An irreducible variant of intertrochanteric fractures: a technique for open reduction.

We report five cases of intertrochanteric fractures that needed open reduction after failed closed reduction techniques. In all cases the shaft fragment included the lesser trochanter, and there was a long spike on the head-neck fragment. This was evident clinically as the proximal shaft, pulled by the iliopsoas tendon, produced a swelling in front of the hip joint. Radiographically, the fracture was minimally comminuted. The anteroposterior view revealed upward riding of the shaft fragment, while lateral view showed the femoral shaft in front of the head and neck. We describe a three-step technique, which was applied for open reduction in these unusual cases. With the patient supine on a standard operating table, the fracture site was exposed. The limb was placed in full adduction and external rotation to slacken the iliopsoas tendon. A Hohmann retractor was then passed medial to the shaft and behind the fractured surface of the sunken femoral neck, levering it anteriorly. Traction in abduction and internal rotation was applied to complete the reduction. Additional iliopsoas tenotomy was performed in two patients. All cases were fixed with a dynamic hip screw and all fractures united uneventfully.