Subtrochanteric Femoral Fractures

Dr.Hisham E. Gheit

Definition Fielding (1973) Interval between lesser troch and around 5-7.5 cm below it.

Fielding JW. Subtrochantric fractures.clin orthop Relat.1973;(92):86-99

Bimodal age distribution

About 10% to 30% of all hip fractures Young patients 20-40y • High energy trauma • Associated with polytrauma, life threatening injuries.

Patients above 60y • Low energy trauma • Associated with osteoporosis and co-morbidities

Anatomy

• subtrochanteric area Composed mainly of cortical bone • Region of maximal compressive forces (medially) and tensile forces(laterally).

Image: Yoon RS and Haidukewych GJ, Subtrochanteric Fractures, Chapter 54,Figure 54-2. Rockwood and Green’s Fractures in Adults, editors Tornetta, Paul; Ricci, William. Wolters Kluwer, 2019

Image: Yoon RS and Haidukewych GJ, Subtrochanteric Fractures, Chapter 54, Figure 54-4. Rockwood and Green’s Fractures in Adults, editors Tornetta, Paul; Ricci, William. Wolters Kluwer, 2019

• Proximal segment Gluteal muscle abduction Iliopsoas muscle Flexion & external rotators.

• Distal segment Adductors Shortening and medial translation

Classification: There is no ideal classification system that guides treatment and establishes prognosis with satisfactory inter-observer reproducibility.

Fielding (1973) : anatomical location

Seinsheimer (1978) : number of fragments involvement of medial lateral cortics Russel taylor (1987) : entirety of piriformis fossa A/O (1990) : oblique, transverse, or multifragmentar

Russel Taylor ClassificationPrior to the development of a trochanteric entry nail, this was historically used to differentiate fractures amenable to intramedullary (IM) nailing versus those requiring a lateral fixed-angle device.

image: Yoon RS and Haidukewych GJ, Subtrochanteric Fractures, Chapter 54, Figure 54-3. Rockwood and Green’s Fractures in Adults, 9th edition. Editors Tornetta, Paul; Ricci, William. Wolters Kluwer, 2019

The AO/OTA classification has utility in its universality and is primarily used in the discussion of research

Bio-mechanical proplems

• Short proximal segment • Long lever arm • Strong musculature • Eccentric load

Treatment options

(Surgery is standard of care) Intramedullary nail

Extra-medullary plate

Biomechanically IMN fixation is superior for several reasons. increased rigidity stiffness shorter moment arm allows for a biomechanically stronger construct with decreased strain placed on the implant. Wang J, et al. 2014

2019Zhang et al. Randomized controlled trial 180 pt Comminuted subtrochanteric femur fracture; compare the efficacy and safety of the proximal femoral anatomical locking compression plate vs proximal femoral nail antirotation. Result Intramedullary nail resulted in better recovery of hip function good and excellent Harris hip scores (p <.05). There was no significant difference in complication rate (p > .05).

Intramedullary nailing Tips and tricks

postion: Supine Traction table hemilithotomy position adduct the affected limb and trunk to allow access to the trochanteric region Avoid excessive pelvic tilt

Reduction • Should be reduce deformity and ensure proper path of guidewire on both views prior to reaming

To Prevention varus, Rotational malreduction

Reduction techniques Traction It is rare to overcome the deforming forces of a subtrochantericfracture with the table alone

Closed reduction Depressing the proximal fragment by use of external pressure from a mallet. Use of a crutch beneath the distal fragment

Percutaneous by: ball spike pusher Shanz pins joysticks blocking wire or screws

Open by: bone hook bone Clamp reduction forceps Cerclage wire

Hoskins et al. 2015 Retrospective review 134 pt

Subtrochanteric fractures; Cerclage wire use improved fracture displacement (3.2 mm vs. 8.8 mm), angulation and quality of reduction (p < 0.05). Result Open reduction and the use of cerclage did not producea negative effect in terms of fracture union

Entery point Starting point medial to tip of greater trochanter

Too anterior entry point… final reduction in flexion

Too lateral entry point final reduction in varus

Implant positioning

Hip Screws centered in femoral head in AP/Lat view best position

Baumgaertner et al,1995

Complications

• Varus malunion

• Implant failure

• Non union

• infection

Revision fixation with poor starting point

Malreduction Note very lateral starting point/nail path

Correcting varus withanother nail in theshort proximalsegment is verydifficult

A plate is still a viable option

Summary

Closed reduction is difficult Don’t be afraid to open fracture to obtain good reduction

Correct entry point is essential to decrease complication

Thank you