Quality standard
Quality statement 4: Trochanteric fracture
Quality statement 4: Trochanteric fracture
Quality statement
Adults with trochanteric fractures above and including the lesser trochanter, except reverse oblique fractures, receive extramedullary implants in preference to intramedullary nails. [2012, updated 2016]
Rationale
Extramedullary implants, such as sliding hip screws, have similar clinical outcomes to intramedullary devices. However, some studies have shown that intramedullary implants have a higher reoperation rate because of periprosthetic fracture. In addition, extramedullary implants are less expensive than intramedullary implants. The evidence covered trochanteric fractures above and including the lesser trochanter, except reverse oblique fractures. There was insufficient evidence to make a recommendation on which implant to use for reverse oblique trochanteric fractures. Therefore, extramedullary implants should be used in preference to intramedullary nails for the treatment of trochanteric fractures except reverse oblique fractures.
Quality measures
The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
Evidence of local arrangements to ensure that people with trochanteric fractures above and including the lesser trochanter, except for reverse oblique fractures, receive extramedullary implants.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by provider organisations, for example, from service specifications and clinical protocols.
Process
a) Proportion of trochanteric fractures above and including the lesser trochanter (excluding reverse oblique fractures) treated with extramedullary implants.
Numerator – the number in the denominator treated with extramedullary implants.
Denominator – the number of trochanteric fractures above and including the lesser trochanter (excluding reverse oblique fractures).
Data source: The National Hip Fracture Database (NHFD) presents data on the proportion of trochanteric fractures, excluding reverse oblique fractures, treated with a sliding hip screw.
Outcome
Reoperation rates for people with trochanteric fractures (except reverse oblique fractures).
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by provider organisations, for example, from service specifications. The NHFD records data on reoperation (within 120 days).
What the quality statement means for different audiences
Service providers (hospitals) ensure that systems are in place for people with trochanteric fractures above and including the lesser trochanter, except for reverse oblique fractures, to receive extramedullary implants in preference to intramedullary nails.
Healthcare professionals (orthopaedic surgeons) ensure that people with trochanteric fractures above and including the lesser trochanter, except for reverse oblique fractures, receive extramedullary implants in preference to intramedullary nails.
Commissioners (such as integrated care systems) ensure that they commission services where people with trochanteric fractures above and including the lesser trochanter, except for reverse oblique fractures, receive extramedullary implants in preference to intramedullary nails.
People with a fracture outside the socket of their hip joint and near the top of the thigh bone (called a trochanteric fracture) have an operation to reposition the broken bone and hold it in place while it heals. This is done using 1 or more special screws inserted into the bone and attached to a metal plate, called an extramedullary implant. A different technique may be used if they have a fracture called a reverse oblique fracture.
Source guidance
Hip fracture: management. NICE guideline CG124 (2011, updated 2023), recommendation 1.6.9
Definitions of terms used in this quality statement
Trochanteric fractures
Fractures that occur outside or distal to the hip joint capsule, which can be 2‑part fractures (stable) or multi-fragmentary (unstable). [NICE's full guideline on hip fracture]
Extramedullary implants
A screw that is attached to a plate on the outside of the femoral head and neck. [NICE's full guideline on hip fracture]
Intramedullary nail
A metal rod, which is inserted down the middle of the femoral shaft. [NICE's full guideline on hip fracture]