TECHNICAL TRICK
The Anterior and Medial Reduction of Intertrochanteric
Fractures: A Simple Method to Obtain a Stable Reduction
James B. Carr, MD
Summary: This article describes a simple method using anterior
and medial bone contact of the distal shaft piece to obtain a stable
reduction for displaced intertrochanteric fractures of the hip. The
technique is based on the observation that the anterior pathoanatomy
of the intertrochanteric hip fracture involves a noncomminuted
fracture plane that can be placed into contact. This reestablishes a
normal neck shaft angle and prevents excessive collapse of the
fracture site. The maneuver is described in the context of the fracture
pathoanatomy and the use of a fracture table.
Key Words: intertrochanteric hip fracture, reduction techniques
(J Orthop Trauma 2007;21:485–489)
INTRODUCTION
Intertrochanteric hip fractures are a common injury
surgically treated by many orthopedic surgeons. Advances in
implant technology include the sliding hip screw and the
intramedullary hip screw.1–7 Both share a central concept of
allowing the fracture fragments to impact, achieve bone-on-
bone stability, and reduce chances of implant failure—
so-called ‘‘controlled collapse.’’ Collapse will occur until
proximal bone rests on stable, intact distal bone. While these
devices represent a definite improvement over the rigid Jewett
nail, their sliding nature can allow excessive shortening of the
fracture and, as a result, cutout of the implants from the
femoral head can occur.
Fracture shortening and implant cutout commonly occur
in tandem.8–10 The best way to prevent fracture sliding is to
obtain a bone-on-bone reduction between the head and neck
fragment and the intact surfaces of the femoral shaft.11,12 For
the intertrochanteric fracture, the best location to obtain bone-
to-bone stability is medially.8,11–16 Reference is also commonly
made to the posteromedial region of the femur, where much of
the strength of the intact proximal femur resides.11,17 However,
when comminuted, the posteromedial region is unable to
provide bone-on-bone stability, and attempts to reestablish the
posteromedial buttress are difficult.
Accepted for publication February 8, 2007.
Associate Clinical Professor of Orthopedic Surgery, University of South
Carolina, Director of Orthopedic Trauma, Palmetto Health Richland
Hospital, Columbia, SC, USA.
Reprints: James B. Carr, MD, 3 Medical Park Drive, Suite 330, Columbia,
South Carolina 29203.
Copyright Ó 2007 by Lippincott Williams & Wilkins
J Orthop Trauma  Volume 21, Number 7, August 2007
The technique described herein obtains a stable re-
duction by using the stable bone that remains on the distal
shaft piece. This intact bone is primarily located anteriorly and
extends to a varying degree medially along the intertrochan-
teric line. Recognition of the characteristic head and neck
displacement (often referred to as ‘‘posterior sag’’) will focus
attention to an open manipulation and thereby bypass pro-
longed attempts at closed, preincision reduction maneuvers.
Although seemingly obvious, this area of intact bone has
been overlooked in the extensive literature on this topic. The
reduction maneuver is best understood by a review of pertinent
pathoanatomy of this fracture and of the forces applied during
reduction when using the fracture table.
INTERTROCHANTERIC
FRACTURE PATHOANATOMY
The unstable intertrochanteric femoral fracture presents
with posteromedial comminution and fracture of the greater
trochanter: the classic 4-part intertrochanteric fracture. In
almost all cases, the anterior cortex fails in tension, producing
a clean fracture line along the intertrochanteric line. The pos-
terior region fails in compression and is commonly commi-
nuted. In a fully developed 4-part intertrochanteric fracture,
the remaining stable anterior/medial bone on the shaft can be
rather small but is still sufficient for the described reduction
maneuver.
Characteristic displacements also occur and are rou-
tinely recognized. The distal femoral shaft piece shortens and
falls into external rotation. The head and neck piece displaces
into varus and commonly translates posteriorly into the com-
minuted intertrochanteric region. More importantly, this frag-
ment subsides (shortens) into the distal shaft piece (Fig. 1).
This is caused by the unopposed medially directed pull of the
powerful adductors on the shaft fragment. This overlapping
displacement of the head and neck piece is critical to
understanding the described reduction maneuver. A stable
reduction is difficult to obtain unless this overlap/translation
deformity is corrected.
PATHOANATOMY AND THE FRACTURE TABLE
Most intertrochanteric hip fractures are reduced and
fixed with the patient on a fracture table. Correct length at the
fracture site is accomplished by adjusting the traction on
the leg. The neck shaft angle is then normalized by adjusting the
abduction/adduction of the leg. The fracture table facilitates
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Carr
FIGURE 1. Lateral view of an intertrochanteric femoral fracture
demonstrating the anterior cortex shortening/overlap and
posterior translation (‘‘posterior sag’’) usually seen with this
injury.
excellent radiographic control, allowing precise placements of
the implants.
However, most fracture tables have no means to laterally
displace the shaft. Lateral displacement of the shaft is required
to disimpact the overlap of the head and neck fragment from
the shaft. Also lacking from many fracture tables is a means to
translate the head and neck piece forward. The end result is
a reduction that looks good in 2 views but in fact is subtly
malreduced and often lacks true bone-on-bone stability. This
malreduction is particularly exaggerated on hips that have
‘‘posterior sag.’’18 Pushing anteriorly on the ‘‘sag’’ will improve
the neck shaft relationship, but it fails to correct the neck shaft
overlap (Fig. 2). If the hip is fixated in this position, shortening
can occur. The commonly recommended maneuver to internally
rotate the leg to ‘‘lock in’’ the reduction will only make this
overlap worse.
Radiographic recognition of the overlap is best made on
the lateral fluoroscopic view, where the anterior cortex is seen
FIGURE 2. Same case as Figure 1, with an intraoperative view
demonstrating bone-on-bone alignment of the anterior
femoral cortex (arrow).
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to have a definite, but sometimes subtle, stepoff (Fig. 1). On
the anteroposterior fluoroscopic view, the deformity is less
recognizable. However, a close examination often reveals a
narrow double density along the intertrochanteric line where
the head and neck fragment overlaps the shaft. This overlap
persists even if the neck shaft angle is reestablished on the
2 views. This leads the surgeon to think that an anatomic
reduction has been obtained, when in reality only an anatomic
alignment has been achieved.
REDUCTION MANEUVER (DESCRIBED FOR
A SLIDING HIP SCREW)
A standard lateral approach is made to the hip. The
vastus lateralis is reflected the width of the side plate. At this
point, the anterior reduction is best assessed by palpating the
region of the intertrochanteric line anteriorly. This entails
minimal dissection. Usually, a stepoff is felt, which identifies
where the shaft overlaps the posteriorly displaced head and
neck fragment. To correct this, one first needs to pull the shaft
laterally to disimpact it from the head and neck fragment. This
is best done with a bone hook passed around the femoral shaft
in a subperiosteal manner distal to the lesser trochanter. Once
the shaft is pulled laterally, a narrow Jocher or Key elevator or
similar instrument is placed between the head and neck shaft
pieces, and the head and neck piece is levered anteriorly. Initial
insertion of the Jocher elevator may require nearly a right angle
between the elevator and the femur. Alternatively, applying
a posterior force to the shaft can align the 2 fragments.
Adjustment in length and rotation of the limb may be required
at this time. The laterally directed traction on the shaft is now
released. This commonly matches the anterior surfaces
together (Fig. 2) or results in a slight anterior overreduction
of the neck on the shaft. At this point, anteroposterior
radiographic views of the hip reveal an anatomic neck shaft
junction—manifested as a ‘‘hairline crack reduction.’’ On the
lateral view, the anterior cortex line is reestablished (Figs. 2
and 4).
Direct pressure alone cannot accomplish this reduction
(Fig. 3). It is instructive to save the prereduction views for
comparison to appreciate the subtle but definite improvement
in reduction. The reduction is now secured with 1, or
preferably 2, 3.2-mm wires that are directed away from the
area of intended lag screw placement. Smaller wires can twist
and break during lag screw insertion. The remainder of the
procedure is carried out in standard fashion. Most commonly
a 130-degree device is required because the neck is reduced
anatomically.
One must be careful the anterior reduction is not lost
during insertion of the hip compression screw, which tends to
rotate the head and neck fragment in a clockwise fashion.
Tapping of the lag screw pathway reduces this possibility.
Connecting the lag screw to the plate can also displace the
head and neck posteriorly to its original position. In difficult
cases, the elevator can be left in place to maintain the
translation of the 2 pieces until the implants are placed. Once
all implants are positioned, the compression screw is used to
impact the pieces together. A firm endpoint will confirm
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FIGURE 3. Example of failure to reduce the overlap deformity
by a levering guide wire in the femoral neck fragment and an
anteriorly applied Key elevator.
a bone-on-bone reduction. Postoperative care is per treating
surgeon protocol.
INTRAMEDULLARY HIP SCREW
The head and neck to shaft reduction can be obtained by
manipulating the fracture in a manner similar to the sideplate
technique. A small lateral approach at the site of the lag screw
insertion can be made to allow placement of the bone hook.
A small accessory incision anterior to the femur at the level of
the femoral neck will allow insertion of the Jocher elevator
(Figs. 4–9). Wire fixation of the neck is still recommended, but
it can be difficult because of the placement of the intra-
medullary device.
DISCUSSION
The recommendation to obtain an anatomic reduction
prior to insertion of a hip screw is nearly universal in the
literature.6,12,19,20 It is a recommendation firmly grounded in
clinical and biomechanical data. Anatomic reduction has
replaced nonanatomic methods such as the medial displace-
ment osteotomy.4–6,11–13,19–22 Techniques to reduce the inter-
trochanteric fracture are numerous. These methods include the
use of unscrubbed assistants, along with various
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Intertrochanteric Fracture Reduction
FIGURE 4. Reduction of anterior cortex (arrow) with the
described maneuver. The bone hook to laterally displace the
shaft was inserted through the lag screw incision, and the neck
was levered through an accessory anterolateral incision used in
Figure 3.
manipulations/positioning of the limb.6,12,19,20 The most
common recommendations involve the use of a fracture table,
using a combination of leg position and traction with fluoro-
scopic guidance. Upward pressure on the greater trochanteric
region, with a device such as a crutch, is commonly recom-
mended for correction of ‘‘posterior sag’’ (which should now
be recognized as posterior translation with overlap of the head
and neck fragment).12,19,20,23 Whereas the neck shaft angle is
improved on the lateral view by this maneuver, the overlap
of the head and neck fragment with the shaft remains
uncorrected.
The term ‘‘anatomic reduction’’ is confusing in a fracture
that has posteromedial comminution that commonly defies
reduction and fixation. Many surgeons interpret the term
FIGURE 5. This example shows an intertrochanteric fracture
with anterior displacement of the head and neck fragment. The
shaft is displaced posteriorly. The bone hook is in place around
the femoral shaft, and the Jocher elevator has been percuta-
neously inserted toward the head and neck fragment.
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Carr
FIGURE 6. Clinical photo of Figure 5 The bone hook has been
inserted to just distal to the lesser trochanter, through an
incision that will be used for the planned lag screw placement.
Lateral traction is applied to disengage the distal fragment
from the head and neck fragment (arrow). The Jocher elevator
is inserted through a percutaneous stab incision located
fluoroscopically. The knee is to the left of the picture.
‘‘anatomic reduction’’ as an anatomic alignment of the
fragments and allowing the ‘‘forgiving’’ sliding hip screw to
do the rest. A reference to the palpation of the intertrochanteric
line, with direct/indirect manipulation of the fragments, is
made in a recent fracture textbook, but not to the specific
maneuver described here, nor to the specific pathoanatomy
that includes a stable anterior cortex to assist with a bone on
bone reduction.12
FIGURE 7. Anteroposterior fluoroscopic view showing the
position of the bone hook and the Jocher elevator. The arrow
shows the direction of the bone hook is pulling.
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FIGURE 8. Lateral fluoroscopic spot view showing reduction of
the anterior cortex (*) with the use of the Jocher elevator to
manipulate the 2 fragments. The large gap in the posterior
medial cortex can be seen just distal to the bone hook (**). The
posteromedial cortex cannot reliably provide bony stability in
this situation.
Biomechanically, an anatomic reduction has been shown
to provide the greatest fixation strength and most resistance to
cutout.4,11,12,16,19,20 Anatomic reduction reestablishes bone-to-
bone contact with the medial anatomy, thereby allowing it to
perform its weightbearing function.11,18 This also reduces
tensile stresses imposed on the implant. The described
reduction maneuver focuses on just this—bringing the
remaining intact bone together for optimal contact.
The issues of excessive shortening and implant cutout
from the femoral head are serious ones.8,10,14,17,19,24 Excessive
FIGURE 9. The nail has now been inserted, and the guide wire
has been placed. The anterior cortex remains reduced (arrow).
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shortening/collapse leads to chronic pain and diminished
ambulation ability and increases the risk of implant cutout.
The average sliding of the lag screw in stable patterns is
reported at 5.3 mm, and for unstable injuries, it is 15.7 mm.8
Even for ‘‘stable patterns,’’ MacEarchern and Heyes-Moore
noted postoperative sliding in 25%.25 In 1 series on unstable
intertrochanteric patterns, only 2% maintained the alignment
obtained at surgery.6 Sliding .15 mm has been correlated with
implant cutout, and settling .20 mm has been correlated with
pain and diminished mobility.8 Cutout has been described in
1–6% of intertrochanteric fractures treated with sliding hip
screws.1,2,8,9,26 Up to 8% have been reported for intramedullary
devices.1 Besides poor placement of the screw within the head,
excessive sliding with fracture collapse has been implicated in
its occurrence—up to 7-fold in 1 series.10 Other important
technical factors in preventing sliding screw failure include
central lag screw placement, the distance of the lag screw to
the subchondral surface of the femoral head, and the amount of
sliding allowed by the side plate.10,14,15,18,24,26–28
The reduction method described in this paper will work
with a majority of intertrochanteric fractures. It is simple and
does not entail extensive soft tissue dissection. Comminution
of the greater trochanter can reduce the area of anterior cortex
available for this maneuver, but almost always some remains
for use.17 One can sometimes obtain the same reduction with
closed methods, but careful scrutiny of the anterior cortex
reduction is required. The one circumstance where this
technique won’t work is when there is comminution involving
the entire anterior/lateral cortex. In this circumstance, there
is no intact bone left for the reduction method. Although
uncommon, the author prefers to use a 95-degree plate in those
circumstances.
A final benefit of this maneuver is the reduction in the
amount of time spent with preincision efforts to align the
fragments. Once one recognizes the overlap between the head
and neck fragment with the shaft, one only need obtain general
length and alignment because a direct reduction is required.
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