Objective To compare the effects of proximal femoral anti-rotation intramedullary nails (PFNA) with and without metaphyseal bone expansion in the treatment of intertrochanteric fractures (FIF) in the elderly. Methods: 110 elderly patients with FIF who all received PFNA treatment and visited our hospital from January 2023 to January 2024 were selected. The patients were randomly divided into the medullary expansion group (n=55) and the non-medullary expansion group (n=55). The medullary expansion group used metaphyseal medullary expansion PFNA, while the non-medullary expansion group used metaphyseal non-medullary expansion PFNA. The perioperative indicators, pain degree [Visual Analogue Scale (VAS)], hip joint function [Harris Hip Score (HHS)], cervical shaft Angle and apical distance, and the occurrence of complications of the two groups were analyzed and compared. Results: There was no significant difference in the length of hospital stay between the two groups (P > 0.05); Compared with the marrow expansion group, the operation time of the non-marrow expansion group was significantly shortened, and the intraoperative blood loss and drainage volume were significantly reduced (P < 0.05). There was no significant difference in VAS scores between the two groups before the operation, 14 days after the operation, and 6 weeks after the operation (P > 0.05). At 1 month, 3 months and 6 months after the operation, there was no significant difference in the Harris scores between the two groups (P > 0.05). Before the operation and 6 months after the operation, there were no significant differences in the cervical shaft Angle and apical distance between the two groups (P > 0.05). There was no significant difference in the incidence of complications between the two groups (P > 0.05). Conclusion: Both metaphyseal expandation and non-expandation PFNA can achieve good results in elderly FIF, which can relieve postoperative pain, improve the cervical shaft Angle and apical distance, and restore the hip joint function of patients. However, compared with medullary dilation, the operation time of PFNA without medullary dilation at the metaphysis is shorter, and both the amount of bleeding and drainage volume are less.