Journal of Orthopaedic Surgery 2007;15(2):238-41
Subcapital femoral neck fracture following
successful trochanteric fracture treatment with
a dynamic hip screw: a report of five cases
YT Lung, WL Kam, YF Leung, OM Chung, YL Wai
Department of Orthopaedics and Traumatology, Yan Chai Hospital, Hong Kong
ABSTRACT
A subcapital femoral neck fracture complicating a
healed trochanteric fracture is rare. Such cases are
managed in a rather heterogeneous manner, i.e. there
exists a mixture of cases treated by either fixed angle
devices or dynamic compression screws. We describe
5 patients who developed subcapital femoral neck
fractures after healed trochanteric fractures treated
with dynamic compression screws. The subjects’
clinical data, operative records, and radiographs
have been studied retrospectively and the literature
reviewed. The risk factors for such a complication
include being of advanced age, female, osteoporotic,
and having a small femoral head and neck, and a
basicervical type of fracture.
Key words: bone screws; femoral neck fractures; hip
fractures
INTRODUCTION
From July 1999 to June 2002, 5 patients presented to
our hospital with spontaneous subcapital femoral
Address correspondence and reprint requests to: Dr Yue-tim Lung, Department of Orthopaedics and Traumatology, Yan Chai
Hospital, 7-11 Yan Chai Street, Tsuen Wan, Hong Kong. E-mail: hklyt68@yahoo.com.hk
fractures following healing of a trochanteric
fracture. All were females aged 79 to 90 years who
had their trochanteric fractures surgically treated
with dynamic compression screws in this hospital.
None recalled suffering any second trauma and
the intervals between the primary fixation and the
subsequent subcapital fracture ranged from 2 months
to 3 years. We analysed the patients’ clinical data,
operative records, and radiographs, and reviewed
the literature to identify possible risk factors for such
a complication.
CASE REPORTS
Case 1
In October 2000, a 79-year-old woman presented to
us 2 months after fixation of a trochanteric fracture.
She complained of a sudden onset of left hip pain, not
associated with any trauma. Radiographs revealed a
healed basal neck fracture treated with a dynamic
hip screw and an additional 16-thread 6.5 screw as
an anti-rotational device. A new subcapital fracture
around the tip of the fixation device—the lag screw—
was noticed. As a result, the patient underwent a
Vol. 15 No. 2, August 2007 Subcapital femoral neck fracture after healed trochanteric fracture 239

(a) (b) (c)

Figure 1 Case 2: radiographs showing (a) a trochanteric fracture, (b) a dynamic hip screw fixation, (c) a subcapital fracture at
the tip of the screw 3 years later.

(a) (b) (c) (d)

Figure 2 Case 4: radiographs showing (a) a trochanteric fracture, (b) with good alignment after a dynamic hip screw fixation,
(c) solid union at one year, (d) a new subcapital fracture around the base of the threads of the screw 18 months after fixation.

cemented Thompson hemiarthroplasty after removal Case 3

of the hardware.
In July 2001, a 78-year-old woman presented with
a recent onset of left hip pain. She had undergone
Case 2 fixation of a left intertrochanteric fracture with a
dynamic hip screw 14 months earlier. Radiographs
In October 2000, an 85-year-old woman presented
revealed a well-healed previous fracture and a
with several months’ history of progressive right
subcapital fracture around the tip of the screw. As
hip pain. She fell 3 years earlier, suffering a right
a result, she underwent a cemented Thompson
trochanteric fracture, which healed well after fixation
hemiarthroplasty.
with a dynamic hip screw. Radiographs revealed a
recent subcapital fracture at the tip of the screw (Fig.
Case 4
1), which was managed with a cemented Thompson
hemiarthroplasty. In July 1999, a 90-year-old woman presented with
240 YT Lung et al. Journal of Orthopaedic Surgery

Table 1
Patient characteristics and treatments

Patient Sex/age Interval between trochanteric Length of Additional Avascular Side plate†/barrel
No. (years) and subcapital fractures dynamic hip 16 thread necrosis
(months) screw (mm) 6.5 screw*
1 F/79 2 80 Yes No 4-hole/short
2 F/85 36 80 No No 4-hole/short
3 F/78 14 80 No No 4-hole/short
4 F/90 18 70 No No 4-hole/short
5 F/77 27 70 Yes Yes 4-hole/short

* An additional anti-rotational screw is inserted in an unstable basicervical fracture

†
All side plates were at 135º

Table 2
Summary of previous cases treated with compression hip screws4,7–11

Studies Patient sex/age Interval between trochanteric and Distance of screw tip from
(years) subcapital fractures (months) articular surface (mm)
Parker and Walsh,7 1993 F/76 6 Not mentioned
F/75 5 14
F/84 10 14
F/89 36 8
Heck et al.,9 1996 F/91 4 Not mentioned
F/91 8 Not mentioned
Fairbank et al.,10 1993 F/82 9 ≤10
Gogan et al.,8 1988 M/42* 3 Not mentioned
Mariani and Rand,4 1989 F/82 7 Not mentioned
Wolff and Kessler,11 1990 F/79 3 ≤10

* The patient had chronic alcoholism–induced osteoporosis predisposing to the complication

a one-month history of progressive right hip pain.
She had undergone fixation of a right trochanteric
fracture with a dynamic hip screw 18 months earlier.
Radiographs showed a well-united previous fracture
and a new subcapital fracture around the base of the
threads of the screw (Fig. 2).
Case 5
In June 2002, a 77-year-old woman presented with
several months’ history of right hip pain. She had
undergone fixation of a right trochanteric fracture with
a dynamic hip screw 27 months earlier. Radiographs
showed good union of the trochanteric fracture, a
collapse of the femoral head suggesting avascular
necrosis, and an impacted subcapital fracture around
the tip of the screw.
DISCUSSION
Trochanteric fractures have traditionally been
treated with fixed angle devices rather than dynamic
compression screws.1 The mechanisms governing
these fixation devices are different and therefore
difficult to compare. Subcapital fractures were more
often associated with trochanteric fractures treated
with fixed angle devices e.g. Zickel nail fixation,2
McLaughlin nail plates,1,3,4 Ender nails,5 and AO blade
plate fixation.6 To avoid the risk of nails penetrating
into the joint as the fracture collapses, the tip of these
static fixation devices should not be placed close to
the articular surface. In some cases, the device did not
even reach the subchondral bone, which could give
rise to a stress fracture around the tip of the device.3
Therefore, it has been recommended that these
fractures be treated with a dynamic hip screw to allow
‘controlled collapse’ of the fracture. The tip of the
fixation device—the lag screw—can be placed close
to the articular surface into the stronger subchondral
bone, thus avoiding stress risers within the bone,
especially in osteoporotic bones.3,4,7 A dynamic hip
screw is considered the optimal fixation device for this
type of fracture, but spontaneous subcapital fractures
Vol. 15 No. 2, August 2007 Subcapital femoral neck fracture after healed trochanteric fracture 241

following healed trochanteric fractures treated with
compression hip screws still happen.
We reviewed 15 such cases (10 from the literature
and 5 from our series, Tables 1 and 2) and identified
the risk factors as advanced age, female gender,
and osteoporosis.4,8,9 Apart from one patient who
had chronic alcoholism–induced osteoporosis
predisposing to the complication,8 all the other
patients had the abovementioned risk factors. The
distance between the articular surface and the
dynamic hip screw tip is another risk factor. The
tip should be placed within 10 mm of the articular
surface. Better placement of the screw can prevent
such spontaneous subcapital fractures.4,7 In all our
cases, radiographs revealed no technical problems
with the fixation, but the complication still occurred
even when all technical aspects of the procedure
had been correctly observed.9,10
In our series, all the side plates were short barrels,
because the length of the lag screws were ≤80 mm,
as the femoral heads and necks of our patients were
small. The dynamic hip screw has a 22-mm long
cancellous thread with an outer diameter of 12.5 mm
and a core diameter of 8.0 mm. The length of the short
barrel is 25 mm while that of the long (standard)
one is 38 mm. In our cases, the subcapital fractures
developed around or at the base of the threads. It is
not uncommon to have femoral heads measuring 40
to 42 mm in diameter. The southern Chinese body
frame, especially that of females, is much smaller than
that of Caucasians. The stress in the bone adjacent to
the screw threads is much higher in patients with
smaller femoral heads and shorter necks, as most of
the screw threads are in the weaker central part of the
femoral head, even though the screw tip is within
10 mm of the articular surface. Whether the use of the
short barrel side plate (greater bending stress) creates
further stress is unknown.
Tapping of the track preceding the insertion of
the screw was not performed. It has been suggested
that torque creates subcapital microfractures as
the screw engages the denser subchondral bone
of the femoral head.11 Four of our patients had the
basicervical type of trochanteric fracture. Two of
these had an additional 16-thread 6.5 screw inserted
for anti-rotation, indicating that such fractures are
inherently unstable.
CONCLUSION
A subcapital femoral neck fracture following a healed
trochanteric fracture is rare. The risk factors for this
complication are: advanced age, female gender,
osteoporosis, smaller size of the femoral head and
neck, and a basicervical type of fracture. Surgeons
should be aware of the ways to recognise, treat, and
prevent such complications.

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