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Subtrochanteric Fractures

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Intramedullary Nailing

Abstract

Subtrochanteric fractures warrant special attention due to the biomechanical characteristics of this skeletal region and the muscle forces acting on the main fracture fragments. In a true subtrochanteric fracture pattern, the mobile proximal fragment is displaced in a flexed, abducted and externally rotated position. The distal femur segment will deviate into adduction and become shortened. The Seinsheimer classification is the most widely used. Advances in design and technology have expanded the indications for intramedullary nailing to nearly all subtrochanteric fracture patterns. The implants ideally should enable a simple and minimal invasive surgical technique and assure superior stress endurance. Correct alignment, length and rotation of the main fracture segments are most critical and should be achieved before the nailing procedure is started. Reduction aids may be used or a limited open reduction performed if necessary. Optimal reduction must be secured intraoperatively in the anteroposterior and lateral image intensifier views. The ideal entry portal is not only depending on the specific morphology of the proximal femur but also on the design of the nail, especially its medial lateral angle. In polytraumatized patients, patients with bilateral femur fractures, patients with severe open or contaminated fractures, primary nailing should be avoided. Advantages and limitations of nailing should be considered in refractures, non-unions and malunions of the subtrochanteric region and in patients with different anatomical features such as enhanced anteversion or varus. If the surgical procedure is performed correctly, good alignment and high fracture stability achieved, uneventful healing can be expected.

Atypical femoral fractures represent a specific fracture entity. These fractures, which are often but not exclusively subtrochanteric, are usually observed after a minimal trauma or even without any trauma in elderly patients that have been under long-term bisphosphonate treatment. Incomplete fractures require prophylactic nailing. Surgical management of complete and unstable fractures is associated with a relevant complication rate. Complications are related to changes in bone morphology as well as to changes in bone metabolism.

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Authors and Affiliations

  1. Department of Orthopaedic/Trauma Surgery, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, Brisbane, QLD, 4102, Australia

    Michael Schuetz MD, PhD, Tamer Mettyas MD & Robert Pichler MD

  2. Department of Orthopaedics and Traumatology, Hospital Nürnberg Süd, Nürnberg, Germany

    Herman Bail MD, PhD

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  1. Michael Schuetz MD, PhD
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  2. Tamer Mettyas MD
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  3. Robert Pichler MD
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  4. Herman Bail MD, PhD
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Correspondence to Michael Schuetz MD, PhD .

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Editors and Affiliations

  1. Center for Orthopedics &Traumatology, University Medical Center Johannes Gutenberg University, Mainz, Germany

    Pol M. Rommens

  2. Academic Teaching Hospital Fulda, Fulda, Germany

    Martin H. Hessmann

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Schuetz, M., Mettyas, T., Pichler, R., Bail, H. (2015). Subtrochanteric Fractures. In: Rommens, P., Hessmann, M. (eds) Intramedullary Nailing. Springer, London. https://doi.org/10.1007/978-1-4471-6612-2_18

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  • DOI: https://doi.org/10.1007/978-1-4471-6612-2_18

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