Hip Fracture ORIF (Intertrochanteric / Femoral Neck)

CPT 27245
Approach Open
Add-on / Variant CPTs
  • 27235 — Percutaneous skeletal fixation of femoral fracture, proximal, neck
  • 27244 — Treatment of intertrochanteric fracture, stable, with plate/screw
Preoperative Diagnosis:

Right [left] [intertrochanteric / subtrochanteric / femoral neck] hip fracture, [stable / unstable / displaced / non-displaced]

Postoperative Diagnosis:

Same

Procedure Performed:

Right [left] hip fracture closed reduction and internal fixation, [cephalomedullary nail / dynamic hip screw (DHS) / cannulated screws]

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

Spinal [/ general endotracheal]

Indications:

The patient is a [age]-year-old [male/female] who sustained a right [left] [intertrochanteric / femoral neck] fracture after [mechanism: fall / low-energy trauma]. The fracture is [stable / unstable, with [reverse obliquity / subtrochanteric extension / comminution]]. Operative fixation was indicated. The risks, benefits, and alternatives were discussed with the patient [/ family].

Findings:

Under fluoroscopy, the fracture was reduced to [anatomic / near-anatomic / acceptable] alignment in [AP / lateral] views. The [cephalomedullary nail / DHS] was positioned with lag screw in the [center / center-inferior] of the femoral head. Tip-apex distance was [<25 mm]. Final fluoroscopic images confirmed [acceptable alignment / restoration of neck-shaft angle / no articular penetration].

Description of Procedure:

The patient was positioned supine on the fracture table with the operative extremity in traction and the contralateral leg in a [scissor / hemilithotomy] position. Closed reduction was achieved under fluoroscopy by [traction / internal rotation / positioning]. Reduction was confirmed in AP and lateral projections.

[CEPHALOMEDULLARY NAIL:]
A [3–4]-cm incision was made proximal to the greater trochanter. The abductors were split longitudinally. The entry portal was established at the tip of the greater trochanter with an awl. A ball-tipped guidewire was advanced into the femoral canal. Sequential reaming was performed to [X] mm. A [X]-mm diameter × [X]-mm length cephalomedullary nail was inserted to the appropriate depth. Under fluoroscopic guidance, a [130° / 135°] angled guide was used and the lag screw guidewire was advanced to the center-inferior of the femoral head with a tip-apex distance <25 mm. The lag screw was inserted. A distal interlocking screw was placed [freehand under fluoroscopy / with jig]. The set screw was tightened. Final fluoroscopic views confirmed acceptable alignment, implant position, and no articular penetration.

Wounds were closed in layers. A sterile dressing was applied.

Complications:

None

Specimens:

None

Estimated Blood Loss:

[X] mL

Drains:

None

Disposition:

The patient was taken to the PACU in stable condition. Weight-bearing as tolerated [/ touch-down weight-bearing] was permitted. DVT prophylaxis was initiated. Physical therapy and early mobilization were ordered for postoperative day 1.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: Right/Left *** hip fracture, ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Right/Left hip fracture CRIF — ***
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: Spinal

INDICATIONS: .PTAGE-year-old .PTSEX with *** hip fracture after ***. Consent obtained.

FINDINGS: Reduction: *** on AP/lateral. Implant position: center-inferior FH. TAD <25 mm. No articular penetration.

PROCEDURE:
Supine on fracture table, traction, *** contralateral leg position. Closed reduction under fluoroscopy — ***. AP/lateral confirmed. *** cm incision proximal GT. Abductors split. Entry portal GT tip. Ball-tipped wire, reamed to *** mm. *** × *** mm nail inserted. Lag screw guide: 135°, center-inferior FH, TAD <25 mm. Lag screw inserted. Distal interlock freehand. Set screw tightened. Final fluoro: alignment *** acceptable, no articular penetration. Closed in layers.

EBL: *** mL
COMPLICATIONS: None
DISPOSITION: WBAT/TDWB. DVT prophylaxis. PT POD 1.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Dynamic Hip Screw (DHS): Stable Intertrochanteric

For a stable two-part intertrochanteric fracture, a dynamic hip screw (DHS) was used. A lateral approach to the proximal femur was made through a [8–10]-cm incision. The iliotibial band and vastus lateralis were incised. Under fluoroscopic guidance, the guidewire was placed in the center-inferior of the femoral head at a [135°] angle. Tip-apex distance was measured and confirmed <25 mm. The guide wire was over-reamed. The [X]-mm × [X]-mm lag screw was inserted. The [4-hole] side plate was applied to the lateral femoral cortex and fixed with cortical screws. The dynamic design permits controlled impaction across the fracture, which promotes healing. DHS is appropriate for stable fractures; cephalomedullary nailing is preferred for unstable or reverse obliquity patterns.

Femoral Neck Fracture: Cannulated Screw Fixation

For a non-displaced [or minimally displaced] femoral neck fracture (Garden I/II) in a physiologically young patient, percutaneous cannulated screw fixation was performed. Three [6.5-mm / 7.3-mm] partially-threaded cannulated screws were placed in an inverted triangle configuration under fluoroscopic guidance with all threads across the fracture. The inferior screw was placed along the calcar for rotational stability. All screws were confirmed to stop short of the subchondral bone. This technique preserves the femoral head and avoids arthroplasty in younger patients with favorable fracture patterns.

Charting Tips
  • Document tip-apex distance (TAD) explicitly. TAD >25 mm is the strongest predictor of lag screw cutout, which is the most common implant failure mode. The TAD is calculated as the sum of the distance from the tip of the lag screw to the apex of the femoral head in AP and lateral views, adjusted for magnification.
  • Document reduction quality and fracture pattern. Unstable patterns (reverse obliquity, subtrochanteric extension, comminution of the medial calcar) drive implant selection. Document whether reduction was anatomic or if translation/angulation was accepted, and why.
  • Document weight-bearing status and rationale. Hip fracture fixation is generally weight-bearing as tolerated (WBAT), as elderly patients cannot comply with restricted weight-bearing. If weight-bearing is restricted, document the reason.
Billing Tips
  • Bill 27235 for percutaneous screw fixation of femoral neck fracture (12.68 wRVU, 90-day global). Bill 27236 for open femoral neck ORIF (17.17 wRVU). Code selection depends on open vs. percutaneous approach.
  • Bill 27244 for intertrochanteric femur fracture ORIF with intramedullary implant (cephalomedullary nail, 17.73 wRVU, 90-day global). Bill 27245 for intertrochanteric fracture ORIF with plate/screw device (17.73 wRVU).
  • Hemiarthroplasty for displaced femoral neck fracture uses 27125 (16.62 wRVU), not ORIF codes. Total hip arthroplasty for fracture uses 27132 (25.05 wRVU). Arthroplasty and ORIF codes are not interchangeable.
  • 90-day global period: weight-bearing protocol, physical therapy coordination, and routine X-ray checks are bundled. DVT prophylaxis management is clinical, not a separate billable procedure.
  • Document ASA class, fracture classification (Garden for femoral neck, AO/OTA for intertrochanteric), reduction quality, and all implants placed. These are essential for orthopedic quality metrics and implant registry.