This document summarizes a presentation on subtrochanteric femur fractures. It describes an 80-year-old male patient who presented with hip pain after a fall and was found to have a subtrochanteric femur fracture on x-rays. It then discusses the epidemiology, anatomy, classification, treatment options and complications of subtrochanteric femur fractures, noting that they are most commonly treated with intramedullary nailing. Complications discussed include malunion, nonunion, fixation failure and implant failure.

1. GRAND ROUND
Dr. Yasir Jameel
Clinical Fellow Orthopadic Trauma

2. • 80 year old male sustaind fall at home and
presented with hip pain to A&E

3. • History

4. • Age, sex, occupation
• Presenting complain
• History of PC
• Past medical history
• Past surgical history
• Drugs, Allergies
• Social history

5. Investigations

6. X-rays

7. X-rays

8. X-rays

9. Subtrochenteric femur fracture
• Subtrochanteric area typically defined as area
from lesser trochanter to 5cm distal.
• fractures with an associated intertrochanteric
component may be called intertrochanteric
fracture with subtrochanteric extension or
peritrochanteric fracture

10. Epidemiology
• Younger patients with a high-energy
mechanism RTA
• may occur in elderly patients from a low-
energy mechanism
• Pathologic or atypical femur fracture
• Bisphosphonate use, particularly alendronate,
can be risk factor
• Preveious neck fixation with screws placed
with entry below lesser trochenter

11. Anatomy

12. Pathoanatomy
• Deforming forces on the proximal fragment
• Abduction
gluteus medius and gluteus minimus
• Flexion
iliopsoas
• External rotation
short external rotators
• deforming forces on distal fragment
• Adduction
hip adductors
• Shortening
quads and hamstrings

13. Pathoanatomy

14. Biomechanics
• Posteriomedial femur undergoes compressive
forces
• Lateral femur undergoes tensile forces

15. Russell-Taylor Classification
• Based on integrity of the piriformis fossa.
• Designed to guide treatment of intramedullary nails
using a piriformis fossa starting point.
Type I - intact piriformis fossa
A - lesser trochanter attached to proximal fragment
B - lesser trochanter detached from proximal fragment
Type II - fracture extends into piriformis fossa
A - stable posterior-medial buttress
B - comminution of lesser trochanter

16. Russell-Taylor Classification

17. RT Type 2 B

18. Treatment
• Nonoperative
– observation with pain management
• indications
– non-ambulatory patients with medical co-morbidities not fit
for surgery
– limited role due to strong muscular forces displacing fracture
and inability to mobilize patients without surgical intervention

19. Treatment
• Operative
– intramedullary nailing (usually cephalomedullary)
• indications
– historically Russel-Taylor type I fractures
– newer design of intramedullary nails has expanded indications
– most subtrochanteric fractures treated with IM nail
– fixed angle plate
• indications
– surgeon preference
– associated femoral neck fracture
– narrow medullary canal
– pre-existing femoral shaft deformity

20. Complications
• Varus/ procurvatum malunion

21. Complications
• Nonunion
Incidence of 0-8% , continued inability to bear
weight at 4-6 months and continued pain.
Varus malreduction is an important predictor
of nonunion accompanied by implant failure.

22. Complications
• Malunion:
Coxa varus: Caused by uncorrected abduction
deformity, nail entry point that is too lateral, and
migration of hardware proximally in the femoral
head and neck
Shortening: Due to uncorrected shortening
intraoperatively and premature dynamization.
Rotational deformity: Do to uncorrected external
rotation of proximal fragment. This can be
assessed intraoperatively with visualization of the
lesser trochanter

23. Complications
• Fixation failure: Most common in osteoporotic
bone. Screw cutout in the femoral head;
backing out of locking screws.
• Failure of implant: Excessive motion at
fracture site leads to implant fatigue

24. • Do you have any question??????????????????

25. THANK YOU