Subtrochanteric Femur Fractures

: Case Scenarios
CASE 1 : Reduction—subtrochanteric femoral fracture
year-old man, motorbike accident-22

Isolated subtrochanteric fracture

Closed injury
Neurovascular status ok
 If using a fracture •
table: supine vs
? lateral

Advantages and •
disadvantages of each
setup ? Potential
? problems
 ? If using a regular table: positioning and setup •

Advantages and disadvantages of using a regular table ? •

? Potential problems
 How to assess reduction •
? (rotation and angulation)

How to make sure the •

reduction instruments do
not interfere with the
? fixation

Is the choice of the •

reduction method implant-
? dependent
Summary
Reduction can be difficult on a fracture table with the patient in -
.supine position
Different implants can be used to fix this fracture, and their choice -
.affects the reduction techniques
.Use of the implant as a reduction aid is possible (nail or plate) -
Use of other adjuncts can be beneficial in these injuries: external -
.fixation, ball spike, percutaneous clamps, bone hooks
 Case 2

Subtrochanteric fractures
Case presentation
year-old man after a motor-50
vehicle accident
?Can we make a plan
?Is the CT scan useful
Case presentation

year-old man after motor-50 •

vehicle accident

:Closed reduction
Long locked recon nail
Long 95° angled blade plate
Long DHS
Long DCS
Postoperative
months postoperative 6
 Take-home messages

Always try a closed reduction -

Long locked recon nail -

Consider minimally invasive cerclages to increase the stability -

in long spiral fracture lines
CASE 3 : Reduction techniques with IM nailing
(subtrochaneric fracture)
year-old woman, slipped down on ski slope-32
?Closed fracture
?Describe the injury. What is your plan? Possible pitfalls
? what went wrong
? what went wrong

Control the proximal fragment

!before you make an incision
weeks later: transfer 3
She complains about toe in gait
?What would you do
?Accept and wait for healing -
?Revision with plating -
?Revision with another nail -
?Other options -
Reference for rotation
Lesser trochanteric profile sign
Internal rotation deformity
External rotation of proximal fragment
New entry posterior to the previous one
Reamer went down through the deformity due to posterior cortical
?defect, what to do now
 Posterior blocking pin did not work
Try to guide the nail anteriorly
Nail falls back into previous track at the entry point
Second blocking pin proximally
Acceptable sagittal alignment
Blocking pins
Replaced with screws •
Result

POP
months 7
post-
operative
Take-home message

Control the proximal fragment

!before you make an incision
CASE 4 :
 year-old man, motorcycle crash-52
Closed -
subtrochanteric
fracture of the left
femur
Multiple fractures -
Pulmonary -
contusion
Normal -
neurovascular status
Discussion

Patient positioning •

Surgical approach •

Reduction technique •
Direct/indirect •

Fixation options •
IM nail, plate •
 Non-nail-able condition
Biological plating (MIPO)

Proximal extension
”“Risk of further break
Polytrauma or lung injury
” “Risking the patient’s life
Narrow femoral canal
Asian female
Failed IM nail

Minimally invasive plate osteosynthesis (MIPO)

 Extramedullary fixation

Conventional plate

Fixed
angle
implant

Angled blade plate Dynamic condylar

(ABP) screw (DCS)
 Extramedullary fixation

Locking plate

Broad locking Proximal femur LCP Reverse LCP-DF

compression plate
(LCP)
Reverse locking compression plate distal femur (LCP-DF)

Anatomically pre-shaped, curved

Less bulky compared to PFP
Maximum of 5–6 screws in proximal
femur

Haq RU, Int Orthop (2014)

Zhou F, J Orthop Trauma (2012)
Positioning (different case)—supine on radiolucent table

More degree of
freedom to
move
the fracture for
reduction
Assessment of fracture displacement
Externally rotated Posteriorly displaced
proximal fragment distal fragment
Surgical approach—lateral approach of femur (MIPO)

Knee Hip

hole reverse distal femoral LCP-11

Reduction of proximal fragment

Internal
rotation
Plate insertion
Proximal plate position

Ant R Pos
Distal plate position

Knee

Traction
Hip
Proximal fixation
Reduction and distal fixation
Final incisions and fixation

Knee

Hip
Postop 4 months
Take-home messages
Plating in subtrochanteric fractures

Good option in case nailing may compromise safety

Quality of reduction Much more important than choice of implant

Fixed angle device can be selected

Blade plate, DCS, LCP Should be performed using less invasive techniques