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Management Of Intertrochanteric Fractures By Using   Dynamic Hip Screw / Dynamic Martin Screw

Anil Kumar  Mishra*

*Military Hospital, Dehradun Cantt-248003

Address for Correspondence:

Dr. Anil Kumar Mishra
Military Hospital,Dehradun Cantt-248003


A review   of 110 cases of intertrochanteric fractures treated by using Dynamic Hip Screw /Dynamic Martin Screws over a period of two years was done. Medial bony contact was obtained before fixation of the fractures. In cases with doubtful medial cortical stability autogenous bone grafting from iliac crest was done. Excellent to good results were obtained in 72 of the cases (66.4%). 32 cases (29.1%) showed satisfactory results. 6 cases (5.5%) had shown poor results.
Keywords: Intertrochanteric fractures, Dynamic Hip Screw, Autogenous bone grafting.

J.Orthopaedics 2007;4(2)e40


Intertrochanteric fractures have been estimated to occur in over 2,00,000 patients in the United States (1). Reported mortality with these fractures ranges from 15 -20%. In its natural history these fractures are known to occur in elderly patients. . These fractures are    thrice more frequent in women than in men. Due to increase in average life expectancy as   a result of better medical care our society is having a large number of aged population those are more prone to intertrochanteric fractures. Surgical management is the treatment of choice for these fractures as to mobilize the patients out of the bed and thus preventing complications of prolonged recumbency. In this paper we review our experiences with Dynamic Hip Screw/Dynamic Martin Screw in the management of    intertrochanteric   fractures.

Material and Methods :

A total of 110 cases managed at three Service Hospitals were reviewed in this study.

A thorough clinical and radiological evaluation was done for every patient. Fractures were classified as per A. O. Group   classification for intertrochanteric fractures (2). Patients were taken up for surgery within 7 -15 days. Preoperative skeletal traction immobilization was done in the ward.  Surgery was performed mostly under spinal anesthesia and occasionally under general anesthesia depending upon the general condition of the patients. Patients were positioned supine on Albees fracture table. Trochanteric region was exposed via lateral approach and guide wire was passed under image intensifier guidance. Fixation was done by using DHS/  DMS. Unstable fractures geometry was made stable by obtaining medial cortical bone contact between femoral neck, trochanter and upper shaft. Post operatively, drain was removed after 48 hours and patients were encouraged to move out of the bed. Non - weight walking was started by 5th day. Suture removal was done after 14 days and patients were discharged home with the advice to walk non-wt bearing with crutch/walker support for a period of 4 to 6-wks depending on the comminution at the fracture site. Partial weight bearing was started thereafter till the consolidation of fracture fragments. Follow up was done up to a period of 2 yrs.

Results :

A total of 110 hips were operated during this period. No of male patients were71 (64.5 %) and the females were 39 ( 35.5 %) . All the patients had unilateral intertrochanteric   fractures. The age distribution was as under.


The youngest patient in our series was 35 years old and the eldest was 78 yeas old. Maximum number of cases was in the age group range of   56-65 years.   All the patients

Sustained direct trauma to the hip having usually involved in a road traffic accidents   or accidental falls. All the patients were operated under spinal anesthesia. All the cases in our series were operated. According to AO classification the distribution was as under.

Table 2

Patient not operated due to various reasons were not considered   in this study. There was no mortality in our series. Patients were ambulant non-weight bearing after 5th post- operative day using a walker. Isometric exercises were started after 48 hours. Antibiotics were used for 5 days with first dose given at time of incision. Post- operative infection occurred in two cases. First case had superficial wound infection and second   case had delayed wound infection, six months after the surgery. These cases were managed  with debridement and antibiotics.

Discussion :

In our series 110 cases of intertrochanteric fractures were managed with Dynamic Hip Screw /Dynamic Martin screw fixation. Patients managed conservatively due to various medical & other related problems were not included. This was done to observed the natural history of this treatment of modality .The male: female ratio in our series is 1.8:1  Average age in these patient is 55 to 75 years .In unstable fractures medial bone contact was  obtained before fixation of the fracture .  As demonstrated by Wolfgang (3) approximately 10%) medial movement of unstable fracture resulted in 90% of union. The use of sliding device theoretically allowed & unstable fracture to impact and there by seek its own position of stability. Jacob & colleagues(4) demonstrated that as  the sliding device shortens with settling of an unstable fractures, the lever arm acting on the nail plate junction shortens thereby reducing the force on the implant. Clowson(5),  Ecker and colleagues(6) noted that unstable fractures treated with sliding  device   underwent shortening and medial displacement but fracture went on to prompt union. Although  shortening   upto 1 cm occurred the head did not fall into  varus, nor did the fixation device cut through the head and damaged the  acetabulum . In our series we had obtained medial and posterior bony stability in treating the unstable fracture and if doubtful bony contact was noticed, autogenous bone grafting from ipsilateral iliac crest was done. We did not have any cases of implant failure and proximal migration of implant into the joint. As noted by Wolfgang and coworkers (3)  that unstable fracture treated without obtaining bony stability had 21 % mechanical failure. This rate was reduced to 10% when bony stability was obtained.  Jenson(7) and Moore(8) reported a 10% in hospital mortality rate associated with  intertrochanteric fractures. In our series fortunately we had no in hospital mortality. The incidence of post-operative wound infection after open reduction and internal fixation of intertrochanteric fracture varies from 1.7% to 16.9%(9,10 ). In our series we had two cases (Case No.ll and 23) of wound infection (1.8%). One case has superficial wound infection (group 1 as per Barr's(11)four group of   post operated infection). Second case had group III (late sepsis after six months). These cases were managed with local wound debridement and wound dressing. Intertrochanteric fracture  occur in cancellous bone with good blood supply, non union has been found to be uncommon. The incidence of non-union is reported to be 1 % -2%(12). Those  intertrochanteric fractures prone to non union includes comminuted  unstable fracture with loss of medial calcar continuity, which when  stabiIised  tends to fall into  varus. Mariani and Rand(13) reported that 10 of 20 patients with non- union of intertrochanteric fractures has unstable fractures with loss of medial support. Laskin  and associates(14) noted that union was present within three months of fracture and that non union was secondary to poor bony opposition at the time of surgery. In our series we did autogenous bone grafting having doubtful medial bony support thus there were no non union noted in our  series . We started partial weight bearing after 4 weeks in patients whom stable internal fixation was obtained .Patients having unstable fracture geometry were allowed partial weight bearing after 8-12 weeks. Full weight bearing was allowed after complete radiological union for all the cases on individual basis.72 patients had good function recovery and sound bony union.32 patient had satisfactory results with shortening up to2.5 centimeters and few degree of terminal restriction of hip joint movements. 6 cases has shown poor results with shortening of more than 3 centimeters and varus  angulation of 100 degrees. These patients had painful restriction of hip joint movement and limp while walking.In our review we concluded that sliding compression hip screw  the implant of choice for  the treatment of intertrochanteric fractures. We also recommend primary bone grafting from ipsilateral iliac crest in unstable fractures where medial bony contact is poor.

Reference :

  1. James L.Guyton. In: Campbell’s operative orthopaedics. S.Terry Canale, M.D.editor. 9th ed. 1998: 2182-2183, Mosby – Year Book, Inc, USA.

  2. Muller ME, Allgower M, Schneider R, Willenegger H; Manual of Internal fixation: techniques recommended by the AO, ASIF group, ed 3, Berlin, 1991 Springer-Verlag.

  3. Wolfgang, G.L.; Bryant, M.H. ; and O’Neill, J.P.; Treatment of Intertrochanteric Fracture of the Femur Using Sliding Screw Plate Fixation Clin.Orthop., 163:148-158,1982

  4. Jacobs, R.R; McClain, O.; and Armstrong, H. J.; Internal Fixation of Intertochanteric Hip Fractures: A Clinical and Biomechanical Study. Clin. Orthop., 146:62-70,1980.

  5. Clawson, D.k.; Trochanteric Fractures Treated by the Sliding Screw Plate Fixation Method.J.Trauma, 4:737-756,1964.

  6. Ecker, M.L.; Joyce, J.J.; and Kohl, E.J; The Treatment of Trochanteric Hip Fractures Using a Compression Screw. J. Bone Joint Surg., 56A23-27, 1975.

  7. Jensen, J.S. : Trochanteric Fractures. Acta Orthop. Scand. (Suppl.), 188:1-100,1981.

  8. Moore, M. ; Treatment of Trochanteric Femoral Fractures With Special Reference to Complications. Am. J. Surg., 84:449-452, 1952.

  9. Cleveland, M, Bosworth, D.M, and Thompson, F.R.; Intertrochanteric Fractures of the Femur. J. Bone Joint Surg., 29:1049-1067,1947.

  10. Kyle, R.F.; Intertrochanteric Fractures. In Chapman M.W. (ed.) : Operative Orthopaedics,pp. 353-359. Philadelphia, J.B.Lippinoctt,1988.

  11. Barr, J.S.; Diagnosis and Treatment of Infections Following Internal Fixation of Hip Fractures. Orthop. Clin.North Am. 5:847-864,1974.

  12. Wilson,H.J.:Rubin,B.D.;Helbig;F.E.J.;Fielding,J.W.;and Unis,G.L.; Treatment of Intertrochantric Fractures  with Jewett Nail: experience with 1,015 cases.Clinical orthopaedics .,148:186-191,1980.

  13. Mariani,E.M.,and Rand,J.A.;Subcapital Fractures after open reduction and internal fixation of Intertrochantric Fractures of the Hip . Clin Orthop, 245:165-168,1989.

  14. Laskin,R.S.:Gruber,M.A.and Zimmerman,A.J.; Intertrochanteric Fractures of the Hip in Elderly :A Retrospective Analysis of 236 cases . Clin Orthop.141: 188-195,1979.                                                                 

This is a peer reviewed paper 

Please cite as :Anil Kumar  Mishra : Management Of Intertrochanteric Fractures By Using   Dynamic Hip Screw / Dynamic Martin Screw

J.Orthopaedics 2007;4(2)e40





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