The definitive decision for the treatment of a simple pertrochanteric fracture with the lesser trochanter attached to the proximal fragment will be made after positioning of the patient and reduction of the fracture. Since emergency department x-rays are often of suboptimal quality, verification of the preoperative diagnosis using image intensification is necessary.
The lesser trochanter is the key in the decision making as to the choice of the appropriate fixation device.
In simple pertrochanteric fractures, the lesser trochanter remains attached to one of the two fragments. In case it is not, we are dealing with another fracture type, and another treatment modality might be a better choice.
Fractures where the lesser trochanter is still attached to the femoral shaft are generally called stable trochanteric fractures because after anatomic reduction and internal fixation there is little tendency to loss of reduction under physiological loading.
If the lesser trochanter is attached to the proximal fragment, closed reduction is usually impossible because the pull of the psoas muscle will flex and externally rotate the proximal fragment, and traction will not correct this displacement. Therefore, one usually has to carry out an open reduction.
Because of the intrinsic stability of fractures with lesser trochanter attached to the distal fragment after reduction, most implants will be adequate to maintain reduction and result in uneventful healing. Simple extramedullary sliding devices like the DHS are the cheapest and most logical choices for fixation. The general concept of the application of these devices is shown on the next pages with the AO dynamic hip screw (DHS) used as an example.