A hip fracture is a break that occurs in the upper part of the femur thigh bone. Ten patients were treated nonoperatively, whilst the other 93 had operative treatment. He then incurred a subtrochanteric femoral fracture with a simple twisting motion of his femur. Metachronous bilateral subtrochanteric fracture of femur. They combine the problem of instability to varus deformation common to comminuted intertrochanteric fractures and the problem of delayed union common to diaphysial fractures of the femur. Fractures of the proximal femur occur predominantly in elderly patients and have a tremendous impact on the health care system. Seinsheimer classification for subtrochanteric fractures. Surgical outcome of atypical subtrochanteric and femoral. Management of subtrochanteric fractures with long pfn. Subtrochanteric femur fractures are an uncommon injury in orthopedics, but when they are encountered they may present difficulties in management. An intertrochanteric fracture is a common hip fracture that happens most often in older adults. These fractures behave differently from other proximal femoral fractures and have their own management pitfalls and. A more detailed knowledge, particularly of avoidable risk factors for subtrochanteric fracture nonunion, is thus desired to develop strategies for reducing nonunion rates.
Bisphosphonaterelated complete atypical subtrochanteric. These fractures behave differently from other proximal femoral. Zuckerman jd, skovron ml, koval kj, aharonoff g, frankel vh. Subtrochanteric and distal femur fractures in a patient with fem. Subtrochanteric femur fractures have a bimodal age distribution. Subtrochanteric fractures take place in the proximal region of the femur, whose anatomical definition is difficult and controversial. Extensive comminuted ieft intertrochanteric fracture.
This lowenergy mechanism of trauma is consistent with an insufficiency fracture and is likely related to inadequate. Currently, the nonsurgical treatment of subtrochanteric fractures of the femur is an exception, and must be performed only in patients with extremely serious clinical comorbidities that counterindicate anesthetic andor surgical procedures. Age is the most dominant factor in hip fracture injuries, with most cases occurring in people over 75. Download full thesis topics for ms dnb orthopaedics degree. Home buy feat download full thesis topics for ms dnb orthopaedics degree. From 2008 to 20, 44 patients with subtrochanteric fractures underwent surgery. Outcomes currently, most subtrochanteric fractures in which the piriformis fossa or greater trochanter are intact can be successfully treated with a cephalomedullary device. Subtrochanteric fractures take place in the proximal region of the femur, whose anatomical definition. Abstract in treating cases of subtrochanteric, intertrochanteric and cervical fractures of the femur, i use a device made from beef bone which i call a key, and on which i rely exclusively for immobilization. The purpose of this paper is to examine the recent literature on the epidemiology, classification, initial evaluation, and definitely treatment for these injuries. These will assist the physician to determine the optimal treatment strategy and avoid. There were six 8 per cent failures of fixation for the 74 fractures treated with the sliding hip screw.
The hip is a ballandsocket joint composed of the femoral head and acetabulum. Subtrochanteric femoral fractures account for approximately 25% of all hip fractures and have a bimodal age and sex distribution 1. The effect of hip fracture on mortality, hospitalization, and functional status. Spontaneous subtrochanteric femoral stress fracture related. Intramedullary nailing of subtrochanteric femoral fractures in the lateral position october 07, 20 contributors. Secondary fractures around femoral nails placed for the management of hip fractures are well known.
Article as pdf 208 kb article as epub print this article. Oblique view of the right pelvis demonstrates a comminuted subtrochanteric fracture inferior to the greater and lesser trochanters. All patients were treated with a lateral entry im locking nail. Treatment of intertrochanteric fractures of the femur pdf.
The closer the fracture to the lesser trochanter, the shorter the lever arm and the lower the bending moment. Treatment of comminuted subtrochanteric fractures of the femur. Outcomes of proximal femoral nail in subtrochanteric femur. Treatment of intertrochanteric fractures of the femur. Pdf subtrochanteric femoral fractures are expected to increase in the coming years. Risk factors for subtrochanteric and diaphyseal fractures. The aim of the present study therefore was to analyse a wide range of parameters as potential risk factors for nonunion. Sliding hip screw side plate angles are available in 5 degree increments from to 150 degrees. Download procedure basics pdf on hip fractures curvo labs. B immediate postoperative anteroposterior view shows additional fracture in the lateral cortex of the proximal femur.
A subtrochanteric femur fracture is a fracture of the femur within 5 cm of the distal extent of the lesser trochanter. Trochanteric and subtrochanteric femoral fractures constitute approximately 50% of all hip. Healing of atypical subtrochanteric femur fractures after ce. Download the pdf to view the article, as well as its associated figures and tables. Radiographs of 38 complete subtrochanteric and diaphyseal femoral fractures in 36 patients were identified in the radiology database using the following search words. Reverse obliquity fractures are best treated as subtrochanteric fractures with either a 95 degree fixed angle implant or an intramedullary device ipsilateral fracture of the femoral shaft, although more common in association with femoral neck fractures, should be.
The above image is a 3d reconstruction from the raw data of a ct of the abdomen and pelvis, such that the patient did not have to undergo additional scanning and radiation exposure to get this image of the femur. A comparative study of the long proximal femoral nail and the long. Nonunion is a common complication after intramedullary nailing of subtrochanteric femoral fractures. University of north carolina chapel hill high compressiontension stress area with cantilever bend deformity. Subtrochanteric intertrochanteric fractures, including any subtrochanteric fracture with extension through the greater trochanter. Subtrochanteric femoral insufficiency fracture following. Poor reduction, varus deformity, nonunion and return to theatre risks are high. A subtrochanteric femur fracture could be a serious injury. During the study, all hip and femur fractures were classified into 1 of 6 categories by anatomical region.
The peculiarity of this case is the presence of femoral shaft fracture malunion and knee disarticulation in the same limb resulting from an accident suffered 30 years ago. Subtrochanteric fractures are fractures in which the section of the femur below the lesser trochanter is broken, generally caused by a higher velocity injury such as a motor vehicle accident or a pathological condition tumor. The management of pediatric subtrochanteric femur fractures. Download full thesis topics for ms dnb orthopaedics degree orthodnb.
A deformity of the hip joint complicates the insertion of the intramedullary nail and varus malreduction is anticipated when surgery is performed on a fracture table with a perineal post. It usually requires surgery and months of physical therapy. Risk factors include osteoporosis, taking many medications, alcohol use, and metastatic cancer. Subtrochanteric fractures are a variant of peritrochanteric fractures of femur extending 5cm distal to the lesser trochanter. Pdf intramedullary nailing of subtrochanteric femur. From this sample study, we conclude that proximal femoral nail through medial entry is a good method for the treatment of subtrochanteric fractures of femur provided optimal reduction of the fracture and good positioning of the nail and screws are achieved. Subtrochanteric fractures after retrograde femoral nailing. Femur subtrochanteric fracture an overview sciencedirect topics. The classification was developed by frank seinsheimer iii in 1978. There is a strong association between bisphosphonate usage and the development of affs, increasing in incidence with longer durations of bisphosphonate usage. Spontaneous subtrochanteric femoral stress fracture related to alendronate. Video shows the setup and operative technique for intramedullary nailing of a femoral shaft fracture in the lateral position. Femur subtrochanteric fracture an overview sciencedirect. Sep 26, 2017 subtrochanteric fracture of the femur.
Atypical femur fractures affs are the result of an uncommon stress reaction developing in the lateral cortex of the femoral shaft. Subtrochanteric femur fractures can occur after highenergy crashes in young patients. The increase of age is related to the increase of the incidence of hip fracture, which is the most frequent cause of hospitalization in centenarians, overcoming congestive heart failure and respiratory infection. Subtrochanteric fracture of left femur treated by limited open reduction and intramedullary fixation. Pediatric patients with subtrochanteric femur fractures with open growth plates. The sliding hip screw is the most widely used implant for stabilization of both stable and unstable intertrochanteric fractures. Khan sk, kalra s, khanna a, thiruvengada mm, parker mj. The wounds were inflicted by infantry weapon missiles in 29 70.
Nevertheless, more data on the treatment outcome of atypical fracture is urgently needed to clarify this issue. Home january 2015 volume 29 issue 1 the management of pediatric subtrochanteric femur fractures. The use of a dynamic condylar screw and biological reduction techniques for subtrochanteric femur fracture. Only a few reports in the existing literature have described these fractures. Aug 20, 2015 subtrochanteric femur fractures have a bimodal age distribution. Data on time to full weight bearing, return to full. C postoperative 1 year anteroposterior view shows union in the femoral shaft and subtrochanteric. This study aimed to investigate the impact on nonunion of the extent of comminution and postoperative displacement in patients surgically treated for subtrochanteric fractures.
The healing rate of atypical subtrochanteric femur fractures treated with cephalomedullary nailing is lower than that previously reported for atypical femur fractures. As an option to manual traction, the surgeon can use an ao distractor. Subtrochanteric neck of femur fractures are a challenge to treat due to anatomical and biomechanical factors. We report, two cases of a fracture of the femur at the interlocking screw site in the subtrochanteric area after retrograde femoral nailing of a femoral shaft fracture. A consecutive series of 103 patients with a subtrochanteric fracture were prospectively studied. Treatment of subtrochanteric femur fractures using the dynamic condylar screw. Apart of the choices of implant used, patient positioning for intramedullary nailing of subtrochanteric femoral fracture plays a crucial role in fracture reduction and should be considered during preoperative planning. Radiograph of left hip showing a subtle periosteal reaction arrow. Challenges in subtrochanteric femur fracture management. Outcome analysis of subtrochanteric fractures fixed with dynamic condylar screw, dynamic hip screw and reconstruction nail. Reconstruction nail techniques are also used for deformity correction and stabilization of malunions, nonunions, and failed plate fixation of subtrochanteric femur fractures.
The subtrochanteric region of the femur is subjected to high compressive and tensile loads. 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. Subtrochanteric femur fractures can occur after highenergy crashes in young patients, or after minimal trauma in the elderly. Subtrochanteric femur fracture fixation remains one of the most challenging procedures to orthopedic surgeons. Per and subtrochanteric femoral fractures request pdf. Pediatric subtrochanteric and supracondylar femur fractures can be challenging to treat due to instability and displacement of the short metaphyseal fragments, as well as limited remodeling potential of the proximal femur in subtrochanteric fractures and the pathologic nature of many supracondylar fractures 7, 10, 22, 26. When a hip fracture is suspected but not apparent on standard xrays, a technetium bone scan or a magnetic resonance imaging mri scan should be obtained. Subtrochanteric fractures of the femur jama surgery. Risk factors for nonunion after intramedullary nailing of. Pdf subtrochanteric femur fracture treated by intramedullary fixation. A cerclage wire can augment an intramedullary nail to help fracture reduction and construct stability. Subtrochanteric femoral fractures are proximal femoral fractures which are located between the trochanter minor and an area of 3 cm below the minor trochanter on the femoral shaft.
Symptoms may include pain around the hip, particularly with movement, and shortening of the leg. Although it is widely used and recommended by the ota, the ao classification has the disadvantage of including the subtrochanteric fracture in a group of fractures with different mechanical and biological behavior. In pagets disease, as a result of abnormal osteoclastic bone resorption. The treatment results of subtrochanteric missile fractures of the femur in 41 casualties are analyzed. It is inherently stable owing to the depth of the acetabulum and surrounding labrum, allowing femoral rotation in the coronal, sagittal, and transverse planes while limiting femoral head translation 3. Younger patients sustain a subtrochanteric fracture as a result of a highenergy injury and typically they have associated. Diagram of pathologic anatomy of subtrochanteric fracture. Intertrochanteric means between the trochanters, which are bony protrusions on the femur thighbone. The management of pediatric subtrochanteric femur fractures with a statically locked intramedullary nail. Subtrochanteric fractures seinsheimer classification.
The subtrochanteric region of the femur is defined as the area extending 5 cm distally from the inferior border of the lesser trochanter. Suthiyuth 2 srinagarind hospital, khon kaen university, khon kaen, thailand and 2the police general hospital, bangkok, thailand we describe an alternative fixation for the pure uncomminuted subtro chanteric. To compare the functional outcomes of subtrochanteric fractures manged by proximal femur nail and proximal femur locking plate. Pires re, santana eo, labronici pj, almeida filho ia. Management of subtrochanteric proximal femur fractures. Cureus subtrochanteric fracture of the femur accompanying. A subtrochanteric femur fracture is a fracture of the femur within 5 cm of the distal extent of the. Management of subtrochanteric fractures is a major challenge and treatment failure is common for it. Revision of subtrochanteric femoral nonunions after intramedullary. The proximal fragment is flexed, abducted, and externally rotated, whereas the femoral shaft is shortened and adducted. Bilateral incomplete or complete femoral diaphysis fractures. Subtrochanteric fractures of the femur springerlink. Subtrochanteric fracture in a woman with pagets disease. Fracture may also occur at the site of screw placement for a femoral neck fracture if the inferior screw is placed too low as this creates a cortical defect and stress riser.
Ten percent of highenergy subtrochanteric fractures are due to gunshot injuries. Subtrochanteric and distal femur fractures in a patient. T1 weighted and t2 weighted magnetic resonance images of upper femur showing signal changes in the marrow at the level of the periosteal reaction. Healing of atypical subtrochanteric femur fractures after. Montavon, in feline orthopedic surgery and musculoskeletal disease, 2009. Subtrochanteric missile fractures of the femur sciencedirect.
Aug 02, 2017 an intertrochanteric fracture is a specific type of hip fracture. Musculoskeletal function and quality of life in elderly patients after a subtrochanteric femoral fracture treated with a cephalomedullary nail. A 45yearold man with known autosomal dominant osteopetrosis sustained left subtrochanteric fracture of the hip after experiencing pain and spontaneously collapsing to the floor after trivial trauma. The hip fracture is a serious consequence of osteoporosis which demands acute surgery with a high risk of complications and a threat to a continued independent living. Subtrochanteric fractures of the femur jama surgery jama. Patients were followed until full fracture consolidation or until implant removal. The purpose of our study is to present the surgical outcome of atypical subtrochanteric and femoral fracture related to bisphosphonates use in patients with or without teriparatide treatment. In the published work, fiftysix patients were treated for subtrochanteric fractures, and their fractures were classified according to the number of major fragments and the. The patients were selected from a database of all clinical radiograph examinations of the femur performed at our institution between january 2007 and. The seinsheimer classification is a system of categorizing subtrochanteric hip fractures based on the fracture pattern of the proximal femoral shaft.
Per convention, the subtrochanteric fracture is characterized as 1. The femur is broken up into different parts including the femoral head, the femoral neck, and the femoral shaft. The lesser trochanter is itself fractured and separated from the femur. Subtrochanteric femur fractures are an uncommon injury in orthopedics, but when they are encountered they may present difficulties in. The overall fixation failure rate was 12 per cent with a reoperation rate of 6 per cent by 1 year. Postoperative complications and mortality associated with operative delay in older patients who have a fracture of the hip. Classification based on the number of fragments and location and pattern of the fracture. Comparative study of subtrochanteric fractures managed by. One type of femur fracture is termed a subtrochanteric femur fracture. Proximal femur nail subtrochanteric femur fractures varus alignment medial entry. However, a specific category for subtrochanteric fractures was not originally used and such fractures could have been classified as in.
Removal of cast 1 right subtrochanteric fracture with impaction. The quality of fracture reduction proved to be the most important factor in bony union and time to union. Intertrochanteric fractures of the femur slideshare. Jun, 2016 segmental fractures of the femur, in which the proximal fracture extends into the upper femoral metaphysis, are also good indications for reconstruction nails. Orthopedics today subtrochanteric fractures of the femur can challenge even the experienced surgeon and preoperative assessment and understanding are key to optimal results. Mar 21, 2016 per convention, the subtrochanteric fracture is characterized as 1. He was treated for right subtrochanteric fracture 4 years back fig. A subtrochanteric fracture of the femur accompanying preexisting osteoarthritis of the ipsilateral hip is rare. Approximately 250 000 fractures of the proximal femur occur in the united states each year 1, and this number is projected.
Mri has been shown to be at least as accurate as bone scanning in identification of occult fractures of the hip, and it will reveal a fracture within 24 hours of injury. Subtrochanteric and distal femur fractures in a patient with femoral shaft fracture malunion and knee disarticulation. Jun 22, 2014 extracapsular occur in the region between the greater and the lesser trochanters of the femur. When to operate a patient with subtrochanteric fracture of the femur. Intramedullary nailing of subtrochanteric femoral fractures. On examination, patient was afebrile with stable vital signs. Aug 17, 20 we therefore 1 evaluated union rate and fracture alignment on radiographs after elastic nailing of pediatric subtrochanteric and supracondylar femur fractures, 2 identified complications associated with the use of elastic nailing, and 3 determined risk factors for the development of complications. Subtrochanteric femur fractures orthopaedicsone articles. Subtrochanteric fractures of the femur comprise only 5% to 7% of hip fractures, but are important because of the difficulty in management. This study demonstrates that intramedullary nail fixation of subtrochanteric femur fractures caused by lowvelocity civilian gunshots is an acceptable option for the treatment of these.
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