Review Question - QID 3677

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.