Subtrochanteric Fractures

Author: Brian Weatherford

Topic updated on 05/11/13 10:12pm

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
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

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
    - 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

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Qbank (8 Questions)

TAG

(OBQ11.109) Which of the following fractures seen in Figures A throug E would be amenable to fixation with a construct using tension band principles? Topic

Review Topic

FIGURES: A

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

PREFERRED RESPONSE ▶

DISCUSSION: In order for a fracture to be successfully treated with tension band principles the bone must be eccentrically loaded, the construct must be applied on the tensile side, and the opposite cortex must be able to withstand compressive forces. Of the fractures seen in Figures A-E, the subtrochanteric fracture seen in Figure A best meets the criteria for stabilization according to tension band principles.

Kinast et al retrospectively compared their results with 95 degree blade plate fixation of subtrochanteric fractures utilizing the blade plate as a dynamic tension band. They performed either wide exposure of the fracture site with autogenous bone grafting according to AO technique at the time (group 1), or indirect reduction techniques without bone grafting the medial side as advocated by Mast et al (group 2). The authors found 100% union rates at six months with indirect reduction techniques without bone grafting (group 2), and emphasize the key concepts of preservation of the medial soft tissues and intraoperative pretensioning of the plate.

Illustration A demonstrates the principles of tension band fixation specifically applied to the femur. Within Illustration A, Figure C shows the correct application of a plate along the lateral cortex to resist tensile forces, along with incorrect application of the plate along the medial cortex (Figure D) or in a fracture pattern with an absent opposite cortex (Figure E). Illustration B shows an example of blade plate fixation of a subtrochanteric fracture.

Incorrect Answers:
Answer 2. Figure B demonstrates a comminuted proximal tibia fracture. Although the tibia is eccentrically loaded and an implant applied to anterior cortex could function as a tension band, the posterior communition would lead to collapse.
Answer 3. Figure C demonstrates a comminuted distal humeral shaft fracture. Again,the comminution prevents application of a tension band construct
Answer 4: Figure D shows a valgus impacted proximal humerus fracture. Eccentric loading is absent for this type of fracture
Answer 5: Figure E demonstrates a comminuted olecranon fracture with extension distal to the coronoid process. Although tension band constructs are commonly used for olecranon fractures, the comminution and distal extension of this fracture would prevent application of a tension band.

Illustrations: A

REFERENCES:

1. Kinast C, Bolhofner BR, Mast JW, Ganz R. Subtrochanteric fractures of the femur. Results of treatment with the 95 degrees condylar blade-plate. Clin Orthop Relat Res. 1989 Jan;(238):122-30 PMID:2910593 (Link to Abstract)

Question Authors:

Brian Weatherford MD, Ben Taylor MD, Jan Szatkowski MD,

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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

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

PREFERRED RESPONSE ▶

DISCUSSION: The image in Figure A shows an unstable intertrochanteric fracture and the image in Figure B shows perforation of the anterior cortex of the femur by the intramedullary implant. This complication is due to a mismatch of the curvature of the nail with the anterior bow of the femur, and was likely caused by a nail of a greater radius of curvature (eg, straighter than the femur).

Egol et al measured the radius of curvature for 474 matched cadaveric femurs and found the average anterior radius of curvature to be 120cm (+/- 36cm). In contrast, the radii of curvature for the measured intramedullary nails ranged from 186cm to 300cm, demonstrating that the nails were straighter than the femurs. The authors advocate for a decreased radius of curvature (more curve) for intramedullary nails, especially larger diameter implants designed for fractures about the hip

Ostrum and Levy present a case series of 3 patients with subtrochanteric fractures who had anterior penetration of the femoral cortex. They state that the mismatch in femoral bow between the bone and the implant is a contributing factor to distal femoral anterior cortex penetration in intramedullary nailing of subtrochanteric fractures.

Simonian et al present 4 iatrogenic femoral neck fractures that occured during a series of 315 femoral nails. The authors attempted to reproduce the iatrogenic fractures with cadaveric femurs and felt that the iatrogenic fractures may be due to a combination of a valgus femoral neck and impingement from the AO insertion jig used at the time.

Harper and Carson examined 14 cadaveric femurs and intramedullary implants at the time. Similar to Egol et al, they found a mismatch between the radius of curvature of the femurs and the intramedullary nails.

Illustration A shows the difference between a lesser and greater radius of curvature. Illustration B demonstrates how to calculate radius of curvature based on an implant with an exaggerated bow. Illustration C shows the anterior bow of a synthetic femoral model compared with several intramedullary implants.

Illustrations: A

REFERENCES:

1. Egol KA, Chang EY, Cvitkovic J, Kummer FJ, Koval KJ. Mismatch of current intramedullary nails with the anterior bow of the femur. J Orthop Trauma. 2004 Aug;18(7):410-5 PMID:15289685 (Link to Abstract)

2. Ostrum RF, Levy MS. Penetration of the distal femoral anterior cortex during intramedullary nailing for subtrochanteric fractures: a report of three cases. J Orthop Trauma. 2005 Oct;19(9):656-60 PMID:16247312 (Link to Abstract)

3. Simonian PT, Chapman JR, Selznick HS, Benirschke SK, Claudi BF, Swiontkowski MF. Iatrogenic fractures of the femoral neck during closed nailing of the femoral shaft. J Bone Joint Surg Br. 1994 Mar;76(2):293-6 PMID:8113296 (Link to Abstract)

4. Harper MC, Carson WL. Curvature of the femur and the proximal entry point for an intramedullary rod. Clin Orthop Relat Res. 1987 Jul;(220):155-61. PMID:3594986 (Link to Abstract)

Question Authors:

Brian Weatherford MD, Ben Taylor MD, John Badylak MD,

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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

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 ▶

DISCUSSION: Subtrochanteric fractures will cause a proximal fragment to be flexed, abducted, and externally rotated due to the imbalanced proximal muscular attachments. The proximal fragment would likely have to be extended, adducted, and internally rotated to obtain a proper reduction.

Lundy did a review on subtrochanteric fractures. He reviews that these fractures can be effectively stabilized with 95 degrees plates, femoral reconstruction nails, or trochanteric femoral nails. Although intramedullary nails produce very stable constructs that are a great treatment option for this fracture, 135 degrees hip screw-plates are not suitable in the treatment of subtrochanteric femoral fractures due to the high risk of loss of fixation and fracture displacement.

Illustration A depicts the applicable deforming muscle forces.

Illustrations: A

REFERENCES:

1. Russell TA, Taylor JC: Subtrochanteric fractures of the femur, in Browner BD, Jupiter JB, Levine AM, Trafton PG (eds): Skeletal Trauma. Philadelphia, PA: WB Saunders, 1992, vol 2, pp 1490-1492.

2. Lundy DW. Subtrochanteric femoral fractures. J Am Acad Orthop Surg. 2007 Nov;15(11):663-71. PMID:17989417 (Link to Abstract)

Question Authors:

David Abbasi MD, Ben Taylor MD, John Badylak MD, Edward Perez M.D.,

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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 ▶

DISCUSSION: The patient is presenting with a reverse obliquity peritrochanteric fracture nonunion, as shown in Figure A. 135-degree compression plate implants (such as the one used in this patient) are designed to stabilize intertrochanteric femoral fractures, and they may be unable to resist the deforming forces inherent in subtrochanteric fractures. When this device is used, the distal fragment often displaces medially and proximally as the fracture settles. The proximal fragment also may rotate on the compression screw because the plate design allows only for one screw in the proximal fragment. Cephalomedullary nails, such as that shown in Illustration A, have been shown to offer biomechanical superiority and diminished risk of implant failure when compared to plating of these injuries.

Lundy provides a review article on the evaluation and treatment of subtrochanteric femur fractures. He states that these fractures can be effectively stabilized with 95° plates, femoral reconstruction nails, or trochanteric femoral nails with interlocking options. With regards to plates, he states that a 135° hip screw-plate is not suitable in the treatment of subtrochanteric femoral fractures, and that use of these implants may result in loss of fixation and fracture displacement.

Menezes et al reviewed 155 consecutive patients who were treated with a proximal femoral nail from 1997 to 2001 to determine the rate of implant specific complications. They concluded that low rates of femoral shaft fractures and failure of fixation support the use of the proximal femoral nail for treatment of unstable trochanteric and subtrochanteric fractures.

Robinson et al used the long Gamma nail to treat a consecutive series of 302 local patients who had sustained a subtrochanteric fracture during low-energy trauma over an 8 year period. They found that trochanteric-entry cephalomedullary nails are associated with an acceptable rate of perioperative complications and favorable functional outcomes.

Incorrect Answers:
1-Increasing the length of the the 135-degree compression plate to 6-holes will not improve its biomechanical properties in this fracture pattern.
2-Addition of autograft would not improve the biomechanical stability of the fracture, and is not appropriate during the index procedure.
3-Long strut allografts are not indicated in the initial treatment of reverse obliquity subtrochanteric fractures.
5-Addition of a de-rotation screw would not change the stability of the fixation construct.

Illustrations: A

REFERENCES:

1. Lundy DW. Subtrochanteric femoral fractures. J Am Acad Orthop Surg. 2007 Nov;15(11):663-71. Review. PMID:17989417 (Link to Abstract)

2. Menezes DF, Gamulin A, Noesberger B. Is the proximal femoral nail a suitable implant for treatment of all trochanteric fractures? Clin Orthop Relat Res. 2005 Oct;439:221-7. PMID:16205163 (Link to Abstract)

3. Robinson CM, Houshian S, Khan LA. Trochanteric-entry long cephalomedullary nailing of subtrochanteric fractures caused by low-energy trauma. J Bone Joint Surg Am. 2005 Oct;87(10):2217-26. PMID:16203886 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, Ben Taylor MD, Jan Szatkowski MD,

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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 ▶

DISCUSSION: Figure A demonstrates a displaced subtrochanteric femur fracture with an intact lesser trochanter. The pull of iliopsoas on the lesser trochanter as well as the intact external rotators and gluteal musculature results in the the proximal fragment being in a flexed and externally rotated or abducted position (the most common post operative deformity). Reduction manuevers must be biologically friendly but also counteract the flexion/abduction moment. Lundy's review article discusses evaluation and treatment of subtrochanteric fractures. The review article details the various implants often used which include 95 degrees plates, femoral reconstruction nails, or trochanteric femoral nails with interlocking options. Lundy's article discourages the use of the 135 degree screw and side plate combo due to high failure rates in these fracture patterns. Bedi et al also review treatment of these fractures and discuss common problems of malunion, nonunion, and implant failure. The article reviews reduction techniques that are soft tissue friendly, as well as the use of appropriate implants in these fracture types.

REFERENCES:

1. Lundy DW. Subtrochanteric femoral fractures. J Am Acad Orthop Surg. 2007 Nov;15(11):663- 71. Review PMID:17989417 (Link to Abstract)

2. Bedi A, Toan Le T. Subtrochanteric femur fractures. Orthop Clin North Am. 2004 Oct;35(4):473-83. Review. PMID:15363922 (Link to Abstract)

Question Authors:

Jan Szatkowski MD, Ben Taylor MD,

Please Rate Educational Value!

3.0

Average 3.0 of 11 Ratings

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 ▶

DISCUSSION: Based on the references provided, the advantages of the lateral position include: facilitates the retraction of the vastus lateralis, allows hip flexion to aid reduction, improves access to the proximal segment (easier to get starting point). Disadvantages of the lateral position include: intraoperative imaging may be more difficult, rotation is more difficult to judge, and lateral positioning may not be practical in the polytraumatized patient.

Advantages of the supine position include: may help protect a potentially unstable spine, facilitates access to sites other than the injured femur, shorter setup time, rotational and angulatory deformities may be more easily appreciated. Disadvantages of the supine position include: starting point localization may be more difficult.

REFERENCES:

1. Wolinsky P, Stephen DJG: Femur, shaft (including subtrochanteric fractures) in, Ruedi TP, Buckley RE, Moran CG (eds): AO Principles of Fracture Management, ed 2. Stuttgart, Germany, Thieme, 2007, pp 767-785

2. Chapman MW: Fractures of the hip and proximal femur, in Chapman MW (ed): Chapman’s Orthopaedic Surgery, ed 3. Philadelphia, PA, Lippincott, 2001, pp 617-670

Question Authors:

Greg Galano MD, Derek Moore, Patrick McCulloch MD,

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3.0

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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 ▶

DISCUSSION: The gluteus medius attaches to the greater trochanter, leading to abduction, while the iliopsoas attaches to the lesser trochanter, leading to flexion. French et al evaluated forty-five Russell-Taylor Type 1B subtrochanteric femoral fractures which were stabilized using an interlocked cephalomedullary nail. The intraoperative complication rate was 13.5%; and the most frequent complication was a varus malreduction. The primary reason for this was failure to counteract the muscle forces acting on the proximal fragment combined with the adducted position of the distal femur during portal creation. This problem can be avoided if the position of the proximal fragment is evaluated carefully and reduced before guidewire insertion.

REFERENCES:

1. French BG, Tornetta P 3rd. Use of an interlocked cephalomedullary nail for subtrochanteric fracture stabilization. Clin Orthop. 1998; 348: 95-100. PMID:9553539 (Link to Abstract)

Question Authors:

Greg Galano MD, Derek Moore, Ben Taylor MD,

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4.0

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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 ▶

DISCUSSION: The most common deformity after antegrade nailing of a subtrochanteric femur fracture is varus and procurvatum (or flexion). This is caused by the hip abductors and iliopsoas pulling the proximal fragment into abduction and flexion, while the distal fragment is pulled into adduction from the adductors.

The reference by French et al is a review on 45 patients with subtrochanteric fractures treated with cephalomedullary interlocked nailing. Based on femoral neck-shaft angle, 61% of the fractures were reduced in at least 5º varus. The authors attributed this malalignment to failure to counteract muscle forces acting on the proximal fragment, combined with the adducted position of the distal femur during portal creation.

The reference by Ricci et al is a report of 403 femoral shaft fractures treated with intramedullary nailing. Patients with proximal femoral shaft fractures were found to have the highest incidence of malalignment. The most common deformity in this group was varus, followed by procurvatum (or flexion).

REFERENCES:

1. French BG, Tornetta P III. Use of an interlocked cephalomedullary nail for subtrochanteric fracture stabilization. Clin Orthop. 1998; 348: 95-100 PMID:9553539 (Link to Abstract)

2. Ricci WM, Bellabarba C, Lewis R. Angular malalignment after intramedullary nailing of femoral shaft fractures. J Orthop Trauma. 2001; 15(2): 90-95 PMID:11232660 (Link to Abstract)

Question Authors:

Ben Taylor MD, Derek Moore, Ben Taylor MD,

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4.0

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Evidence & References Show References

Level of Evidence 4 (Case Series)

Kinast C, Bolhofner BR, Mast JW, Ganz R. Subtrochanteric fractures of the femur. Results of treatment with the 95 degrees condylar blade-plate. Clin Orthop Relat Res. 1989 Jan;(238):122-30 PMID:2910593 (Link to Abstract)
Ostrum RF, Levy MS. Penetration of the distal femoral anterior cortex during intramedullary nailing for subtrochanteric fractures: a report of three cases. J Orthop Trauma. 2005 Oct;19(9):656-60 PMID:16247312 (Link to Abstract)
Simonian PT, Chapman JR, Selznick HS, Benirschke SK, Claudi BF, Swiontkowski MF. Iatrogenic fractures of the femoral neck during closed nailing of the femoral shaft. J Bone Joint Surg Br. 1994 Mar;76(2):293-6 PMID:8113296 (Link to Abstract)
Menezes DF, Gamulin A, Noesberger B. Is the proximal femoral nail a suitable implant for treatment of all trochanteric fractures? Clin Orthop Relat Res. 2005 Oct;439:221-7. PMID:16205163 (Link to Abstract)
Robinson CM, Houshian S, Khan LA. Trochanteric-entry long cephalomedullary nailing of subtrochanteric fractures caused by low-energy trauma. J Bone Joint Surg Am. 2005 Oct;87(10):2217-26. PMID:16203886 (Link to Abstract)
French BG, Tornetta P III. Use of an interlocked cephalomedullary nail for subtrochanteric fracture stabilization. Clin Orthop. 1998; 348: 95-100 PMID:9553539 (Link to Abstract)
Ricci WM, Bellabarba C, Lewis R. Angular malalignment after intramedullary nailing of femoral shaft fractures. J Orthop Trauma. 2001; 15(2): 90-95 PMID:11232660 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Egol KA, Chang EY, Cvitkovic J, Kummer FJ, Koval KJ. Mismatch of current intramedullary nails with the anterior bow of the femur. J Orthop Trauma. 2004 Aug;18(7):410-5 PMID:15289685 (Link to Abstract)
Harper MC, Carson WL. Curvature of the femur and the proximal entry point for an intramedullary rod. Clin Orthop Relat Res. 1987 Jul;(220):155-61. PMID:3594986 (Link to Abstract)
Lundy DW. Subtrochanteric femoral fractures. J Am Acad Orthop Surg. 2007 Nov;15(11):663-71. PMID:17989417 (Link to Abstract)
Lundy DW. Subtrochanteric femoral fractures. J Am Acad Orthop Surg. 2007 Nov;15(11):663-71. Review. PMID:17989417 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Russell TA, Taylor JC: Subtrochanteric fractures of the femur, in Browner BD, Jupiter JB, Levine AM, Trafton PG (eds): Skeletal Trauma. Philadelphia, PA: WB Saunders, 1992, vol 2, pp 1490-1492.

Undefined

Lundy DW. Subtrochanteric femoral fractures. J Am Acad Orthop Surg. 2007 Nov;15(11):663- 71. Review PMID:17989417 (Link to Abstract)
Bedi A, Toan Le T. Subtrochanteric femur fractures. Orthop Clin North Am. 2004 Oct;35(4):473-83. Review. PMID:15363922 (Link to Abstract)
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Subtrochanteric Fractures

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