questions
11

Subtrochanteric Fractures

Topic updated on 04/14/15 8:52pm
Introduction
  • Subtrochanteric typically defined as area from lesser trochanter to 5cm distal
    • fractures with an associated intertrochanteric component may be called
      • intertrochanteric fracture with subtrochanteric extension
      • peritrochanteric fracture
  • Epidemiology
    • usually in younger patients with a high-energy mechanism
    • may occur in elderly patients from a low-energy mechanism 
      • rule out pathologic or atypical femur fracture  
        • bisphosphonate use, particularly alendronate, can be risk factor 
  • Pathoanatomy
    • deforming forces on the proximal fragment are     
      • abduction
        • gluteus medius   and gluteus minimus 
      • flexion
        • iliopsoas 
      • external rotation
        • short external rotators 
    • deforming forces on distal fragment
      • adduction & shortening
        • adductors 
Anatomy
  • Biomechanics
    • weight bearing leads to net compressive forces on medial cortex and tensile forces on lateral cortex
Classification
 
Russel-Taylor Classification
Type I No extension into piriformis fossa
 
Type II Extension into greater trochanter with involvement of piriformis fossa
 •  look on lateral xray to identify piriformis fossa extension
 
 • Historically used to differentiate between fractures that would amenable to an intramedullary nail (type I) and those that required some form of a lateral fixed angle device (type II)
 • Current interlocking options with both trochanteric and piriformis entry nails allow for treatment of type II fractures with intramedullary implants
 
AO/OTA Classification Examples
32-A3.1 Simple (A), Transverse (3), Subtrochanteric fracture (0.1)   
32-B3.1 Wedge (B), Fragmented (3), Subtrochanteric fracture (0.1)
32-C1.1 Complex (C), Spiral (1), Subtrochanteric fracture (0.1)
 Facture Location 
 • Femur (3) , Diaphysis (2), Subtrochanteric region (0.1)
Fracture Pattern
 •  Simple (A), Wedge (B), Complex (C)
 
 
Presentation
  • Symptoms
    • hip and thigh pain
    • inability to bear weight
  • Physical exam
    • pain with motion
    • typically associated with obvious deformity (shortening and varus alignment)
    • flexion of proximal fragment may threaten overlying skin
Imaging
  • Radiographs
    • required views
      • AP and lateral of the hip
      • AP pelvis
      • full length femur films including the knee
    • additional views
      • traction views may assist with defining fragments in comminuted patterns but is not required
    • findings
      • bisphosphonate-related fractures have 
        • lateral cortical thickening
        • transverse fracture orientation
        • medial spike
        • lack of comminution
Treatment
  • Nonoperative
    • observation with pain management
      • indications
        • non-ambulatory patients with medical co-morbidities that would not allow them to tolerate surgery
        • limited role due to strong muscular forces displacing fracture and inability to mobilize patients without surgical intervention
  • 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
Techniques
  • Intramedullary Nailing
    • position
      • lateral positioning post
        • advantages 
          • allows for easier reduction of the distal fragment to the flexed proximal fragment 
          • allows for easier access to entry portal, especially for piriformis nail
      • supine positioning
        • advantages
          • protective to the injured spine
          • address other injuries in polytrauma patients
          • easier to assess rotation
    • techniques
      • 1st generation nail (rarely used)
      • 2nd generation reconstruction nail
      • cephalomedullary nail 
      • trochanteric or piriformis entry portal 
        • piriformis nail may mitigate risk of iatrogenic malreduction from proximal valgus bend of trochanteric entry nail  
    • pros
      • preserves vascularity
      • load-sharing implant
      • stronger construct in unstable fracture patterns
    • cons
      • reduction technically difficult 
        • nail can not be used to aid reduction 
        • fracture must be reduced prior to and during passage of nail
        • may require percutaneous reduction aids or open clamp placement to achieve and maintain reduction  
      • mismatch of the radius of curvature
        • nails with a larger radius of curvature (straighter) can lead to perforation of the anterior cortex of the distal femur 
    • complications
      • varus malreduction (see complications below)
  • Fixed angle plate 
    • approach  
      • lateral approach to proximal femur 
        • may split or elevate vastus lateralis off later intermuscular septum
        • dangers include perforating branches of profunda femoris
    • technique
      • 95 degree blade plate or condylar screw
      • sliding hip screw is contraindicated due to high rate of malunion and failure
      • blade plate may function as a tension band construct 
        • femur eccentrically loaded with tensile force on the lateral cortex converted to compressive force on medial cortex
    • cons
      • compromise vascularity of fragments
      • inferior strength in unstable fracture patterns
Complications
  • Varus/ procurvatum malunion 
    • the most frequent intraoperative complication with antegrade nailing of a subtrochanteric femur fracture is varus and procurvatum (or flexion) malreduction
  • Nonunion 
    • can be treated with plating
      • allows correction of varus malalignment
  • Bisphosphonate fractures  
    • nail fixation
      • increased risk of iatrogenic fracture
        • because of brittle bone and cortical thickening
      • increased risk of nonunion with nail fixation resulting in increased need for revision surgery
    • plate fixation
      • increased risk of plate hardware failure
        • because of varus collapse and dependence on intramembranous healing inhibited by bisphosphonates


 

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Qbank (12 Questions)

TAG
(OBQ12.173) A 76-year-old female with underlying osteoporosis presents with severe right leg pain after stepping off a curb. Current femur radiographs are shown in Figure A. Review of the patient's medical records reveal that she had been evaluated 3 months prior for right hip pain, and work-up at that time was negative. Radiographs of the patient's femur from that previous visit are shown in Figure B. What is the most likely cause of this patient's femur fracture? Topic Review Topic
FIGURES: A   B        

1. Fibrous cortical defect
2. Metastatic lesion
3. Acute trauma
4. Bisphosphonate treatment
5. Osteomyelitis

PREFERRED RESPONSE ▶
TAG
(OBQ11.109) Which of the following fractures seen in Figures A through E would be amenable to fixation with a construct using tension band principles? Topic Review Topic
FIGURES: A   B   C   D   E  

1. Figure A
2. Figure B
3. Figure C
4. Figure D
5. Figure E

PREFERRED RESPONSE ▶
TAG
(OBQ11.137) An 80-year-old female falls and sustains the fracture seen in Figure A. She is treated with an antegrade cephalomedullary nail. Which of the following led to the complication seen in Figure B? Topic Review Topic
FIGURES: A   B        

1. Nail with a lesser radius of curvature
2. Nail with a greater radius of curvature
3. Piriformis entry portal
4. Trochanteric entry portal
5. Lateral decubitus patient position

PREFERRED RESPONSE ▶
TAG
(OBQ11.199) A 66-year-old male with a remote history of prostate cancer sustains a fall down a hill while gardening. During intramedullary nailing of his fracture, which intraoperative reduction maneuvers should take place to the proximal fragment to properly align the fracture? Topic Review Topic
FIGURES: A   B        

1. Flexion and internal rotation
2. Extension and internal rotation
3. Flexion and external rotation
4. Extension and external rotation
5. Abduction and internal rotation

PREFERRED RESPONSE ▶
TAG
(OBQ11.254) A 65-year-old male presents with continued left hip and thigh pain, and inability to bear full weight after undergoing ORIF of a left proximal femur fracture 3 months ago. Current radiographs are shown in Figure A. The patient denies any fevers, or other systemic signs of illness. Which of the following would have potentially decreased the risk of excess fracture collapse and implant failure in this patient? Topic Review Topic
FIGURES: A          

1. Use of a six-hole 135 degree compression plate
2. Addition of iliac crest autograft to the fracture site
3. Application of long strut allografts around the fracture site
4. Placement of a cephalomedullary nail
5. Addition of an 7.3mm de-rotation screw in the femoral head

PREFERRED RESPONSE ▶
TAG
(OBQ10.230) A 35-year-old-male sustains the fracture seen in Figure A. Which of the following reduction forces must be applied to the proximal fragment to correct the deformity commonly seen in these fractures? Topic Review Topic
FIGURES: A          

1. Adduction and extension
2. Abduction and extension
3. Adduction and flexion
4. Abduction and flexion
5. External rotation

PREFERRED RESPONSE ▶
TAG
(OBQ08.237) All of the following are advantages of supine over lateral positioning during intramedullary nailing of subtrochanteric femur fractures EXCEPT: Topic Review Topic

1. Can be protective to an injured spine
2. Facilitates access to other injured sites in the polytrauma patient
3. Provides easier fluoroscopic imaging
4. Allows for easy reduction of the distal fragment to the flexed proximal fragment
5. Easier to assess rotation

PREFERRED RESPONSE ▶
TAG
(OBQ05.148) Which muscles cause the fracture displacement of the proximal fragment shown in figure A? Topic Review Topic
FIGURES: A          

1. gluteus maximus and adductors
2. gluteus maximus and rectus femoris
3. gluteus medius and hamstrings
4. gluteus medius and iliopsoas
5. rectus femoris and hamstrings

PREFERRED RESPONSE ▶
TAG
(OBQ04.118) What muscles are responsible for the most common deformity after antegrade intramedullary nailing for a subtrochanteric femur fracture? Topic Review Topic

1. Hip abductors and iliopsoas muscle
2. Hip internal rotators and iliopsoas muscle
3. Quadriceps and iliopsoas muscle
4. Hamstring and iliopsoas muscle
5. Quadriceps and hip adductors

PREFERRED RESPONSE ▶
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