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Hip fracture fixation (dynamic hip screw)

Fixation of an intertrochanteric hip fracture with a sliding screw-and-plate that lets the fracture compress as the patient walks on it, the fracture-clinic operation most on-call students will see first.

Indication: Stable intertrochanteric (extracapsular) fractures of the proximal femur; the femoral head keeps its blood supply, so it is fixed, not replaced.

Part of Orthopedic Surgery →4 stages3 complications to knowopen

Read the imaging first

X-ray
Hip X-ray showing the appearance of a comminuted proximal femoral fracture
Hip X-ray · comminuted proximal femoral fracture

Practice before you scrub

Classify the hip fracture

An 84-year-old found on the floor: a shortened, externally rotated leg. AP radiograph of the hip. (Fictional educational case.)

  • The fracture line's address against the capsule is the operation: intracapsular displaced gets replaced, extracapsular gets fixed.
  • The radiograph is read with the patient attached: activity and cognition choose between hemiarthroplasty and total hip replacement.
Practice this image View the anatomy

On the tray for this operation

Test yourself on the tray

Stage

1 / 4

Reduction on the traction table

On the traction table under image intensifier, the fracture is reduced closed with traction and rotation, checked on two views before anything is opened.

Watch for: Malreduction accepted and then fixed in place · Traction injuries (pudendal nerve)

Why are we operating?

The dynamic hip screw fixes extracapsular hip fractures with a deliberately sliding implant: a large screw in the femoral head engages a plate on the shaft through a barrel that lets the screw telescope, so weight-bearing compresses the fracture instead of levering the metal out. It exists because these fractures keep their blood supply, so fixation (not replacement) is the right answer, and because controlled collapse is how they want to heal.

Pulls toward surgery

Extracapsular (intertrochanteric) hip fractureStable fracture patterns suiting a sliding constructBlood supply intact, so the head is worth keepingSurgery within 36 hours as part of the hip-fracture pathway

Gives the team pause

Unstable and reverse-oblique patterns (the nail's territory)Intracapsular fractures wearing an extracapsular labelFrailty demanding the pathway's medical half in parallel

Shared foundations

Fracture healing & the stability spectrum

Every fixation choice in the specialty is the same decision: how much movement will this fracture see, and which healing biology does that invite. Taught once here; the fixation operations assume it.

Understand it once, in the specialty hub

What the surgeon is thinking

  • Reduction on the traction table

    Why is the reduction on the traction table the operation's real first step?

    The implant fixes whatever position it finds: traction and rotation on the table restore length and alignment under the image intensifier before a single incision, because a DHS in a malreduced fracture is a well-fixed wrong answer. Both views, AP and lateral, must say yes.

  • Guidewire and lag screw

    What is the tip-apex distance, and why does everyone recite it?

    The summed distance from the screw's tip to the femoral head's apex on both views: keep it under about 25 mm and cut-out is rare, let it grow and the screw ploughs out of the head under load. It is the operation's single most predictive number, set by the guidewire's position, centre-centre, deep but not through.

  • Plate, compression and closure

    How does the sliding mechanism turn walking into treatment?

    The screw telescopes into the plate's barrel along the fracture's compression axis: every step drives the fragments together, loading the fracture in exactly the way bone healing likes. The construct is relative stability by design, callus is the goal, and controlled collapse of a centimetre is success, not failure.

  • Lateral approach

    Why is this exposure deliberately unglamorous?

    A direct lateral approach splitting vastus lateralis onto the femoral shaft: short, extensile and bloodless when respected, in a patient population that cannot afford operative adventure. The elegance of the operation is in the fluoroscopy, not the incision.

Decision points

  • DHS or intramedullary nail for this intertrochanteric fracture?

    • DHS

      The proven, cheaper answer for stable patterns with an intact lateral wall: decades of evidence and a forgiving technique.

    • IM nail

      The unstable, reverse-oblique and subtrochanteric patterns, where a sliding screw would collapse past control: the nail buttresses from inside.

    The fracture's geometry chooses: the lateral wall and the fracture line's direction decide whether sliding compression helps or destroys. Reciting 'stable gets a DHS, unstable gets a nail' is the exam answer; reading the pattern on the film is the skill.

  • The closed reduction will not come: the fracture sits displaced on both views.

    • Adjust and retry systematically

      Traction, rotation, adduction-abduction: most reductions are won on the table with patience and the intensifier.

    • Open the fracture and reduce directly

      The unashamed answer when closed methods fail: a well-reduced fracture through a slightly bigger exposure beats malreduction through a small one.

    Reduction outranks approach: the implant cannot rescue what the reduction surrendered. The discipline is declaring the closed attempt failed early enough to still do the open one well.

Leaving the OR

The handoff

Procedure
DHS fixation, left intertrochanteric fracture; tip-apex distance 18 mm
Pathway
Theatre at hour 26; fascia iliaca block pre-op; orthogeriatric team involved
Weight-bearing
Full weight-bearing immediately, as the construct intends
Watch for
Day-one mobilisation, delirium prevention bundle, bloods and bone protection before discharge

A fictional educational patient, handed over the way real ones are.

The postoperative course

  1. POD 0-1Sat out and walking with the physios: immediate weight-bearing is the construct's purpose and the pathway's strongest medicine.
  2. POD 1-3The medical half runs in parallel: delirium prevented rather than treated, analgesia regular rather than requested, and the fall's cause pursued.
  3. Week 1-2Discharge planning against the real home situation; bone protection and falls assessment completed, not deferred to a letter.
  4. MonthsUnion with expected controlled impaction on films; lag screw prominence or new pain earns review, and function, not radiology, is the outcome that matters.

Watch it done

Find Hip fracture fixation (dynamic hip screw) videos on YouTube

What can go wrong

Venous thromboembolismSurgical-site infectionPostoperative bleeding
OR Prep this operationReview the instruments