Advances in the Restoration and Fixation of Lateral Femoral Wall Fracture
Download PDF


Intertrochanteric fracture
Lateral femoral wall
Hip fracture



Submitted : 2023-02-05
Accepted : 2023-02-20
Published : 2023-03-07


Hip fractures, especially intertrochanteric fractures, are more common with aging. After decades of progress, it is a general consensus to carry out internal fixation for this group of patients. However, the recent focus is on unstable intertrochanteric fractures to ensure better prognosis and prevent internal fixation failure. The lateral femoral wall, as a novel concept, is often disregarded. Many scholars have recognized that the lateral wall of the proximal femoral plays a crucial role in the stability of internal fixation for intertrochanteric fractures. In this paper, the historical evolution, definition, clinical significance, injury classification, choice of internal fixation, and possible prognosis of lateral femoral wall fracture are reviewed in order to provide clinicians strong evidence of treatment strategies.


Attum B, Pilson H, 2022, Intertrochanteric Femur Fracture, StatPearls Publishing, viewed on December 30, 2022,

Carpintero P, Caeiro JR, Carpintero R, et al., 2014, Complications of Hip Fractures: A Review. World J Orthop, 5(4): 402–411.

Kanis JA, Odén A, McCloskey EV, et al., 2012, A Systematic Review of Hip Fracture Incidence and Probability of Fracture Worldwide. Osteoporos Int., 23(9): 2239–2256.

Martinho T, Stoffel K, 2021, Treatment of Intertrochanteric Femur Fractures with Hip Arthroplasty in Older Patients: A Narrative Review of Indications and Outcomes. Medicina, 57(8): 763.

Sonawane DV, 2015, Classifications of Intertrochanteric Fractures and Their Clinical Importance. Trauma International, 1(1): 7–11.

Knobe M, Gradl G, Ladenburger A, et al., 2013, Unstable Intertrochanteric Femur Fractures: Is There a Consensus on Definition and Treatment in Germany?. Clin Orthop Relat Res, 471(9): 2831–2840.

Zhao JG, Wang J, Wang C, et al., 2015, Intramedullary Nail Versus Plate Fixation for Humeral Shaft Fractures: A Systematic Review of Overlapping Meta-Analyses. Medicine (Baltimore), 94(11): e599.

Boopalan PRJVC, Oh JK, Kim TY, 2012, Incidence and Radiologic Outcome of Intraoperative Lateral Wall Fractures in OTA 31A1 and A2 Fractures Treated with Cephalomedullary Nailing — Korea University. Journal of Orthopaedic Trauma, 26(11): 638–642.

Ritter G, Degreif J, 1991, Basic Considerations in Fractures of the Trochanter Major in and After Angle Plate Osteosynthesis. Unfallchirurgie, 17(2): 106–110.

Parker MJ, 1996, Trochanteric Hip Fractures Fixation Failure Commoner with Femoral Medialization, a Comparison of 101 Cases. Acta Orthopaedica Scandinavica, 67(4): 329–332.

Gotfried Y, 2004, The Lateral Trochanteric Wall: A Key Element in the Reconstruction of Unstable Pertrochanteric Hip Fractures. Clinical Orthopaedics and Related Research, 425: 82–86.

Palm H, Jacobsen S, Sonne-Holm S, et al., 2007, Integrity of the Lateral Femoral Wall in Intertrochanteric Hip Fractures: An Important Predictor of a Reoperation. J Bone Joint Surg Am, 89(3): 470–475.

Haq RU, Manhas V, Pankaj A, et al., 2014, Proximal Femoral Nails Compared with Reverse Distal Femoral Locking Plates in Intertrochanteric Fractures with a Compromised Lateral Wall; a Randomised Controlled Trial. Int Orthop, 38(7): 1443–1449.

Zhang S, 2010, The Concept of Lateral Wall in Intertrochanteric Fractures and Its Clinical Significance. Chinese Journal of Orthopaedic Surgery, 2010(17): 1489–1492.

Ma Z, Zhang S, 2012, Research Progress on Lateral Lateral Wall of Femoral Tuberosity. International Journal of Orthopaedics, 33(4): 221–224.

Abram S, Pollard T, Andrade A, 2013, Inadequate “Three-Point” Proximal Fixation Predicts Failure of the Gamma Nail. The Bone & Joint Journal, 95–B(6): 825–830.

Hsu CE, Chiu YC, Tsai SH, et al., 2015, Trochanter Stabilising Plate Improves Treatment Outcomes in AO/OTA 31-A2 Intertrochanteric Fractures with Critical Thin Femoral Lateral Walls. Injury, 46(6): 1047–1053.

Jensen JS, Michaelsen M, 1975, Trochanteric Femoral Fractures Treated with Mclaughlin Osteosynthesis. Acta Orthopaedica Scandinavica, 46(5): 795–803.

Müller ME, 1991, The Comprehensive Classification of Fractures of Long Bones, in Manual of Internal Fixation, 3rd Edition, Springer-Verlag, New York.

Pradeep AR, KiranKumar A, Dheenadhayalan J, et al., 2018, Intraoperative Lateral Wall Fractures During Dynamic Hip Screw Fixation for Intertrochanteric Fractures-Incidence, Causative Factors and Clinical Outcome. Injury, 49(2): 334–338.

Sun LL, Li Q, Chang SM, 2016, The Thickness of Proximal Lateral Femoral Wall. Injury, 47(3): 784–785.

Gu H, Yang J, Wang W, et al., 2016, Treatment Strategies for Unstable Intertrochanteric Lateral Wall Fractures. Chinese Journal of Orthopaedic Trauma, 18(8): 679–684.

Ma Z, Yao X-Z, Chang S-M, 2017, The Classification of Intertrochanteric Fractures Based on the Integrity of Lateral Femoral Wall: Letter to the Editor, Fracture Morphology of AO/OTA 31-A Trochanteric Fractures: A 3D CT Study with an Emphasis on Coronal Fragments. Injury, 48(10): 2367–2368.

Meinberg EG, Agel J, Roberts CS, et al., 2018, Fracture and Dislocation Classification Compendium—2018. Journal of Orthopaedic Trauma, 32: S1–S10.

Díaz VJ, Martín IA, García JP, et al., 2021, Does the Fracture of the Lateral Wall Affect the Degree of Collapse and the Degree of Sliding of the Cephalic Plate, in Pertrochanteric Fractures Treated by Intramedullary Interlocking? Radiological Study and Review of the Literature. Rev Esp Cir Ortop Traumatol, 65(2): 108–115.

Zhang Z, Zhang T, Zhou F, et al., 2020, Classification Method of Proximal Femoral Fracture Based on the Integrity of the Proximal Lateral Wall of the Femur: With 888 Case Analysis. Chinese Journal of Bone and Joint Surgery, 13(3): 196–204.

Butler M, Forte M, Kane RL, et al., 2009, Treatment of Common Hip Fractures. Evid Rep Technol Assess, 2009(184): 1–85.

Morris AH, Zuckerman JD, 2002, National Consensus Conference on Improving the Continuum of Care for Patients with Hip Fracture. JBJS, 84(4): 670–674.

Russell TA, Sanders R, 2011, Pertrochanteric Hip Fractures: Time for Change. J Orthop Trauma, 25(4): 189–190.

Zhou F, Zhang ZS, Yang H, et al., 2012, Less Invasive Stabilization System (LISS) Versus Proximal Femoral Nail Anti-Rotation (PFNA) in Treating Proximal Femoral Fractures: A Prospective Randomized Study. Journal of Orthopaedic Trauma, 26(3): 155–162.

Zhou F, Zhang Z, Tian Y, et al., 2006, A Preliminary Report of a Minimally Invasive Internal Fixation System in the Treatment of Complex Trochanteric Fractures. Chinese Journal of Orthopaedic Trauma, 8(12): 1113–1117.

Zha GC, Chen ZL, Qi XB, et al., 2011, Treatment of Pertrochanteric Fractures with a Proximal Femur Locking Compression Plate. Injury, 42(11): 1294–1299.

Varela-Egocheaga JR, Iglesias-Colao R, Suárez-Suárez MA, et al., 2009, Minimally Invasive Osteosynthesis in Stable Trochanteric Fractures: A Comparative Study Between Gotfried Percutaneous Compression Plate and Gamma 3 Intramedullary Nail. Archives of Orthopaedic and Trauma Surgery, 129(10): 1401–1407.

Gotfried Y, 2000, Percutaneous Compression Plating of Intertrochanteric Hip Fractures. Journal of Orthopaedic Trauma, 14(7): 490–495.

Langford J, Pillai G, Ugliailoro AD, et al., 2011, Perioperative Lateral Trochanteric Wall Fractures: Sliding Hip Screw Versus Percutaneous Compression Plate for Intertrochanteric Hip Fractures. Journal of Orthopaedic Trauma, 25(4): 191–195.

Zha GC, Chen ZL, Qi XB, et al., 2011, Treatment of Pertrochanteric Fractures with a Proximal Femur Locking Compression Plate. Injury, 42(11): 1294–1299.

Xu S, Han L, Hu Y, et al., 2017, Comparison of Efficacy of Inverted Minimally Invasive Internal Fixation System with Gamma Nail in the Treatment of Intertrochanteric Fracture of the Femur with Lateral Wall Fracture. Chinese Journal of Trauma, 33(1): 57–62.

Knobe M, Drescher W, Heussen N, et al., 2012, Is Helical Blade Nailing Superior to Locked Minimally Invasive Plating in Unstable Pertrochanteric Fractures?. Clinical Orthopaedics and Related Research®, 470(8): 2302–2312.

Tawari AA, Kempegowda H, Suk M, et al., 2015, What Makes an Intertrochanteric Fracture Unstable in 2015? Does the Lateral Wall Play a Role in the Decision Matrix?. Journal of Orthopaedic Trauma, 29: S4–9.

Haidukewych GJ, 2009, Intertrochanteric Fractures: Ten Tips to Improve Results. JBJS, 91(3): 712–719.

Mereddy P, Kamath S, Ramakrishnan M, et al., 2009, The AO/ASIF Proximal Femoral Nail Antirotation (PFNA): A New Design for the Treatment of Unstable Proximal Femoral Fractures. Injury, 40(4): 428–432.

Harrington P, Nihal A, Singhania AK, et al., 2002, Intramedullary Hip Screw Versus Sliding Hip Screw for Unstable Intertrochanteric Femoral Fractures in the Elderly. Injury, 33(1): 23–28.

Zhang S, Ma Z, Du S, et al., 2016, Anatomical Study of the Proximal Lateral Wall of the Femur and Its Significance for Internal Fixation of Intertrochanteric Fractures. Chinese Journal of Clinical Anatomy, 34(1): 39–42.

Sadowski C, Lübbeke A, Saudan M, et al., 2002, Treatment of Reverse Oblique and Transverse Intertrochanteric Fractures with Use of an Intramedullary Nail or a 95 Screw-Plate: A Prospective, Randomized Study. JBJS, 84(3): 372–381.

Min WK, Kim SY, Kim TK, et al., 2007, Proximal Femoral Nail for the Treatment of Reverse Obliquity Intertrochanteric Fractures Compared with Gamma Nail. Journal of Trauma and Acute Care Surgery, 63(5): 1054–1060.

Al-Yassari G, Langstaff RJ, Jones JWM, et al., 2002, The AO/ASIF Proximal Femoral Nail (PFN) for the Treatment of Unstable Trochanteric Femoral Fracture. Injury, 33(5): 395–399.

Schipper IB, Steyerberg EW, Castelein RM, et al., 2004, Treatment of Unstable Trochanteric Fractures: Randomised Comparison of the Gamma Nail and the Proximal Femoral Nail. The Journal of Bone and Joint Surgery British Volume, 86(1): 86–94.

Zhang H, Zhu X, Pei G, et al., 2017, A Retrospective Analysis of the Intertan Nail and Proximal Femoral Nail Anti-Rotation in the Treatment of Intertrochanteric Fractures in Elderly Patients with Osteoporosis: A Minimum Follow-Up of 3 Years. Journal of Orthopaedic Surgery and Research, 12(1): 1–8.

Xu R, Zhu G, Cheng L, et al., 2011, A Preliminary Efficacy Analysis of Intertan Intramedullary Nail in the Treatment of Intertrochanteric Fractures of the Femur. Bioorthopedic Materials and Clinical Research, 8(6): 16–19.

Ciufo DJ, Zaruta DA, Lipof JS, et al., 2017, Risk Factors Associated with Cephalomedullary Nail Cutout in the Treatment of Trochanteric Hip Fractures. Journal of Orthopaedic Trauma, 31(11): 583–588.

Gupta RK, Sangwan K, Kamboj P, et al., 2010, Unstable Trochanteric Fractures: The Role of Lateral Wall Reconstruction. International Orthopaedics, 34(1): 125–129.

Kulkarni SG, Babhulkar SS, Kulkarni SM, et al., 2017, Augmentation of Intramedullary Nailing in Unstable Intertrochanteric Fractures Using Cerclage Wire and Lag Screws: A Comparative Study. Injury, 48: S18–22.

Wang Z, Xu X, Chen Q, et al., 2017, Effect of Proximal Lateral Femur Reconstruction on Surgical Efficacy for Type A3 Intertrochanteric Fracture. Journal of Huazhong University of Science and Technology: Medical Edition, 46(3): 332–335.

Kim Y, Bahk WJ, Yoon YC, et al., 2015, Radiologic Healing of lateral Femoral Wall Fragments After Intramedullary Nail Fixation for A3.3 Intertrochanteric Fractures. Archives of Orthopaedic and Trauma Surgery, 135(10): 1349–1356.

Wu K, Tang J, 2019, Accurate Understanding of Intertrochanteric Femoral Fractures “Lateral Wall”. Chinese Journal of Reparative and Reconstructive Surgery, 33(10): 1210.