Updated: 9/10/2018

Subtrochanteric Fractures

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https://upload.orthobullets.com/topic/1039/images/subtroch fracture_moved.jpg
https://upload.orthobullets.com/topic/1039/images/subtrochanteric deforming forces.jpg
https://upload.orthobullets.com/topic/1039/images/Xray 0 AP - subtrochanteric fx_moved.gif
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  
        • 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
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)
 
 

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 
    • 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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Questions (16)
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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? Review Topic

QID: 3329
FIGURES:
1

Adduction and extension

76%

(1126/1487)

2

Abduction and extension

9%

(139/1487)

3

Adduction and flexion

7%

(111/1487)

4

Abduction and flexion

5%

(68/1487)

5

External rotation

2%

(33/1487)

ML 2

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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? Review Topic

QID: 4533
FIGURES:
1

Fibrous cortical defect

3%

(128/4161)

2

Metastatic lesion

5%

(193/4161)

3

Acute trauma

2%

(64/4161)

4

Bisphosphonate treatment

90%

(3743/4161)

5

Osteomyelitis

0%

(5/4161)

ML 1

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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? Review Topic

QID: 3532
FIGURES:
1

Figure A

50%

(1190/2393)

2

Figure B

0%

(6/2393)

3

Figure C

0%

(10/2393)

4

Figure D

3%

(77/2393)

5

Figure E

46%

(1103/2393)

ML 3

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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? Review Topic

QID: 3677
FIGURES:
1

Use of a six-hole 135 degree compression plate

1%

(34/2477)

2

Addition of iliac crest autograft to the fracture site

1%

(26/2477)

3

Application of long strut allografts around the fracture site

1%

(17/2477)

4

Placement of a cephalomedullary nail

91%

(2254/2477)

5

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

6%

(138/2477)

ML 1

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PREFERRED RESPONSE 4

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

QID: 1223
1

Hip abductors and iliopsoas muscle

89%

(520/586)

2

Hip internal rotators and iliopsoas muscle

4%

(25/586)

3

Quadriceps and iliopsoas muscle

2%

(14/586)

4

Hamstring and iliopsoas muscle

2%

(14/586)

5

Quadriceps and hip adductors

2%

(13/586)

ML 1

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PREFERRED RESPONSE 1

(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? Review Topic

QID: 3622
FIGURES:
1

Flexion and internal rotation

9%

(187/2012)

2

Extension and internal rotation

72%

(1450/2012)

3

Flexion and external rotation

8%

(159/2012)

4

Extension and external rotation

8%

(159/2012)

5

Abduction and internal rotation

3%

(51/2012)

ML 2

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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? Review Topic

QID: 3560
FIGURES:
1

Nail with a lesser radius of curvature

28%

(474/1680)

2

Nail with a greater radius of curvature

67%

(1129/1680)

3

Piriformis entry portal

2%

(37/1680)

4

Trochanteric entry portal

2%

(30/1680)

5

Lateral decubitus patient position

0%

(7/1680)

ML 2

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

QID: 1034
FIGURES:
1

gluteus maximus and adductors

3%

(53/1802)

2

gluteus maximus and rectus femoris

1%

(13/1802)

3

gluteus medius and hamstrings

1%

(14/1802)

4

gluteus medius and iliopsoas

95%

(1715/1802)

5

rectus femoris and hamstrings

0%

(2/1802)

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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: Review Topic

QID: 623
1

Can be protective to an injured spine

2%

(14/567)

2

Facilitates access to other injured sites in the polytrauma patient

2%

(10/567)

3

Provides easier fluoroscopic imaging

12%

(68/567)

4

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

74%

(421/567)

5

Easier to assess rotation

8%

(48/567)

ML 2

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PREFERRED RESPONSE 4
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