Subtrochanteric Femoral Fractures

Douglas W. Lundy, MD, FACS

Abstract Subtrochanteric femoral fractures are complicated injuries that may be associated with other life-threatening conditions. Patients should be carefully evaluated and appropriately treated for hypovolemic shock. These fractures can be effectively stabilized with 95 plates, femoral reconstruction nails, or trochanteric femoral nails with interlocking options. Nails produce very stable constructs and consistently can be placed with the patient in the lateral position on the radiolucent table or in the supine position on the fracture table. Standard antegrade femoral nails may be indicated in certain fracture patterns. The 135 hip screw-plate is not suitable in the treatment of subtrochanteric femoral fractures; use of these implants may result in loss of fixation and fracture displacement. Chemical and mechanical prophylaxis for deep vein thrombosis should be initiated unless contraindicated by other medical comorbidities. An accurate reduction and excellent surgical technique with minimal soft-tissue dissection can routinely produce good results without the need for secondary procedures.

Dr. Lundy is Orthopaedic Trauma Surgeon, Resurgens Orthopaedics, Marietta, GA. Neither Dr. Lundy nor the department with which he is affiliated has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article. Reprint requests: Dr. Lundy, Resurgens Orthopaedics, Suite 1100, 61 Witcher, Marietta, GA 30060. J Am Acad Orthop Surg 2007;15:663671 Copyright 2007 by the American Academy of Orthopaedic Surgeons.

ubtrochanteric femoral fractures are fractures of the proximal femur that may extend proximally into the piriformis fossa or distally into the isthmus of the femur. The proximal extension of the fracture varies and may include fracture patterns combined with intertrochanteric and femoral neck fractures. The common element of subtrochanteric femoral fractures is that the fracture extends to the level of the lesser trochanter, leaving a short proximal fragment. Wiss and Brien1 described these fractures as involving the zone between the lesser trochanter and the junction of the proximal and middle thirds of the femur. The surgeon should recognize that a subtrochanteric fracture may masquerade as an intertrochanteric fracture. Failure to fully appreciate the

true nature of the fracture may lead to unplanned difficulties with reduction and improper selection of fixation devices. Fracture reduction may be challenging because of comminution and deforming muscle forces. Ninety-fivedegree blade-plates and reconstruction nails are not commonly used by most orthopaedic surgeons because of the difficulty of the surgical techniques and the relatively rare presentation of this fracture pattern. More recent fixation devices, such as trochanteric starting-point nails, provide additional options for fracture stabilization.

Mechanism
The calcar is a vertical sheet of bone in the medial femur that projects from the posteromedial side of the
663

Volume 15, Number 11, November 2007

Subtrochanteric Femoral Fractures

Figure 1
Piriformis fossa Greater trochanter

compression to treat osteonecrosis of the femoral head.

Classification
The Russell-Taylor classification7 (Figure 1) is a practical system that describes the fracture pattern based on mechanical stability and fracture extension. The binary points include the extension of the fracture into the piriformis fossa (types I and II) and the comminution of the lesser trochanter (types A and B). Type IA is the simplest in that the fracture does not extend into the piriformis fossa and there is no comminution of the lesser trochanter. Type IB fractures also have an intact piriformis fossa, but there is comminution of the lesser trochanter. Compared with the IA fracture, internal fixation used to treat the type IB injury will endure greater varus stress because of the lack of intact medial cortical bone. Both of these injuries are amenable to treatment with intramedullary (IM) nails. Type II fractures are characterized by fracture extension into the piriformis fossa. Although these patterns can still be stabilized with IM nails, the technique is more difficult than in the type I subtrochanteric fractures because the piriformis starting point is fractured. Type IIB injuries are the most complex and frequently present with a shattered proximal femur. The fracture of the piriformis fossa and the comminution of the lesser trochanter can make stabilization technically difficult, and the fixation is under significant strain. The Orthopaedic Trauma Association also designed a fracture classification system for subtrochanteric femoral fractures.8 The proximal segment of the femur is identified as 31; the trochanteric area is labeled 31-A. The reverse-obliquity intertrochanteric fracture is called 31-A3.1. The transverse subtrochanteric fracture is labeled 31-A3.2, and the multifragmentary subtrochanteric fracture is called 31-A3.3.

Lesser trochanter Type IA Type IB Type IIA Type IIB

Russell-Taylor classification of subtrochanteric femoral fracture. Type I fractures do not extend into the piriformis fossa. Type IA has no comminution of the lesser trochanter; type IB does have comminution of the lesser trochanter. Type II fractures are characterized by fracture extension into the piriformis fossa. (Adapted with permission from Russell TA, Taylor JC: Subtrochanteric fractures of the femur, in Browner BD, Jupiter JB, Levine AM, Trafton PG [eds]: Skeletal Trauma. Philadelphia, PA: Saunders, 1992, vol 2, pp 1490-1492.)

femur just inferior to the lesser trochanter and extends proximally to the posteroinferior femoral neck. In 1917, Koch2 described the compressive forces that he observed in the proximal femur. He reported that a 200-lb man could generate forces of up to 1,200 lb/in2 on the medial side of the femur, 1 to 3 inches distal to the lesser trochanter. Because of these stresses, the subtrochanteric area of the proximal femur is composed of very dense bone that in a young person is difficult to fracture. A bimodal age distribution exists for subtrochanteric femoral fractures.3 The younger group is usually characterized as trauma patients who sustain the fracture from a high-energy mechanism of injury (eg, motor vehicle collision, fall from a height). These patients typically have concomitant injuries and require trauma team activation. The older patient often has osteoporotic bone, and the strength of the calcar has deteriorated significantly. These patients are usually injured from a ground-level fall, and they may develop the same problems associated
664

with other hip fractures, such as loss of independence and ambulation, pneumonia, sepsis, and death. Subtrochanteric femoral fractures also may occur subsequent to surgery on the proximal femur. Cannulated screws may cause a stress riser in the proximal lateral femoral cortex, leading to subsequent fracture. Kloen et al4 reported on four patients who sustained delayed subtrochanteric femoral fractures through the lateral entry point used to place a cannulated hip screw. To minimize this risk, they recommended that the starting point for cannulated screws be proximal to the level of the lesser trochanter. When placing three cannulated screws to stabilize a femoral neck fracture, the inverted triangle pattern (ie, triangle apex distal) is less likely to be associated with a subsequent subtrochanteric femoral fracture than when the base of the triangle is distal (ie, triangle apex proximal).5 In their series of 707 patients, Aluisio and Urbaniak6 reported 18 subtrochanteric fractures that originated from the entry point used in core de-

Journal of the American Academy of Orthopaedic Surgeons

Douglas W. Lundy, MD, FACS

Evaluation and Initial Management

The younger patient with a subtrochanteric fracture often has multiple injuries, including cranial, thoracic, and abdominal trauma.3 Blood loss from these fractures may be significant, and the patient may require volume resuscitation with crystalloid and blood products, as described in the Advanced Trauma Life Support (ATLS) program and courses of the American College of Surgeons. The patient with subtrochanteric femoral fracture presents with a shortened and externally rotated lower extremity. The proximal fragment is usually flexed and abducted from the effects of the iliopsoas and gluteal muscles. The distal fragment is typically adducted and externally rotated. Often crepitus is noted with movement of the thigh, and the softtissue envelope is very swollen. Application of immediate traction will minimize fracture-related blood loss by decreasing the potential third space within the zone of injury. Traction also will lessen the pain associated with these injuries. Immediate traction may be applied at the scene of the injury by paramedics and emergency technicians using any of the commonly available lower extremity traction devices. Balanced skeletal traction should be considered in the patient who will have a significant delay until surgical stabilization. Surgical stabilization should be performed in an expedient manner provided that the necessary expertise, implants, and personnel are available. Early surgery may reduce the blood loss and pain associated with these fractures. However, the patient should be adequately resuscitated, and the surgical team should be aware that there may be additional significant blood loss during surgery. The physiologic second hit of a major operation, combined with substantial blood loss, may be too traumatizing for some severely inVolume 15, Number 11, November 2007

jured patients; a damage-control procedure to initially stabilize the patient may be indicated.

Definitive Treatment
In general, implants for stabilization of subtrochanteric femoral fractures are of two kinds: (1) plate-and-screw devices used with open reduction and internal fixation and (2) IM nails applied with open or closed minimally invasive techniques. Antegrade IM femoral nails are either centromedullary (standard interlocked femoral nails) or cephalomedullary (reconstruction and trochanteric femoral nails). Cephalomedullary nails have screws that engage the bone in the femoral head. The reconstruction femoral nail was designed to enter the femur through the piriformis fossa; it has a widened proximal section that incorporates one or more interlocking screws that proceed up the femoral neck into the femoral head. The trochanteric femoral nail is placed through the tip of the greater trochanter; it also has screws that stabilize the proximal femoral fragment by engaging the neck and head. Intramedullary Nails Wiss and Brien1 reported good results using standard IM nails to treat subtrochanteric femoral fractures. They used antegrade proximal femoral locking nails in either standard or reversed mode. In reverse mode, the screw was placed up the neck into the femoral head, as with a reconstruction nail. The authors reported a 99% union rate at an average of 25 weeks. They recognized that subtrochanteric femoral fractures have a short proximal fragment with a wide medullary canal, which explains the difficulty in stabilizing subtrochanteric femoral fractures with standard IM nails without the cephalomedullary interlocking option.1 Standard locking techniques may not adequately secure the proximal fragment, and the

nail may toggle in the wide canal of the proximal fragment. A subtrochanteric femoral fracture can be stabilized with standard interlocking nails if it has an intact proximal fragment large enough for the nail and locking screw to control securely. The only firm contact the fixation has with this fragment is the cortical entry point in the piriformis fossa and the purchase of the interlocking bolts. Failure to stabilize the proximal fragment adequately results in fracture deformity, usually consisting of flexion and varus. Reconstruction Nails For many orthopaedic surgeons, the reconstruction nail is the preferred fixation device to treat subtrochanteric fractures. The reconstruction nail uses screws or a blade that engages the bone in the femoral head. This feature allows the nail to better secure the proximal fragment because of the increased contact with the bone in the femoral neck and head (Figure 2). Reconstruction nails can be used to stabilize all patterns of subtrochanteric femoral fracture, including those with comminution of the lesser trochanter and extension of the fracture into the piriformis fossa. Earlier algorithms suggested that plate-and-screw constructs were the best option for Russell-Taylor type IIB fractures; however, because of improved techniques, reconstruction nails are now successfully applied to subtrochanteric fractures with any degree of proximal comminution. In their biomechanical study, Roberts et al9 found that the type of reconstruction nail used made a difference in the amount of motion at the fracture site. Implant choice did not particularly matter in the wellreduced fracture, but comminuted femoral fractures were better stabilized with devices that had improved control of the proximal fragment. The implant factors that affected
665

Subtrochanteric Femoral Fractures

Figure 2

Anteroposterior (A) and lateral (B) radiographs of a Russell-Taylor IA subtrochanteric femoral fracture, showing the abduction and external rotation of the proximal fragments. Anteroposterior (C) and lateral (D) radiographs after intramedullary nail fixation.

motion in the proximal segment were material composition (stainless steel nails performed better than did titanium nails) and nail geometry (nails with a larger proximal diameter performed better than did those with lesser proximal diameters).9 Pugh et al10 found that reconstruction nails prevented deformation more than did standard femoral nails in a synthetic subtrochanteric fracture model. In their biomechan666

ical study, Kraemer et al11 reported that the reconstruction nail was stronger than the trochanteric femoral nail. Kang et al,12 in a study of complex subtrochanteric femoral fractures, found that the reconstruction nail produced stable constructs; however, they also noted that the complex nature of both the fracture and the implant were responsible for frequent complications (ie, fixation failure and malunion).

Traditionally, the traction table has been the operating table of choice for subtrochanteric femoral fractures; however, many surgeons use the radiolucent operating table without traction devices. The patient usually is positioned in either the supine or lateral position, although some surgeons prefer a socalled sloppy lateral position, that is, a supine position with a large bump under the affected hip. Fluoroscopic images are easily obtained with the patient in the lateral position on the radiolucent table. The lateral view is acquired with the C-arm in its normal configuration. To attain the anteroposterior image, the C-arm anode is swung under the operating table. A sterile drape is placed over the end of the anode portion of the C-arm to maintain sterility. The anteroposterior view is fairly easy to interpret, but the lateral image may be confusing because the two hips may overlap. A small amount of rotation of the C-arm will ensure that the correct lateral proximal femoral image is being evaluated. Regardless of the type of operating table or patient position used, the starting point for reconstruction intramedullary fixation of subtrochanteric fractures must be more anterior than is the point for standard antegrade nails (ie, the piriformis fossa) (Figure 3). The axis of the femoral neck is anterior to the axis of the femoral shaft. Placing the nail more anteriorly in the proximal fragment allows the proximal screws to be directed in a straighter path into the femoral head rather than crossing from posterolateral to anteromedial. The operating surgeon must remember that hoop stress forces potentially could burst the proximal fragment because these stresses increase as the starting point is moved anteriorly out of the piriformis fossa.13 Another factor that must be considered is the effect that the radius of curvature of the nail will have on the femur. The radius of curvature of some commercially available

Journal of the American Academy of Orthopaedic Surgeons

Douglas W. Lundy, MD, FACS

Figure 3

Figure 4

B A C

Axial view of the greater trochanter, neck, and femoral head. Starting point locations on the proximal femur: A, a standard antegrade nail (ie, the piriformis fossa); B, a reconstruction nail; and C, a trochanteric femoral nail.

nails may be greater than the average femoral curvature of 114 to 120 cm. Ostrum and Levy14 described three cases in which the anterior cortex of the femur was penetrated during nail placement. Before placing the reaming wire down the canal, the surgeon must ensure that the fracture is adequately reduced and that all deformity is recognized and corrected. The nail will not reduce the fracture. Pointed reduction forceps may be used by carefully placing one tine of the forceps on the medial cortex of the femur (Figure 4). Traction and bumps made of towels also assist with fracture reduction. These techniques, along with other closed reduction maneuvers (eg, rotation of the fragments, externally applied force to the lateral or anterior thigh), may adequately reduce the fracture to the extent that percutaneous nailing may be possible. When assessing the adequacy of the reduction, the surgeon should strive for perfection; however, 10 of angulation or 1 cm of shortening is common in difficult subtrochanteric fractures. When closed reduction is inadequate, the fracture should be opened to ensure that reduction is achieved. Open reduction techniques should be employed that minimize softVolume 15, Number 11, November 2007

Anteroposterior (A) and lateral (B) fluoroscopic images demonstrating Weber clamp placement stabilizing the subtrochanteric fracture. The reaming wire is in the intramedullary canal. In the anteroposterior view, the starting line is in line with the femoral canal within the piriformis fossa.

tissue dissection and that avoid placement of traumatic clamps on the medial femoral fragments. The viability of the medial femoral fragments is very important; these pieces should be handled carefully to avoid iatrogenic injury. Restoration of femoral length should be assessed by judging the alignment of the reduced fragments or by comparison with the contralateral femur. Rotational alignment should be assessed by comparing the orientation of the greater trochanter to that of the distal lateral femoral epicondyle through palpation of these structures and comparison of their positions. The intramedullary canal is then reamed to allow passage of the nail. If the femur is reamed with the fracture malreduced, the final reduction usually is unsatisfactory. The nail is then inserted into the intramedullary canal of the femur. Using fluoroscopic guidance, the nail is impacted until the proximal locking screws will appropriately engage the proximal fragment, as seen in the anteroposterior fluoroscopic view. Lateral images of the proximal fragment are then obtained to ensure that the proximal screws will be

placed straight down the axis of the femoral neck and into the femoral head. By rotating the fluoroscopic image, the surgeon can appreciate that the wires are directed down the appropriate axis. The cannulated interlocking screws may then be inserted over the wires (Figure 5). The proximal interlocking screws are then placed according to the technique specific to the brand of nail being used. Distal interlocking screws, placed with fluoroscopic guidance, should be inserted to provide rotational stability and prevent femoral shortening. The wounds are then closed in normal fashion. The patient is mobilized with limited weight bearing as soon as possible. In unstable fractures, weightbearing restrictions are typically maintained for 6 to 10 weeks. Trochanteric Intramedullary Nails Nails placed starting proximally in the greater trochanter are frequently employed in subtrochanteric fractures. These devices have an apex-medial bend in the proximal aspect of the nail to allow the nail to easily traverse the intramedullary
667

Subtrochanteric Femoral Fractures

Figure 5

A and B, Oblique lateral fluoroscopic images demonstrate that the proximal screws are directed into the appropriate quarter of bone in the proximal femur for the reconstruction nail. Panel A shows the screws in the posterior head and panel B, in the anterior head.

be used in subtrochanteric fractures rather than the short trochanteric nails indicated in the treatment of intertrochanteric fractures. Robinson et al17 reported a 7.1% incidence of nail revision because of fracture or implant complications in their series of patients with subtrochanteric fractures treated with a trochanteric IM nail. Sadowski et al18 compared results of using the trochanteric IM femoral nail with the 95 screw-plate in 39 elderly patients who had either transverse or reverse-obliquity proximal femoral fractures. They found that the nail group had shorter surgical times and hospital stays and that the patients required fewer blood transfusions. These authors also noted 7 nonunions or hardware failures in the 19 patients treated with the blade-plate; by contrast, only 1 of the 20 patients treated with the femoral nail developed a nonunion. They recommend that this fracture pattern be treated with a trochanteric femoral nail. 95 Angled Plates Ninety-fivedegree angled plate implants have been used for many years to stabilize subtrochanteric femoral fractures. These implants are available in both 95 blade-plate (Figure 6) and 95 compression screwplate options. Before intramedullary fixation techniques were described for use of reconstruction nails in Russell-Taylor type II fractures, the 95 angled implants were often the devices of choice in these injuries. Many of the early advances in stabilizing difficult proximal femoral fractures were in large part the result of the successful deployment of the 95 condylar blade-plate. Nevertheless, the surgical technique is very challenging; the plate must be inserted precisely in all three planes (axial, sagittal, and coronal). Many surgeons found that using this device was a difficult experience. The 95 compression screw-plate also has been used successfully for

canal. Similar to reconstruction nails, trochanteric nails feature screws or blades that engage the bone in the femoral head and neck, making them suitable for treating subtrochanteric fractures. Many surgeons find that these trochanteric nails are easier to insert than are nails with an entry point at the piriformis fossa. A number of clinical studies have indicated that these implants stabilize difficult subtrochanteric fractures.15-18 The correct entry point on the greater trochanter was investigated by Ostrum et al.19 These authors compared five different trochanteric nails using three different entry points on a reverse-obliquity subtrochanteric femoral fracture model. They found that the best starting point was at the tip of the greater trochanter. A slightly medial starting point was an acceptable alternative, but starting laterally on the greater trochanter invariably led to a varus malreduction. In placing the
668

nail, it is also important to establish the correct anterior-to-posterior position on the greater trochanter so that the screws will be in line with the axis of the femoral neck. Several studies demonstrate that these devices effectively stabilize subtrochanteric femoral fractures. Starr et al15 performed a prospective, randomized clinical trial comparing nails placed through the greater trochanter versus the piriformis fossa in high-energy proximal femoral fractures. They found no difference with respect to blood loss, rate of nonunion, complications, or duration of surgery between the two techniques. Menezes et al16 reviewed 155 patients treated with proximal femoral nails inserted through the greater trochanter for unstable trochanteric and subtrochanteric fractures. They used short nails in this series and reported one patient with a secondary femoral fracture at the distal end of the nail. Full-length trochanteric nails should

Journal of the American Academy of Orthopaedic Surgeons

Douglas W. Lundy, MD, FACS

many years in treating subtrochanteric fractures. The technique is familiar to orthopaedic surgeons who use 135 compression hip screws in treating intertrochanteric femoral fractures. An obvious advantage of the 95 compression hip screw compared with the 95 condylar bladeplate is that the construct can be adjusted in the sagittal plane after the compression screw has been placed. As a result, this device has less potential for error in placement, particularly in the sagittal plane. Pai20 reported excellent results in type II subtrochanteric femoral fractures treated with the 95 condylar plate and indirect reduction techniques. Yoo et al21 reported an average of 19 weeks to union in 38 patients with subtrochanteric or reverse-obliquitytype fractures treated with the 95 condylar blade-plate. Only one patient developed nonunion and hardware failure. In the management of subtrochanteric fractures, Vaidya et al22 emphasized that indirect reduction techniques and maintenance of the biology of the fracture environment were imperative when using the 95 condylar screw-plate. They reported no nonunions in their series and found that careful attention to preserving soft-tissue attachments to bone would enable the fracture to heal without the use of bone grafts. The time to weight bearing averaged nearly 5 months; this prolonged period is a potential downside of using the 95 plates. 135 Compression Plates Although 135 compression plates have been employed in the treatment of subtrochanteric fractures, their use in these fracture patterns is quite controversial. These implants were designed to stabilize intertrochanteric femoral fractures, and they may be unable to resist the deforming forces inherent in subtrochanteric fractures. They are intended to allow controlled collapse of the intertrochanteric fracture, which
Volume 15, Number 11, November 2007

may be undesirable in the subtrochanteric fracture. When this device is used to stabilize the reverseobliquity subtrochanteric fracture, 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. For these reasons, the design of the 135 compression screw-plate devices is not well suited to stabilization of subtrochanteric fractures. The study by Haidukewych et al23 underscores these concerns. These authors retrospectively reviewed 47 reverse-obliquity fractures and found that 32 (68%) healed without a second operation. Nine of the 16 fractures (56%) treated with 135 compression screws had loss of fixation compared with 2 (13%) treated with a 95 blade-plate. With the availability of devices that are better designed for treating subtrochanteric fractures, the 135 compression plate should be used only in the management of intertrochanteric femoral fracture and not in the management of subtrochanteric femoral fracture. Bone Grafts/Bone Graft Substitutes Modern indirect reduction techniques have allowed most subtrochanteric fractures to be treated successfully without the use of bone grafts. Kinast et al24 demonstrated that indirect reduction techniques resulted in good outcomes and dramatically reduced the need for bone grafts. When the vascularity of comminuted bone on the medial side of the proximal fragment is maintained and when the fracture is stabilized sufficiently to reduce the substantial stresses in this area, the fracture has a good chance of healing. Blatter and Janssen25 reported no nonunions after stabilizing subtrochanteric femoral fractures with indirect reduction techniques and the

Figure 6

Anteroposterior radiograph of a subtrochanteric femur fracture stabilized with a 95 angled bladeplate. The medial cortex was left undisturbed.

95 condylar screw without bone grafts. Kulkarni and Moran26 found no correlation between fracture union and the application of bone graft. Pai20 reported a 93.7% union rate without using bone graft when they applied indirect reduction techniques to subtrochanteric fractures stabilized with 95 compression plates.

Complications
Deep Vein Thrombosis In treating the patient with subtrochanteric femoral fracture, the relatively high incidence of deep vein thrombosis seen in conjunction with fracture of the proximal femur should be kept in mind. Both mechanical and chemical prophylaxis should be considered, based on the clinical situation. A pneumatic compression device on the lower extremity should be applied before surgery, and the surgeon should add chemical prophylaxis postoperatively when the clinical situation allows. The
669

Subtrochanteric Femoral Fractures

Figure 7

Anteroposterior radiograph of a failed 95 compression screw with a lateral plate. It is probable that the cerclage wire (at the location of the nonunion) injured the vascularity of the medial fragment and may have been responsible for the nonunion.

treating surgeon should be sensitive to the signs and symptoms associated with deep vein thrombosis and should thoroughly evaluate any patient with suspected thromboembolic phenomena with Doppler ultrasound or chest computed tomography. Loss of Fixation and Malunion The limited proximal bone available for fixation, the poor bone quality in the proximal femur in elderly patients, and the tremendous forces acting on the proximal femur all contribute to the loss of fixation seen in subtrochanteric femoral fracture. Careful attention in choosing the appropriate implant and obtaining optimal fixation in the wellaligned fracture may ensure more consistent results. Ensuring anatomic alignment of the fracture decreases the possibility of fixation failure. The surgeon must be aware of the deforming muscle forces that affect the fracture frag670

ments. The proximal fragment often remains flexed, resulting in a reduction with apex anterior angulation. The distal fragment should be flexed to match the alignment of the proximal fragment and rotated appropriately. Percutaneously applied bone hooks, spiked pushers, Schanz pins, and pointed reduction clamps also may be used to control the proximal fragment and bring it into satisfactory alignment. The fact that the reamers or nail will not reduce the subtrochanteric fracture is key in determining the appropriate preliminary steps to achieve anatomic reduction. When reduction cannot be achieved, the fracture should be opened, with careful attention paid to minimizing soft-tissue stripping. Kulkarni and Moran26 reported a 20% incidence of fixation failure in the elderly when stabilizing subtrochanteric femoral fractures with 95 compression screw-plates. This problem was not seen in the younger patients in their series or in the patients who observed restricted weight bearing after fixation. The authors recommended using a different device when early weight bearing is unavoidable in the elderly patient. Haidukewych et al23 noted that patients with a nonanatomic reduction of the reverse-obliquity fracture had a significantly (P = 0.060) higher incidence of hardware failure compared with the patients who had an anatomic reduction. They also noted that the 95 implants performed much better in this fracture type than did the 135 implants. Wiss and Brien1 defined subtrochanteric malunion as shortening >1 cm, 10 angulation in any plane, or rotational malalignment <15. French and Tornetta27 noted that 61% of the 45 Russell-Taylor IB subtrochanteric femoral fractures in their series were reduced in at least 5 of varus. They emphasized achieving an adequate reduction and maintaining control of the proximal fragment during reaming and nail placement.

Nonunion Wiss and Brien1 reported a nonunion rate of 1% (1/95). Their sole nonunion was in a fracture that was initially open, and it healed after bone grafting. Pai20 reported a union rate of 93.7% in his series of 16 subtrochanteric fractures treated with the 95 condylar screw. Kang et al12 reported a union rate of 92%, and French and Tornetta27 reported 100% union at an average of 13.5 weeks. These reports indicate that nonunion is unusual in the management of subtrochanteric femoral fractures; however, nonunion can be problematic when it does occur. Excessive soft-tissue stripping, placement of cerclage wires (Figure 7), or reckless handling of the medial fragments may well contribute to nonunion. Subtrochanteric fractures treated with 135 compression screws are inherently unstable, and their application also may increase the risk of nonunion. Haidukewych and Berry28 reported on 21 patients with subtrochanteric nonunions that underwent revision surgery and were stabilized with a variety of methods. Their series included both young and old patients. The authors found that the subtrochanteric nonunions in their series healed when stabilized with either IM nails or plate-screw devices. They bone-grafted 78% of the nonunions with either autograft or allograft. Haidukewych and Berry28 had only one recalcitrant nonunion in their series, indicating that subtrochanteric nonunion managed with revision fixation and bone grafting often yields good results.

Summary
Subtrochanteric femoral fractures are relatively complicated. On the initial injury radiographs, they may be mistaken for intertrochanteric femoral fractures. The subtrochanteric fracture may not be identified accurately until the patient is anesthetized in the operating room. These fractures

Journal of the American Academy of Orthopaedic Surgeons

Douglas W. Lundy, MD, FACS

often require special surgical techniques to achieve satisfactory reductions. Unsatisfactory reduction can lead to hardware failure. The surgeon should endeavor to obtain stable fixation, minimize soft-tissue dissection, and avoid varus malreduction. Indirect reduction techniques that preserve the soft-tissue attachments to fracture fragments usually result in good outcomes without the need for bone grafting. Reconstruction nails and trochanteric femoral nails are the most commonly used implants, but surgeons experienced in the use of 95 plate devices can achieve good results in these injuries.

6.

7.

8.

9.

Acknowledgment
This article is dedicated to the memory of Kenneth D. Johnson, MD, who was an outstanding surgeon, researcher, and teacher of orthopaedic trauma.
10.

11.

References
Evidence-based Medicine: References of prospective, randomized level I and level II studies are cited (references 15 and 18). The remaining references are level III/IV casecontrol or cohort studies, or references to which levels of evidence are not applicable (eg, textbook). Citation numbers printed in bold type indicate references published within the past 5 years.
1. Wiss DA, Brien WW: Subtrochanteric fractures of the femur: Results of treatment by interlocking nailing. Clin Orthop Relat Res 1992;283:231-236. Koch JC: The laws of bone architecture. Am J Anat 1917;21:177-298. Waddell JP: Subtrochanteric fractures of the femur: A review of 130 patients. J Trauma 1979;19:582-592. Kloen P, Rubel IF, Lyden JP, Helfet DL: Subtrochanteric fracture after cannulated screw fixation of femoral neck fractures: A report of four cases. J Orthop Trauma 2003;17:225-233. Oakey JW, Stover MD, Summers HD, Sartori M, Havey RM, Patwardhan 12.

13.

14.

15.

2. 3.

4.

16.

5.

AG: Does screw configuration affect subtrochanteric fracture after femoral neck fixation? Clin Orthop Relat Res 2006;443:302-306. Aluisio FV, Urbaniak JR: Proximal femur fractures after free vascularized fibular grafting to the hip. Clin Orthop Relat Res 1998;356:192-201. Russell TA, Taylor JC: Subtrochanteric fractures of the femur, in Browner BD, Jupiter JB, Levine AM, Trafton PG (eds): Skeletal Trauma. Philadelphia, PA: Saunders, 1992, vol 2, pp 1490-1492. Orthopedic Trauma Association Committee for Coding and Classification: Femur: Fracture and dislocation compendium. J Orthop Trauma 1996; 10(suppl 1):31-35. Roberts CS, Nawab A, Wang M, Voor MJ, Seligson D: Second generation intramedullary nailing of subtrochanteric femur fractures: A biomechanical study of fracture site motion. J Orthop Trauma 2002;16:231-238. Pugh KJ, Morgan RA, Gorczyca JT, Pienkowski D: A mechanical comparison of subtrochanteric femur fracture fixation. J Orthop Trauma 1998;12: 324-329. Kraemer WJ, Hearn TC, Powell JN, Mahomed N: Fixation of segmental subtrochanteric fractures: A biomechanical study. Clin Orthop Relat Res 1996;332:71-79. Kang S, McAndrew MP, Johnson KD: The reconstruction locked nail for complex fractures of the proximal femur. J Orthop Trauma 1995;9:453463. Johnson KD, Tencer AF, Sherman MC: Biomechanical factors affecting fracture stability and femoral bursting in closed intramedullary nailing of femoral shaft fractures, with illustrative case presentations. J Orthop Trauma 1987;1:1-11. 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;19:656660. Starr AJ, Hay MT, Reinert CM, Borer DS, Christensen KC: Cephalomedullary nails in the treatment of highenergy proximal femur fractures in young patients: A prospective, randomized comparison of trochanteric versus piriformis fossa entry portal. J Orthop Trauma 2006;20:240-246. 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;439:221-227.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

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;87:22172226. Sadowski C, Lbbeke A, Saudan M, Riand N, Stern R, Hoffmeyer P: Treatment of reverse oblique and transverse intertrochanteric fractures with use of an intramedullary nail or a 95 degrees screw-plate: A prospective, randomized study. J Bone Joint Surg Am 2002;84:372-381. Ostrum RF, Marcantonio A, Marburger R: A critical analysis of the eccentric starting point for trochanteric intramedullary femoral nailing. J Orthop Trauma 2005;19:681-686. Pai CH: Dynamic condylar screw for subtrochanteric femur fractures with greater trochanteric extension. J Orthop Trauma 1996;10:317-322. Yoo MC, Cho YJ, Kim KI, Khairuddin M, Chun YS: Treatment of unstable peritrochanteric femoral fractures using a 95 degrees angled blade plate. J Orthop Trauma 2005;19:687-692. Vaidya SV, Dholakia DB, Chatterjee A: The use of a dynamic condylar screw and biological reduction techniques for subtrochanteric femur fracture. Injury 2003;34:123-128. Haidukewych GJ, Israel TA, Berry DJ: Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am 2001;83:643650. 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;238:122130. Blatter G, Janssen M: Treatment of subtrochanteric fractures of the femur: Reduction on the traction table and fixation with dynamic condylar screw. Arch Orthop Trauma Surg 1994;113:138-141. Kulkarni SS, Moran CG: Results of dynamic condylar screw for subtrochanteric fractures. Injury 2003;34: 117-122. French BG, Tornetta P: Use of an interlocked cephalomedullary nail for subtrochanteric fracture stabilization. Clin Orthop Relat Res 1998; 348:95-100. Haidukewych GJ, Berry DJ: Nonunion of fractures of the subtrochanteric region of the femur. Clin Orthop Relat Res 2004;419:185-188.

Volume 15, Number 11, November 2007

671