ASBMR Task Force Case Definition of Atypical Femur Fractures (AFFs), Revised criteriaFour of five major features should be present to designate a fracture as atypical; minor features may or may not be present in individual cases
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Average 4.3 of 53 Ratings
Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
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?
Fibrous cortical defect
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The patient's injury is most consistent with a bisphosphonate induced atypical femur fracture.
Atypical subtrochanteric femoral fractures have been identified as a potential complication of long-term bisphosphonate therapy for the treatment of osteoporosis. Prodromal symptoms of thigh pain are common prior to fracture, and bony failure is usually associated with low energy mechanisms.
Puhaindran et al. performed a retrospective review of the imaging studies and case notes for patients with skeletal malignant involvement who received a minimum of twenty-four doses of intravenous bisphosphonates. Patients were classified as having an atypical subtrochanteric femoral fracture if they had a transverse subtrochanteric fracture following low-energy trauma or an impending fracture, together with radiographic findings. In the study cohort of 327 patients, four patients developed an atypical subtrochanteric femoral fracture. All four patients were female, three had breast cancer, and one had myeloma.
Feldman et al. reviewed the imaging presentations on routine radiographs, alternate imaging modalities, and associated pitfalls in nine atypical femur fractures in six patients. The author states that effects may differ with each bisphosphonate's route of administration and prolongation of activity, despite discontinuation. The review also discusses the theoretical mechanisms of bisphosphonates as a class rather than with a specific alendronate association and provides a broader basis for evaluating the recently observed clinical and radiographic complications.
Figure A shows a transverse subtrochanteric femur fracture. Figure B shows diaphyseal cortical thickening and cortical beaking at the subtrochanteric area.
Answer 1: The radiographic findings are not consistent with a fibrous cortical defect.
Answer 2: The radiographic findings are not consistent with the presence of a metastatic lesion.
Answer 3: Subtrochanteric fractures are typically associated with high energy trauma, and this patients mechanism of injury is atypical.
Answer 5: There is no radiographic or clinical evidence supporting the presence of chronic osteomyelits.
Puhaindran ME, Farooki A, Steensma MR, Hameed M, Healey JH, Boland PJ
J Bone Joint Surg Am. 2011 Jul;93(13):1235-42. PMID: 21776577 (Link to Abstract)
Puhaindran, JBJS 2011
Skeletal Radiol. 2012 Jan;41(1):75-81. Epub 2011 Mar 4. PMID: 21369720 (Link to Abstract)
Feldman, SRAD 2012
Case - Subtrochanteric Fx Complication - Roy Sanders, MD - (NYT #10 - S2-6 - 201...
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Average 4.0 of 10 Ratings
Which of the following fractures seen in Figures A through E would be amenable to fixation with a construct using tension band principles?
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.
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 comminution 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.
Kinast C, Bolhofner BR, Mast JW, Ganz R.
Clin Orthop Relat Res. 1989 Jan;(238):122-30. PMID: 2910593 (Link to Abstract)
Kinast, CORR 1989
Average 2.0 of 96 Ratings
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?
Nail with a lesser radius of curvature
Nail with a greater radius of curvature
Piriformis entry portal
Trochanteric entry portal
Lateral decubitus patient position
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.
Egol KA, Chang EY, Cvitkovic J, Kummer FJ, Koval KJ
J Orthop Trauma. 2004 Aug;18(7):410-5. PMID: 15289685 (Link to Abstract)
Egol, JOT 2004
Ostrum RF, Levy MS
J Orthop Trauma. 2005 Oct;19(9):656-60. PMID: 16247312 (Link to Abstract)
Ostrum, JOT 2005
Simonian PT, Chapman JR, Selznick HS, Benirschke SK, Claudi BF, Swiontkowski MF.
J Bone Joint Surg Br. 1994 Mar;76(2):293-6. PMID: 8113296 (Link to Abstract)
Simonian, BJJ 1994
Harper MC, Carson WL.
Clin Orthop Relat Res. 1987 Jul;(220):155-61. PMID: 3594986 (Link to Abstract)
Harper, CORR 1987
Average 4.0 of 17 Ratings
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?
Flexion and internal rotation
Extension and internal rotation
Flexion and external rotation
Extension and external rotation
Abduction and internal rotation
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.
J Am Acad Orthop Surg. 2007 Nov;15(11):663-71. PMID: 17989417 (Link to Abstract)
Lundy, JAAOS 2007
Average 3.0 of 27 Ratings
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?
Use of a six-hole 135 degree compression plate
Addition of iliac crest autograft to the fracture site
Application of long strut allografts around the fracture site
Placement of a cephalomedullary nail
Addition of an 7.3mm de-rotation screw in the femoral head
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.
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.
Menezes DF, Gamulin A, Noesberger B
Clin. Orthop. Relat. Res.. 2005 Oct;439:221-7. PMID: 16205163 (Link to Abstract)
Menezes, CORR 2005
Robinson CM, Houshian S, Khan LA
J Bone Joint Surg Am. 2005 Oct;87(10):2217-26. PMID: 16203886 (Link to Abstract)
Robinson, JBJS 2005
HPI - A 65-year diabetic female had fracture Rt. femur(subtrochanteric) before 4 year ago. She admitted at that to the hospital and according to the facility available at that hospital lmultiple operations done for her as sort of 135 deg, angled plate ( as badly inserted and badly managed ).
later on bone graft added to achieve the union but with out benefit .Now the instrument was removed and the bone still not united (atrophic non union).
how can manage this lady now
Average 4.0 of 15 Ratings
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?
Adduction and extension
Abduction and extension
Adduction and flexion
Abduction and flexion
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.
Bedi A, Toan Le T.
Orthop Clin North Am. 2004 Oct;35(4):473-83. PMID: 15363922 (Link to Abstract)
Average 3.0 of 24 Ratings
All of the following are advantages of supine over lateral positioning during intramedullary nailing of subtrochanteric femur fractures EXCEPT:
Can be protective to an injured spine
Facilitates access to other injured sites in the polytrauma patient
Provides easier fluoroscopic imaging
Allows for easy reduction of the distal fragment to the flexed proximal fragment
Easier to assess rotation
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.
Average 3.0 of 25 Ratings
Which muscles cause the fracture displacement of the proximal fragment shown in figure A?
gluteus maximus and adductors
gluteus maximus and rectus femoris
gluteus medius and hamstrings
gluteus medius and iliopsoas
rectus femoris and hamstrings
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.
French BG, Tornetta P 3rd.
Clin Orthop Relat Res. 1998 Mar;(348):95-100. PMID: 9553539 (Link to Abstract)
French, CORR 1998
HPI - Subtrochanteric hip fracture treated 4 months ago at a peripheral hospital. Transferred after loss of fixation and femoral head screw cut out. ESR, CRP normal. Vital signs stable. Wounds well healed.
What would be your approach in the management of this fracture?
Average 4.0 of 19 Ratings
What muscles are responsible for the most common deformity after antegrade intramedullary nailing for a subtrochanteric femur fracture?
Hip abductors and iliopsoas muscle
Hip internal rotators and iliopsoas muscle
Quadriceps and iliopsoas muscle
Hamstring and iliopsoas muscle
Quadriceps and hip adductors
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).
Ricci WM, Bellabarba C, Lewis R, Evanoff B, Herscovici D, Dipasquale T, Sanders R.
J Orthop Trauma. 2001 Feb;15(2):90-5. PMID: 11232660 (Link to Abstract)
Ricci, JOT 2001
Average 4.0 of 26 Ratings
Title: Subtrochanteric Fracture - What Works? Presenter: Donald Wiss, MDColumbia...
Title: Bisphosphonate Related Femur Fractures: Acute Management and Nonunion Tre...
This surgical video demonstrates intramedullary nailing in lateral position with...
HPI - An 80 year old male patient presents with new onset right hip pain.
The patient sustained a right hip subtrochanteric fracture in February 2015 and underwent fixation with a short gamma nail. A follow-up X-ray showed no evidence of callus formation. Full weight bearing as tolerated started 2 months after the index surgery.
The patient presented in January 2017 with right hip pain; X-rays are shown.
How would you manage this patient?
HPI - Injury 18 months ago treated with DCS
Patient has been walking for last year
Had new fall 2 days ago
What is your recommended treatment?
HPI - Elderly gentleman sustained a fracture of his left femur when he had fall from a standing height. He underwent open reduction and internal fixation with a 130 degree hip screw and side plate with placement of synthetic hydroxyapatite bone graft on 12/05/2015
How would you classify this nonunion?
HPI - Had a tibial fracture on the other side
What is your recommended treatment and why?
HPI - Trauma. Bicyclist struck by car.
How would you classify this injury?
HPI - Truck driver
Fall getting out of truck
Complex femoral shaft fracture 30 years ago
Treated with unreamed, unlocked nail -> non-union
Revised to locked Russell-Taylor nail -> united in maligned position
Hardware removed 20+ years ago
Medullary canal obliterated at level of malunion
How would you manage this subtroch fracture shown in the P2 images above?
HPI - Sub trochanteric fracture treated by long gamma nail 1 year ago.
Patient lost of FU
Come to ER for right hip pain.
How would you manage this case ?
HPI - 55yo male with fall from height resulting in subtroch fracture. Treated with CMN and cerclage cabling. Non-compliant with initial WB status. 3 months postop had distal interlock screw breakage but no significant pain with WB. Follow up films showed decent callous and maintained alignment. Lost to follow up. 8 months post-op felt a pop and pain while walking. New films show breakage of proximal nail.
How would you treat this initial fracture?
HPI - Road traffic accident, fall from bike. no other injury. patient vitally and systemically stable.
How would you treat this injury?
HPI - Patient has a mechanic fall in Asia in April 2014. Treated with ORIF with proximal locking plate done there.
What is your preferred treatment for femoral subtrochanteric fractures?
HPI - 90f frail, AAA, HTN with mechanical fall onto left hip. Isolated left hip pain.
What is your preferred treatment for reverse obliquity subtrochanteric proximal femur fractures?
HPI - Optd at a different center with DHS fixation for subtrochanteric fracture right femur.
Reinjury in 1st week Feb 2015. Reported to us after 01 month of injury.
What would be your fixation method of choice for the initial injury
HPI - Operated for Comminuted Subtrochanteric fracture of right femur in Dec 2014 at different center. DHS fixation was done.
Sustained slip and fall in Feb 2015 during rehabilitation. Presented 15 days after re injury to our center.
Pain and inability to bear weight.
How would you have fixed the initial fracture.
HPI - MVA since 5 days with comminuted proximal femur , patient underwent fixation of an ipsilateral supracondylar fracture 9 years ago which is healed in varus and shortening with bend plate
Best way to fix the proximal fracture
HPI - MVA 3 days ago - intact neurovascular state with moderate edema slight ecchymosis
HPI - Motor vehicle accident since 5 days with closed comminuted subtrochanteric fracture femur with ipsilateral medial mallelous fracture
HPI - Alleged Motorvehicle Accident (frontal collision between cars)
Patient was sitting in cross-legged position.
The Right lower limb hit the gears and dashboard. Following the accident the patient was unable to ambulate
Which classification system do you prefer for this fracture?
HPI - Sustained fracture after simple fall on the ground on her side
Best treatments possible ?
HPI - motor vehicle accident.
How would you treat this fracture pattern?
HPI - Fall from a standing height 3 weeks ago , the patient denies to be operated
When is the best time to operate?
HPI - fell of a cycle at hihg speed
nailing or plating
HPI - s/p IM nailing at outside hospital after ATV rollover injury 4 months ago
How would you treat this?
HPI - 3 months back h/o trauma hit by car. treated with 95 dhs. h/o unprotected weight bearing.
what would be you treatment preference
HPI - 87F community ambulator, left subtroch fracture treated with IM nail and cerclage cable x10 months. Nonunion was imminent and bone stimulator was placed. One month into bone stimulator treatment, patient twisted getting out of car, felt a pop, unable to bear weight.
How would you revise this case?
HPI - fell into a drainage ditch
HPI - Unable to bearweight with the right lower limb following fall injury.
Pain and swelling right hip and thigh.
What is the best treatment option?
HPI - 30 y/o otherwise healthy male with left femur fracture. Presents ~45 min after MVC. Radiographs/CT also reveal a left LC-1 pelvic ring injury and right minimally displaced lateral rib 7-10 fractures (all treated nonoperatively).
What implant do you use for this fracture?