1. This document discusses hip fractures, specifically subtrochanteric fractures. It notes that 10-30% of hip fractures are subtrochanteric and they have a bimodal age distribution in those 20-40 years old from high-energy injuries and those over 60 from low-energy falls. 2. It reviews treatment options for subtrochanteric fractures including traction, extramedullary fixation with plates, and intramedullary fixation with nails. Intramedullary nails are preferred as they better resist axial loads and torsion compared to plates. 3. Complications of treatment include infection, malunion, nonunion, and implant failure. Proper reduction and fixation are important to

1. By Hiren M Divecha (CT2)
NMGH
3/2/2010

2. • 10 -30% of hip fractures
• Bimodal age distribution
– 20-40yrs
• HIGH ENERGY
• RTA, fall from height, GSW (10%)
– >60yrs
• low energy
• Simple fall, osteoporotic, pathological (17-35%)
• Cann. screws below lesser troch
• Bisphosphonate Rx

3. • Screws must not enter lateral femoral cortex
below level of lesser troch
– Kloen et al JOT 2003
• Triangular configurations
– Highest load to failure
– Apex superior – higher risk of subtroch #
– Selvan et al Injury 2004, Lichtblau et al Bull NYU
Hosp Jt Dis 2008

5. • Inhibited remodelling leads to accumulation of
microdamage
• Associated with >7yrs use
• Prodromal thigh pain
• Cortical thickening, unicortical beak
• Simple transverse/ oblique pattern
• Bilateral (Capeci JBJS-Am 2009)
• Goh JBJS-Br 2007, Lenart NEJM 2008, Neviaser
JOT 2008, Kewkwa Injury 2008

6. • Between lesser trochanter and 5cm distal
• Stresses
– Posteromedial – compressive
– Lateral – tensile
– 6 x BW
• Cortico-cancellous junction
– Vascularity
– Healing

8. • Proximal fragment
– Flexed – iliopsoas
– Ext rot – iliopsoas + short ext rots
– Abducted – gluteus med + min
• Distal fragment
– Adducted/ varus – adductors
– Shortened – quads/ hamstrings

10. Proximal Border Distal Border Subdivisions
Boyd & Griffin 1949 2
Fielding 1966 PBLT 5cm 4
Zickel 1976 PBLT 10cm 6
Seinsheimer 1978 DBLT 5cm 7
Russell & Taylor 1987 3
AO Muller 1990 DBLT 3cm 9
Parker & Pryor 1994 DBLT 5cm

11. 1. <2mm displacement
2. 2-parts
A. Transverse
B. Spiral. Less troch prox
C. Spiral. Less troch distal
3. 3-parts
A. Less troch butterfly
B. Lateral butterfly
4. 4-parts or comminuted
5. Greater troch extension

12. • History
• Pain, NWB, deformity of thigh
• Open/ closed injury
• Neurovascular status
• Full ATLS
– Haemorrhagic shock
– Cranial, thoracic, abdominal injuries (Waddell’s
triad)

13. • Analgesia, femoral nerve block???
– Significantly reduced pain scores and use of opiates
– AK Fletcher et al. Ann Emerg Med. 2003;41:227-233
• Thomas splint
• X-rays
– AP pelvis
– full length femur views
– Contralateral femur (bisphosphonate Rx)
• Pathological
– Full assessment
– Bloods – myeloma screen, bone profile, LFTs
– Bone scan, MRI

14. • Unfit for surgery, open #s
• Skeletal traction
– Hamilton-Russell
– Perkins
• 90-90 position
• Aim for
– <5 varus/valgus
– >25% cortical apposition
– <1cm shortening
– No axial rotation
• Weekly x-rays + adjustments
• Traction until signs of union (8-12 weeks)
• Problems
– Pressure ulcers, VTE, pneumonia

15. Author Date No. Satisfactory Non-union
Watson 1964 8 50
Seinsheimer 1978 8 48 0
Velasco & 1978 22 50 0
Comfort
Waddell 1979 18 56 11
DeLee 1981 15 100 0
Bajaj 1988 23 83 0

17. • Key issues
– Medial cortical buttress
– Reduction (esp varus deformity)
• Extramedullary
– ORIF
– DHS, Medoff Sliding Plate, DCS, blade plate, locking plates
• Intramedullary
– Centromedullary
– Cephalomedullary
– Short vs long

18. Bending moment = F x D
d1 d2
d1 > d2

19. • Technically demanding
• Soft tissue dissection
• Plate/ screw breakage
• 30% failure
– Elderly
– Unstable #s
– Early weight bearing
• Nonunions

21. • Easier to insert than
blade plate
• Plate/ screw breakage
• 20-30% failure
– Elderly
– Unstable #s
– Early weight bearing
• Nonunions

23. • Designed for
intertrochanteric #s
• Easier to insert
• Entry point may be #
• 25% failure
– Loss of fixation
• ? Should be avoided

25. • Resist axial loading better • Less stiff in torsion
• Closed Rx • Short nails = femoral shaft
– Preserve fracture biology fracture
• Decreased moment arm • Femoral head screw cut
on implant out
• ? Autogenous grafting
during reaming
• Segmental/ pathological #
• >97% union

28. • Tencer J Orth Res 1984
– Cadaveric study
– Torsional stiffness better in plate devices
– Axial loading better in locked IM nails
– IM nail=3000N; plates=1000-1500N
• Haynes Med Eng Phys 1997
– Cadaveric study
– SGN=5761N; DHS=4660N(hard) 3225N(soft)
• Aune Acta Orth Scan 1994 & Madsen J Ortho Res 1998
– Femoral shaft fractures with SGN
• Parker & Handoll Cochrane Rev 2004, 2008, 2009
– Better intraoperative results and less fixation failures in
cephalomedullary devices
– Femoral shaft fractures with short nails

29. • Infection
• VTE
• Implant failure
– Varus malreduction
– Screw placement in femoral head
• Malunion
– Shortening
– Rotational deformity
– Varus
• Nonunion ( 0-8%)
– Significant pain >6 months with the inability to FWB
– Stable fixation - autogenous bone grafting
– Exchange nailing with over-reaming

30. • Fletcher AK et al. Three-in-One Femoral Nerve
Block as Analgesia for Fractured Neck of
Femur in the Emergency Department: A
Randomized, Controlled Trial. Ann Emerg
Med. 2003;41:227-233
• Craig N et al. Subtrochanteric fractures. Bull
Hosp Joint Dis 2001;60:35-46
• Lundy DW. Subtrochanteric femoral fractures.
AAOS 2007;15:663-671

31. 1. Kloen P et al. Subtrochanteric fracture after
cannulated screw fixation of femoral neck
fractures: a report of four cases. J Orthop
Trauma. 2003;17(3):225-9
2. Lichtblau S et al. A biomechanical
comparison of two patterns of screw
insertion. Bull NYU Hosp Jt Dis.
2008;66(4):269-71

32. 1. Goh et al. Subtrochanteric insufficiency fractures in
patients on alendronate therapy. JBJS 89-B(3); 349-
353
2. Lenart et al. Atypical Fractures of the Femoral
Diaphysis in Postmenopausal Women Taking
Alendronate. NEJM 2008 358;12:1304-6
3. Neviaser et al. Low-Energy Femoral Shaft Fractures
Associated With Alendronate Use. J Orth Trauma
2008; 22(5): 346-350
4. Kweka et al. An emerging pattern of subtrochanteric
stress fractures: A long-term complication of
alendronate therapy. Injury 2008 39; 224—231