Internal fixation is the treatment of choice as it enables early mobilisation and good anatomical reduction.
Stable fractures may be reduced by slight traction with the leg in internal or external rotation, or placed in neutral, as dictated from the radiograph. Once confirmed by subsequent x-ray, the reduction may be held using any suitable device which will grip the femoral head and neck, and be secured to the intact femoral shaft e.g. a fixed angle blade plate or preferably, a sliding screw and plate. These patients may be mobilised early.
Unstable fractures are best managed with a device that will enable the fragments to impact, such as a "dynamic hip screw".
In severely comminuted fractures, it may be necessary to push the femoral shaft medially to provide support for the head, and then fix. Bone grafting may be necessary if the medial cortex has been badly destroyed.
Weight bearing is usually deferred until callus appears and is seen to be reinforcing the fixation device.
Pathological fractures may require the addition of cement to improve the stability provided by internal fixation.
Alternatively, in patients unfit for anaesthesia or with problems from other injuries, an intertrochanteric or per-trochanteric fracture may be successfully treated by bed rest and traction, since union is seldom a problem. However, the risks to these patients from internal fixation must always outweigh the advantages of early mobilisation.
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