Updated: 5/27/2021

Subtrochanteric Fractures

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  • Summary
    • Subtrochanteric fractures are proximal femur fractures located from the lesser trochanter to 5cm distal to it that may occur in low energy (elderly) or high energy (young patients) mechanisms.
    • Diagnosis is made with orthogonal radiographs of the hip in patients that present with inability to bear weight.
    • Treatment is generally operative with cephalomedullary nail fixation. 
  • Epidemiology
    • Incidence
      • common
        • 7 to 34% of femur fractures
  • Etiology
    • Pathophysiology
      • young patients
        • high-energy mechanism (MVC)
      • elderly patients
        • low-energy mechanism (ground level falls)
      • rule out pathologic or atypical femur fracture
        • denosumab or 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
      • 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
      • 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
    • AO/OTA classification 
      • 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)
    • ASBMR Task Force Case Definition of Atypical Femur Fractures (AFFs), Revised criteria
      • ASBMR Task Force Case Definition of Atypical Femur Fractures (AFFs), Revised criteria
        Four of five major features should be present to designate a fracture as atypical; minor features may or may not be present in individual cases
        Major criteria








        • Associated with no trauma or minimal trauma, as in a fall from a standing height or less
        • Fracture originates at the lateral cortex and is substantially transverse in its orientation, although it may become oblique as it crosses the medial femur
        • Noncomminuted
        • Complete fractures extend through both cortices and may be associated with a medial spike; incomplete fractures involve only the lateral cortex
        • Localized periosteal or endosteal thickening of the lateral cortex is present at the fracture site
        Minor criteria







        • Generalized increase in cortical thickness of the femoral diaphyses
        • Prodromal symptoms such as dull or aching pain in the groin or thigh
        • Bilateral incomplete or complete femoral diaphysis fractures
        • Delayed fracture healing
        • Specifically excluded are fractures of the femoral neck, intertrochanteric fractures with spiral subtrochanteric extension, pathological fractures associated with primary or metastatic bone tumors, and periprosthetic fractures
  • Presentation
    • History
      • long history of bisphosphonate or denosumab
      • history of thigh pain before trauma occurred
    • 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
      • recommended views
        • AP and lateral of the hip
        • AP pelvis
        • full length femur films including the knee
      • optional views
        • traction views may assist with defining fragments in comminuted patterns but is not required
      • findings
        • proximal fragment flexed and abducted
        • distal fragment adducted and ER
        • bisphosphonate-related fractures have
          • lateral cortical thickening
          • increased diaphyseal cortical thickness
          • transverse vs. short oblique fracture orientation
          • medial spike (if complete fracture)
          • 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
          • patients on bisphosphonate therapy with pain and radiographic evidence of stress fracture
      • 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
    • 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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(OBQ13.268) An 80-year-old patient presents 8 months postoperatively with right groin pain. Examination reveals a leg length discrepancy of 1.5cm. Recent radiographs are seen in Figures A and B. What is the most appropriate treatment plan?

QID: 4903
FIGURES:
1

Nail dynamization

4%

(175/4824)

2

Hardware removal, correction of alignment with a Taylor spatial frame, insertion of bone autograft

1%

(59/4824)

3

Exchange unreamed nailing with a longer, larger implant

11%

(542/4824)

4

Augmentative plate fixation without nail removal, insertion of bone autograft

5%

(234/4824)

5

Hardware removal, correction of alignment, plate fixation, insertion of bone autograft

78%

(3779/4824)

L 2 B

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(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?

QID: 4533
FIGURES:
1

Fibrous cortical defect

3%

(143/4697)

2

Metastatic lesion

5%

(214/4697)

3

Acute trauma

1%

(67/4697)

4

Bisphosphonate treatment

90%

(4238/4697)

5

Osteomyelitis

0%

(7/4697)

L 2 B

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(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?

QID: 3532
FIGURES:
1

Figure A

46%

(1411/3059)

2

Figure B

0%

(8/3059)

3

Figure C

0%

(12/3059)

4

Figure D

3%

(97/3059)

5

Figure E

50%

(1520/3059)

L 3 C

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(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?

QID: 3677
FIGURES:
1

Use of a six-hole 135 degree compression plate

2%

(49/3007)

2

Addition of iliac crest autograft to the fracture site

1%

(43/3007)

3

Application of long strut allografts around the fracture site

1%

(27/3007)

4

Placement of a cephalomedullary nail

89%

(2686/3007)

5

Addition of an 7.3mm de-rotation screw in the femoral head

6%

(189/3007)

L 1 C

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(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?

QID: 3622
FIGURES:
1

Flexion and internal rotation

10%

(253/2597)

2

Extension and internal rotation

71%

(1852/2597)

3

Flexion and external rotation

8%

(199/2597)

4

Extension and external rotation

8%

(207/2597)

5

Abduction and internal rotation

3%

(79/2597)

L 2 B

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(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?

QID: 3560
FIGURES:
1

Nail with a lesser radius of curvature

29%

(594/2056)

2

Nail with a greater radius of curvature

65%

(1340/2056)

3

Piriformis entry portal

3%

(60/2056)

4

Trochanteric entry portal

2%

(42/2056)

5

Lateral decubitus patient position

1%

(14/2056)

L 2 B

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(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?

QID: 3329
FIGURES:
1

Adduction and extension

75%

(1571/2105)

2

Abduction and extension

10%

(207/2105)

3

Adduction and flexion

8%

(161/2105)

4

Abduction and flexion

5%

(101/2105)

5

External rotation

2%

(48/2105)

L 2 B

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(OBQ08.237) All of the following are advantages of supine over lateral positioning during intramedullary nailing of subtrochanteric femur fractures EXCEPT:

QID: 623
1

Can be protective to an injured spine

3%

(29/969)

2

Facilitates access to other injured sites in the polytrauma patient

2%

(22/969)

3

Provides easier fluoroscopic imaging

11%

(111/969)

4

Allows for easy reduction of the distal fragment to the flexed proximal fragment

75%

(722/969)

5

Easier to assess rotation

8%

(79/969)

L 2 C

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(OBQ05.148) Which muscles cause the fracture displacement of the proximal fragment shown in figure A?

QID: 1034
FIGURES:
1

gluteus maximus and adductors

3%

(70/2289)

2

gluteus maximus and rectus femoris

1%

(20/2289)

3

gluteus medius and hamstrings

1%

(20/2289)

4

gluteus medius and iliopsoas

95%

(2168/2289)

5

rectus femoris and hamstrings

0%

(3/2289)

L 1 B

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(OBQ04.118) What muscles are responsible for the most common deformity after antegrade intramedullary nailing for a subtrochanteric femur fracture?

QID: 1223
1

Hip abductors and iliopsoas muscle

88%

(777/884)

2

Hip internal rotators and iliopsoas muscle

5%

(41/884)

3

Quadriceps and iliopsoas muscle

2%

(19/884)

4

Hamstring and iliopsoas muscle

2%

(19/884)

5

Quadriceps and hip adductors

3%

(27/884)

L 1 B

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