Objective To explore the surgical technique and efficacy of intramedullary nails fixation in treatment of unstable femoral intertroehanteric fracture in elderly patients. Methods We retrospectively analyzed the data of 64 elderly patients with unstable intertrochanteric fractures who were treated with intramedullary nail fixation in our department from Jul. 2014 to Dec. 2015. There were 21 males and 43 females, with a mean age of (81.9±5.2) years old, ranging from 75 to 96 years. Thirty-one cases were type 31-A2.2, 23 were type 31-A2.3, and 10 were type 31-A3.3 according to AO classification.All patients were treated with intramedullary nail fixation and were divided into Group 1 (limited open reduction and temporary fixation by accessory appliances, n=19) and Group 2 (direct close reduction and fixation, n=45). The operation time, intraoperative blood loss, follow-up and fracture healing time, and Harris score of the hip at the last follow-up of patients were compared between the two groups. Results Compared with the Group 2, the intraoperative blood loss in the Group 1 was significantly higher ([365.8±81.2] mL vs [238.9±56.7] mL, P<0.05) and the operation time was significantly longer ([93.4±10.4] min vs [79.4±12.7] min, P<0.05). All patients were followed up for 12 to 18 months. There were no significant differences in the fracture healing time ([17.4±3.1] weeks vs [16.7±2.2] weeks) or the Harris score at the last follow-up (84.7±8.3 vs 86.4±7.4) between the two groups (P>0.05). There were no complications such as deep infection, avascular necrosis of the femoral head, hip varus deformity, femoral shaft fractures, implant failure or fracture in the two groups. Conclusion Unstable femoral intertrochanteric fractures is common in elderly patients. The limited open reduction combined with temporary fixation by accessory appliances is required for good reduction when the closed reduction is hard to reset. Although the technique will greatly increase intraoperative blood loss and operation time, it does not affect the overall clinical effectiveness.