Table of Contents
Subtrochanteric femoral fractures commonly present in two different populations under very different circumstances. The elderly are commonly affected by low-energy events, such as a simple fall to the floor, while younger populations are more likely to be involved in high-energy events such as motor vehicle accidents. The majority of elderly injuries can be attributed to fragility fractures due to loss of bone density, but it is important to note an atypical fracture pattern that is present in those who have been taking bisphosphonates. This video demonstrates an intramedullary fixation of a reverse oblique trochanteric femoral fracture in the lateral position. There is a classic deformity seen in subtrochanteric fractures due to strong muscular attachments in the region. In this video, we show that while the lateral position may be more difficult for obtaining x-rays, it provides natural external forces that make reduction and fixation easier.
The subtrochanteric region of the femur is defined as the first 5 cm distal to the lesser trochanter.1 Fractures of this region account for 25% of proximal fractures of the femur.2 There are numerous reasons why a fracture in this area can have difficulty healing and lead to complications. The greatest contributing factor is the deforming forces from muscle attachments in the area that lead to a difficult reduction.2
There have been several fracture classification systems that have been used to describe subtrochanteric fractures.1,2
Type IA - No extension into piriformis fossa
Type IB- No extension into piriformis fossa but the involvement of the lesser trochanter
Type IIA- Extension into piriformis fossa without the involvement of lesser trochanter
Type IIB- Extension into piriformis fossa with the involvement of lesser trochanter
32-A3.1 Simple (A) Transverse (3), Subtrochanteric fracture (0.1)
32-B3.1 Wedge (B) Fragmented (3), Subtrochanteric fracture (0.1)
32-C1.1 Complex (C) Spiral (1), Subtrochanteric fracture (0.1)
It is important to determine the mechanism of injury and to review prescribed medications for bisphosphonate use. The patient will report an inability to bear weight and will likely have significant swelling on the affected side. Younger patients are more likely to present with polytrauma and will often require a multidisciplinary approach to determine the best course of action.
A shortened extremity will likely be noted on the affected side. The common deformity pattern that is seen for the proximal fragment is flexion from the iliopsoas, abduction from the gluteus medius, and external rotation from the external rotators. The distal fragment is pulled into varus by the hip adductors.2 Extensive soft tissue swelling may be present from local hemorrhage. The patient’s hemodynamic status must be monitored for shock, and the afflicted area monitored for compartment syndrome.4 If the patient is presenting from high-energy trauma, a thorough exam for injuries to the thorax, abdomen, and contralateral cranium should be done. Injury to these areas together is known as Waddell’s triad and is common in pediatric patients struck by motor vehicles.5
Orthogonal imaging of the entire femur, knee, and hip should be obtained. These views will allow the surgeon to view if there has been an intertrochanteric extension of the fracture, which can influence the starting point for the nail. A traction CT can also help evaluate the fragments and determine whether an open reduction may be necessary.1
Surgical management is the definitive approach to treatment. The exception would be in a patient that has many comorbidities that contraindicate surgery.6 There are strong muscular forces in the area that will displace the fracture, shorten the leg length, and not allow the patient to ambulate properly if surgical intervention is not taken. The two common surgical approaches are cephalomedullary nailing, as seen in the video, and submuscular fixed-angle plating.1 Cephalomedullary nailing is preferred in most scenarios, except when the fracture extends through the lesser trochanter or piriformis fossa, which interferes with the entry point for the nail.1
The goal of cephalomedullary nailing is to promote union, avoid rotational mal-alignment, and provide structural support while preserving vascularity.7 Cephalomedullary nailing allows patients to begin weight-bearing as tolerated. Evidence supports that early weight-bearing promotes more rapid time to the union while allowing earlier initiation of physical therapy, leading to an overall faster recovery.8
Studies have shown that the timing of surgery relative to the injury plays an important role in improving outcomes. Data suggests that operations performed within 48 hours had a lower complication rate.9
This case illustrates a repair of a reverse oblique subtrochanteric fracture using an intramedullary (IM) nail in the lateral position. The alternative position that is commonly used is supine on a fracture table. IM nails have been shown to be superior to submuscular fixed-angle plates in the repair of subtrochanteric fractures.10 IM nails provide more support, can be inserted through smaller incisions resulting in less blood loss, decrease operative time, and decrease length of hospital stay compared with other methods.1,2,10 The challenge with IM nails is the fracture must be properly reduced before the nail can be inserted. In this case, it is accomplished through manual traction and held by cerclage wires. The general steps of the procedure are exposure and reduction, preparing the medullary canal for insertion of the nail, inserting the nail, and locking the proximal fragment, followed by locking the distal portion of the nail with screws that prevent rotation of the nail within the canal.
Operative time is usually between 40–120 minutes and intraoperative blood loss is within the range of 250–1300 ml.11 The average length of hospital stay is around 15 days, but this can be highly variable depending on other comorbidities.12 Femoral fractures pose a high risk of mortality in the elderly population with a five-year mortality rate of 25%.2 The most common complications are infection, pseudoarthrosis, vicious consolidation, and loss of reduction.2 Special consideration must be taken when using the lateral position because the force of gravity, combined with the muscles attached to the distal segment, promotes a varus deformity.
Fluoroscopy is used throughout the procedure to guide and confirm proper placement of the hardware and to confirm a proper reduction and fixation has been performed. These X-rays are more difficult to obtain in the lateral position, but this position allows better access to the operative site, which results in a better reduction. The initial reduction is done through the use of cerclage wires. Due to the complexity of the fracture in this case, two cerclage wires were ultimately used to achieve and hold proper reduction while the nail was positioned and secured. These wires can be left in place or removed at the end of the procedure. It has been postulated that long-term use of cerclage wires may pose a risk of bone devascularization.2,13 Therefore, the surgeon must evaluate on a case-by-case basis whether it will promote a better outcome for the patient if they are left in place.
The tip apex distance (TAD) represents the distance from the tip of the screw to the apex of the femoral head measured through anteroposterior and lateral X-rays. Geller et al. recommend a TAD of 25 mm or less.14 In their study, the mean TAD of those who experienced screw failure was 38 mm compared with 18 mm in those who did not.14 The goal for the TAD in this patient is 15 mm. Short and long nails can be used for fixation. Advocates for short nails believe that they are more cost-effective, have a shorter operative time, and result in less blood loss. Long nails, however, provide greater stability throughout the entire femur and prevent the complication of distal femur shaft fracture that is associated with short nails.15,16
Postoperatively, patients may begin weight-bearing as tolerated.1 This is one of the advantages of the IM nail over plate fixation.
The future of IM nailing will likely combine nail technology with the study of fracture healing biology, which will result in surface components of the nail that provide the optimal bone mechanobiological environment for each stage of fracture healing.17
- Ball-tipped guidewire and reamer
- Portable fluoroscopy system
- Cephalomedullary nail
- Interlocking screws
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
The article is written by Robert W. Burk IV, MS and under review by Dr. Michael J. Weaver.
- Medda S, Reeves RA, Pilson H. Subtrochanteric Femur Fractures. Treasure Island, FL: StatPearls; 2020.
- Barbosa de Toledo Lourenço PR, Pires RE. Subtrochanteric fractures of the femur: update. Rev Bras Ortop. 2016;51(3):246-253. https://doi.org/10.1016/j.rboe.2016.03.001
- Rizkalla, James M. MD; Nimmons, Scott J. B. MD; Jones, Alan L. MD Classifications in Brief: The Russell-Taylor Classification of Subtrochanteric Hip Fracture. Clinical Orthopaedics and Related Research: January 2019 - Volume 477 - Issue 1 - p 257-261. https://doi.org/10.1097/CORR.0000000000000505
- Bhandari M, Swiontkowski M. Management of Acute Hip Fracture. N Engl J Med. 2017;377(21):2053-2062. https://doi.org/10.1056/NEJMcp1611090
- Núñez-Fernádez AI, Nava-Cruz J, Sesma-Julian F, Herrera-Tenorio JG. Evaluación clínica del paciente pediátrico con tríada de Waddell [Clinical assessment of pediatric patients with Waddel's triad]. Acta Ortop Mex. 2010;24(6):404-408. PMID: 21400764
- Qiu C, Chan PH, Zohman GL, et al. Impact of Anesthesia on Hospital Mortality and Morbidities in Geriatric Patients Following Emergency Hip Fracture Surgery. Journal of Orthopaedic Trauma. 2018;32(3):116-123. https://doi.org/10.1097/bot.0000000000001035
- Alho A, Ekeland A, Grogaard B, Dokke JR. A Locked Hip Screw-Intramedullary Nail (Cephalomedullary Nail) for the Treatment of Fractures of the Proximal Part of the Femur Combined with Fractures of the Femoral Shaft. The Journal of Trauma: Injury, Infection, and Critical Care. 1996;40(1):10-16. https://doi.org/10.1097/00005373-199601000-00003
- Paterno, Mark V PT, MS, SCS, ATC; Archdeacon, Michael T MD, MSE Is There a Standard Rehabilitation Protocol After Femoral Intramedullary Nailing?. Journal of Orthopaedic Trauma: May-June 2009 - Volume 23 - Issue - p S39-S46. https://doi.org/10.1097/BOT.0b013e31819f27c2
- Sircar P, Godkar D, Mahgerefteh S, Chambers K, Niranjan S, Cucco R. Morbidity and Mortality Among Patients With Hip Fractures Surgically Repaired Within and After 48 Hours. American Journal of Therapeutics. 2007;14(6):508-513. https://doi.org/10.1097/01.pap.0000249906.08602.a6
- Lundy DW. Subtrochanteric femoral fractures. J Am Acad Orthop Surg. 2007;15(11):663-671. https://doi.org/10.5435/00124635-200711000-00005
- Pahlavanhosseini H, Valizadeh S, Banadaky SH, Karbasi MH, Abrisham SM, Fallahzadeh H. Management of Hip Fractures in Lateral Position without a Fracture Table. Arch Bone Jt Surg. 2014;2(3):168-173. PMID: 25386577
- Tan ST, Tan WP, Jaipaul J, Chan SP, Sathappan SS. Clinical outcomes and hospital length of stay in 2,756 elderly patients with hip fractures: a comparison of surgical and non-surgical management. Singapore Med J. 2017;58(5):253-257. https://doi.org/10.11622/smedj.2016045
- Agarwala S, Menon A, Chaudhari S. Cerclage Wiring as an Adjunct for the Treatment of Femur Fractures: Series of 11 Cases. J Orthop Case Rep. 2017;7(4):39-43. https://doi.org/10.13107/jocr.2250-0685.842
- Geller JA, Saifi C, Morrison TA, Macaulay W. Tip-apex distance of intramedullary devices as a predictor of cut-out failure in the treatment of peritrochanteric elderly hip fractures. Int Orthop. 2010;34(5):719-722. https://doi.org/10.1007/s00264-009-0837-7
- Li Z, Liu Y, Liang Y, Zhao C, Zhang Y. Short versus long intramedullary nails for the treatment of intertrochanteric hip fractures in patients older than 65 years. Int J Clin Exp Med. 2015;8(4):6299-6302. Published 2015 Apr 15. PMID: 26131244
- Dunn J, Kusnezov N, Bader J, Waterman BR, Orr J, Belmont PJ. Long versus short cephalomedullary nail for trochanteric femur fractures (OTA 31-A1, A2 and A3): a systematic review. J Orthop Traumatol. 2016;17(4):361-367. https://doi.org/10.1007/s10195-016-0405-z
- Rosa N, Marta M, Vaz M, et al. Recent developments on intramedullary nailing: a biomechanical perspective. Ann N Y Acad Sci. 2017;1408(1):20-31.
- Lateral Incision Over Trochanter
- Provisional Wire Fixation
- Insert Guidewire for Drill
- Drill Through Proximal Cortex
- Ream Medullary Canal
- Insert Nail
- Attach Aiming Arm
- Insert Lateral Guidewire for Drill
- Drill Through Lateral Cortex
- Insert Spiral Blade
- Engage Locking Mechanism
- Adjust as Needed
- Align Drill with Distal Nail
- Drill Through Cortex
- Insert Distal Screw
- Repeat for 2nd Screw
Get right through the iliotibial band - just get through there. Cut. Good, so you see that band? Yeah. That’s a little piece there. Proximally? Yeah, so you’ve got to go just a little bit more proximally. Do you have a Weit-y? Yeah, sure. Good. Actually, do you have a Gelpi? Thank you. Alright, so the iliotibial band is open, and there’s vastus lateralis, right? Now do you have your Schnidt? So you’re right on that piece of bone, so what I want you to do now is just take this and get behind this - you know, spread it open so you’re kind of behind vastus lateralis, okay? Back there, yep. You want back here? Yep. You know what? Good. Good. Alright, we’re a little bit cross - let me see. Alright, so I think you're - that's right where our fragment is? Yep, you're right on it, so that's perfect. And there’s the distal piece there.
Alright, so now get your wire - get your wire passer. X-ray there. X-ray. Usually, it’s internal rotation. X-ray. So that’ll be good. So this - so the way this works - so this is above? Yeah. So you just kind of put that together. Put that together and then flip it apart? Okay, so you’re just gonna put it and go on and that way. X-ray. So you’re only around - only around that. Well, you’ve got to get around the other way. So you’re doing this - you just gonna - I'm just hitting some soft tissue again - yeah. X-ray. Good, so now we’re around there. So now, take this one - and get over the top - and you’re just gonna loop it that way. X-ray. Good, that’ll do it.
Okay, so now - now pop that. Good. And now take off that. Leave this one. Yeah, take this one out? Take that one out. Now with the wires, I always kind of do this. I kind of treat it like a screw - okay - and so I go clockwise, so that way I can always go back to it and tighten it if I want. So give that a pretty good pull up. X-ray. Good, as you tightening - good, pull. Come south just a little bit. X-ray. X-ray. We may have to adjust a little bit, but I think that’s a pretty good start. We need to have a better reduction when we’re done, but this is a pretty good start. Oftentimes, the nail will kind of finish it for you.
Alright, guidewire. No, that looks fine. X-ray. That’s fine. There you go, yep. Drive that in, please. Good. X-ray. Good, now try tapping that in with a mallet just a little bit. That’s when I use the mallet - it’s once it’s down. To bounce off the cortex? Yep, exactly. X-ray. Yeah, and now you can tell you’re down cuz it’s staying inside the canal. Yep, good. X-ray there. Good, and you already saw the other views, so you know that’s good. Good. Dropping your hand aims lateral, okay? And that’s the - the last place you want to be with this, okay? You shouldn’t be cramped for space with this. Yeah, I got it. Good. Good. You got to be real careful about going lateral, alright? Because if it goes - that’s the soft bone. It’s gonna want to go lateral, and then it’ll tip you into varus cuz your - your bl - your blade will push you over - or sorry, your nail will push you over. X-ray.
That’s good. Keep going. Good. Are you - are you all the way in? Hub it. Hub it. Hub it. And out. Good. Is that down the be - down pipe? It’s good. Come down to the knee please. X-ray there. You always measure before you ream. There you go. X-ray. What does that measure? If it measures exactly 360 and this is your x-ray on the right, what do you want? 8-5? X-ray. Alright. Good. 12 please. That’s it. You’re good. 12 in it? Yep, 12’s it. 12 and then the nail. Cuz there’s no chatter - it’s a wide capacious canal - no need to ream up, but I always like to pass that 12, the - the final reamer, just to make absolutely sure. Now if you hit a lot of chatter here, I’d say, “Oh, let’s back up and starting reaming it out,” but you’re not gonna hit any chatter.
Alright, we’re ready for the nail. You can see as the reamer and the guidewire have gone down, it helps with your reduction. It just kind of goes in like a corkscrew. And just remember we’re lateral, so this is going to start in the front and then corkscrew it in that way. There you go. Yep. Good. X-ray. Mallet. X-ray. Alright, why don’t you come down to the knee? Just make sure that’s okay. Good. X-ray there. Yep, that’s perfect. Good, come back up to the top. A little less like that, probably. Good, X-ray there. That looks pretty good there. X-ray. Alright.
Just keep careful of those wires, okay? What’s that? So be - be careful of those wires. So if you go like this, see, it just keeps pulling that back. If you go the other way, then it tightens up. After it locks? Yep. Yep. X-ray there. That’s good. X-ray. Stop there. So next time, I want you to be really careful. That’s most likely in the hip joint. You - next time, before you drive it beyond halfway, you really need to check your lateral. Come up to a lateral. X-ray there. Alright so, that’s right in the joint. Alright, so back that out. X-ray. X-ray. X-ray. Okay. X-ray. Keep driving it forward. X-ray. X-ray there. X-ray there. Drive it forward just a tiny bit more. Good. X-ray. Good. Let’s swing around to an AP. So that looks pretty good. So you can go ahead and drive that a little bit more. X-ray. X-ray. So you want to go a little bit more than that. So if - so back out when you drill. X-ray. Okay. Save that. Can you just swing up to an AP? X-ray there. X-ray there. Can I have the wide driver? So that’s just a tiny, tiny bit posterior. X-ray. X-ray. X-ray. That looks pretty centered to me.
Alright, swing around to an AP. X-ray there. See if you can tighten that wire just a little bit more. I get the sense that it’s - that we keep losing our reduction ever so slightly. I think we’ll probably take that wire out at the end. You know, oftentimes, I’ll leave it if it’s a really nice reduction. You know, in this case, we - we couldn’t capture that piece, so I don’t think it’s worth keeping it - but it’s helping us - helping us hold it. Are you pulling? I’m pulling. Good. X-ray. X-ray. Okay, alright. So let’s go do the blade.
So before you measure, you’ve got to get this thing down, okay? See how it’s not on the bone yet? It’s off the bone there. Because the blade is stopped by this cannula, so if you’re not on the bone, the blade is going to stick out the side of the femur, and it’s just really prominent and can bother people. Good. X-ray there. So even that’s not down. Do you have a Tommy Bar? I think it might be hitting on the - yeah, I agree. It’s hitting on the wire a little bit. Can you suck?
Do you have a chubby please? Bone tamp and a mallet. So often, you can just kind of tap that wire around in a circle. Even when it’s tight, it’ll move that way. X-ray. Now that’s down. X-ray. I think that’s pretty good. X-ray. X-ray. X-ray. Yeah, that looks good. Okay. Yep. I’ll take the wire driver first, please? Yeah, sure. Now if you - if you measure to 90 and put in a 90 there, you’re not going to be able to keep that guidewire in because it’s just gonna come right out. So I always - that’s why I put it in before, but then we changed it - but I’d like to put it in further so it’s got fresh bite in the head. So you drive it in just to touch? Normally, I - I have it touch the subcondylar bone because then you’re actually measuring your tip apex distance, right? And the tip apex distance is probably the second most important thing. X-ray. As far as keeping it from losing its reduction. X-ray. So now, you know, you can double check, but - yeah, so I think 90 is fine. That measures 97 or something like that, so tip apex distance would be about 15. So what do you want? 90. 9-0. X-ray. You’ve got to check X-rays to make sure you don’t drive the pin into the head. X-ray. X-ray. Don’t - don’t trust your stop. Okay. X-ray. We still got one. X-ray. So yeah, a little bit more. X-ray. That’s down.
Okay. So it’s important to know that this blade is longer than the drill. You can’t hold that. It’s rifled. If you hold this, it won’t go in. Yep. You have to hold it here cuz it’s rifled - so it’s grabbing in the barrel. There we go. X-ray. X-ray. X-ray. Go down. Let me see. Good. Flexible? Alright.
Alright. Wire driver. Thank you. Alright. X-ray there. X-ray. X-ray. Back out for a second. Do you have a wire cutter for me? So at some point, we lost our reduction there. It was like really good until our blade went in. We’ve got to take this wire out. X-ray. X-ray. X-ray. Just a little bit. Alright. I’m gonna go take this out. I need the flexible screwdriver. Sorry. Can you get me the extractor handle for the blade? Yep. I don’t know where I went wrong there. We had a really nice reduction - it was great - with the wire, and then when we put the blade it, it didn’t - somehow, it displaced. Back to the shaft - like that. X-ray. Okay.
X-ray there. Now we’ve got that posterior piece as part of it. X-ray. Come south for me a little bit. Give it a really good pull and slight internal rotation there. X-ray there. Okay, can you pull hard? Like real hard. X-ray. Alright. Time to make the magic happen. Here we go. X-ray. This is gonna be a her - herculean pull, okay? X-ray. And then internal - or external maybe? Pull away. X-ray. There we go. It’s starting to go in. X-ray. Now internal. X-ray. X-ray. Watch out for a second. I just want to see what happens when I pull. X-ray. X-ray. X-ray. X-ray. X-ray. Just hold that there. I think that piece is rotated still. Can I see the nail please? X-ray. X-ray. Mallet.
X-ray. So sometimes when you get it close, the - the nail will help kind of fill the canal. So now we have that reduction a lot better. It’s not perfect yet, but we’re much better. I think we’re even better than when we were at the beginning cuz - unless there’s a free piece, but now that other piece is - X-ray. Alright, so that’s good there. Alright, Gelpi. Now I’m back to happy. Like, I think that’s an acceptable reduction. It’d be nice if we could key that in just a little bit more. Do you have the 1x1? X-ray. Now release - release it. Good. X-ray. Just a little bit more. X-ray. You can see that - that wire - if it was a tiny bit more distal, would probably be helping us a little bit better. I definitely don’t want to put a third wire - you know, I think we’ve got plenty.
Okay. Guide. And guidewire stuff. I’ll take the wire freehand. Mallet please. Yep. X-ray there. X-ray. Wire driver. X-ray. X-ray. That looks pretty centered. X-ray. Alright, let’s come up to an AP. Yep. X-ray there. Power. X-ray. I think that’s the same hole. That didn’t feel like a lot of - anything. Looks like we’re gonna stick with a 90. Do have - I’m gonna use the one I said I wouldn’t use now. Same thing. X-ray. X-ray. X-ray. Blade. So this turns, and then once it locks in, you just push it. If you hold here, it stops it from turning, so it can’t go in. X-ray. X-ray. X-ray. Lock that down for me. Glad we changed it though. Anytime you see it like kind of fall apart, it’s like, “Eeehhh.” Yeah, it came all the way apart.
But, you know, the - the tip apex distance is what’s written about as being the most important thing, but I think that’s secondary to reduction. You have a good reduction, you’re not gonna fail. X-ray. Okay, and acorn.
That’s good. Let’s come up to an AP now please and then tilt a little bit more. X-ray there. Knife please. Yes. Coming up. Knife please. X-ray. How far do you want to spread it? I don’t know. I’m gonna spread with the drill. X-ray. X-ray. Bullseye. Depth gauge. 50. X-ray. X-ray. If we had reviewed on this lateral, would you still have opened? For this one, probably. X-ray. It would have been harder. It would’ve been harder to get a good reduction. I think we would - I think - supine, you mean? Yes. X-ray. I think we would’ve - we wouldn’t have ended up quite as good. Watch your hand. Thank you. X-ray. X-ray. X-ray. X-ray. X-ray. X-ray. So that’s id - the ideal - like when it falls right through. 46. 46. X-ray. X-ray. Do you want one to close off? Yeah, definitely. Yes, please. Can you square up for me - nice and straight? X-ray. Save that. Come up proximal. Drop your machine as far as it’ll go. Table up please. You got it. X-ray there. X-ray there. You can see that piece is folded around the back. That was what I was trying to undo. X-ray. Save that. Come up proximal just a little bit more. X-ray there. Save that.
Swing around to an AP please. X-ray. Save that. Come down to the knee please. X-ray. Save that. These screws are adding - aiming slightly posterior to anterior, which is kind of what you want cuz that - that means your version is about right. That’s another check for version, right? Thank you.
So that was challenging, but things came out nicely in the end. So we performed an intramedullary fixation of a reverse obliquity in the lateral position. This positioning is useful because it allows the soft tissue to fall away and makes a direct reduction a little bit easier than if you’re on a fracture table. And also, it neutralizes the deforming forces of the proximal femur when you’re in that lateral position, but the X-rays are a little bit more challenging. And it’s something you have to get used to, but it - it works out pretty well. I think, when you need them, cerclage wires around the proximal femur are pretty useful, but you’ve got to make sure you’ve got a good reduction. If you leave a large fracture gap, you can have trouble with healing, and you want to be careful not to make too many passes cuz that can lead to the stripping of the bone fragments, which can lead to a non-union.