Clement ND. The Bone & Joint Journal. 2023.
15. Optimizing Recovery After a Hip Fracture: Protocol of a Randomized Controlled Trial to Study the Effects, Costs, and Cost-Effectiveness of a Combined Protein and Exercise Intervention in Older Adults After a Hip Fracture (ProBUS Study). — Treijtel E, Wijnen HH, Golüke NMS, et al. Experimental Gerontology. 2025.
16. Nutritional Intake and Bone Health. — Rizzoli R, Biver E, Brennan-Speranza TC. The Lancet. Diabetes & Endocrinology. 2021.
17. Malnutrition in Older Hip Fracture Patients: Prevalence, Pathophysiology, Clinical Outcomes, and Treatment-a Systematic Review. — Meermans G, van Egmond JC. Journal of Clinical Medicine. 2025.
18. Hip Fracture Management: Tailoring Care for the Older Patient. — Hung WW, Egol KA, Zuckerman JD, Siu AL. The Journal of the American Medical Association. 2012.
19. Preoperative Comorbidities Associated With Early Mortality in Hip Fracture Patients: A Multicenter Study. — McHugh MA, Wilson JL, Schaffer NE, et al. The Journal of the American Academy of Orthopaedic Surgeons. 2023.
20. Risk Factors and Prognosis of Perioperative Acute Heart Failure in Elderly Patients With Hip Fracture: Case-Control Studies and Cohort Study. — Zhao W, Fu M, Wang Z, Hou Z. BMC Musculoskeletal Disorders. 2024.
21. ACR Appropriateness Criteria® Acute Hip Pain: 2024 Update. — Bartolotta RJ, Ha AS, Bateni CP, et al. Journal of the American College of Radiology : JACR. 2025.
22. Analysis of Cardiac Events and the Subsequent Impact for Geriatric Patients Undergoing Hip Fracture Surgeries. — Chao TC, Lee HP, Wu JC, Hsu CJ. Journal of Clinical Medicine. 2023.
23. Perioperative Myocardial Infarction/Myocardial Injury Is Associated With High Hospital Mortality in Elderly Patients Undergoing Hip Fracture Surgery. — Rostagno C, Cartei A, Rubbieri G, et al. Journal of Clinical Medicine. 2020.
24. Arthroplasties for Hip Fracture in Adults. — Lewis SR, Macey R, Parker MJ, Cook JA, Griffin XL. The Cochrane Database of Systematic Reviews. 2022.
25. Surgical Interventions for Treating Extracapsular Hip Fractures in Older Adults: A Network Meta-Analysis. — Lewis SR, Macey R, Lewis J, et al. The Cochrane Database of Systematic Reviews. 2022.
26. Cephalomedullary Nails Versus Extramedullary Implants for Extracapsular Hip Fractures in Older Adults. — Lewis SR, Macey R, Gill JR, Parker MJ, Griffin XL. The Cochrane Database of Systematic Reviews. 2022.
27. Multidisciplinary Rehabilitation for Older People With Hip Fractures. — Handoll HH, Cameron ID, Mak JC, Panagoda CE, Finnegan TP. The Cochrane Database of Systematic Reviews. 2021.
28. Anabolic Medications for Rehabilitation After Hip Fracture in Older People. — Deacon C, Busby C, Rollins KE, et al. The Cochrane Database of Systematic Reviews. 2026.
29. Complications Following Hip Fracture: Results From the World Hip Trauma Evaluation Cohort Study. — Goh EL, Lerner RG, Achten J, et al. Injury. 2020.
30. In-Hospital Outcome After Trochanteric Femur Fractures Is Related to Preoperative Delay but Not to the Time of Day of the Procedure: A Nationwide Retrospective Cohort Study of 7184 Patients. — Egger V, Mittlmeier AS, Canal C, Neuhaus V. European Journal of Trauma and Emergency Surgery : Official Publication of the European Trauma Society. 2025.
31. Impact of Timing of Surgery in Elderly Hip Fracture Patients: A Systematic Review and Meta-Analysis. — Klestil T, Röder C, Stotter C, et al. Scientific Reports. 2018.
32. Interventions for Improving Mobility After Hip Fracture Surgery in Adults. — Fairhall NJ, Dyer SM, Mak JC, et al. The Cochrane Database of Systematic Reviews. 2022.