Challenges in Subtrochanteric Femur Fracture Management: A Case Report of Inappropriate Implant Choice Leading to Fixation Failure and Update on Management Options
Asian Journal of Orthopaedic Research,
Subtrochanteric fractures of the femur remains one of the most challenging fractures encountered by orthopaedic surgeons. They account for 10 to 15% of all hip fractures. Subtrochanteric region of the femur is defined as the proximal femoral shaft located within 5 cm of the lesser trochanter. It is common in older patients after low energy trauma along with osteoporosis and in younger patients with high energy trauma. The management of subtrochanteric fractures is challenging because of the inherent instability of the fracture pattern. Fractures to this area can result in significant complications and poor clinical outcomes such as failure of fixation, shortening, malrotation and non-union if not managed properly and inappropriate choice of implant was used. We are presenting a case report of an elderly lady with history of alleged fall in bathroom at home and sustained closed left subtrochanteric femur fracture. She was initially planned for dynamic hip screw fixation however choice of implant was changed to interlocking femoral nail during preoperative census meeting. Patient underwent interlocking nail of left femur. Intraoperative reduction was satisfactory. However, on day 1 postoperative was noted that distal femur was externally rotated and proximal femoral fragment displaced in valgus direction. There was a failure of fixation and patient was counselled for operation in which patient’s family declined and opted for conservative management. The purpose of this presentation is to highlight the challenges, examine the various treatment modalities and implant options in treatment of subtrochanteric femur fracture for optimal postoperative outcome.
- Subtrochanteric fractures
- hip fractures
- proximal femoral fractures
- trochanteric fractures
- muscle forces
How to Cite
Subtrochanteric fractures of femur treated with Zickel nail. Archortho. Bleg. 1994;60:129-33.
Canale ST, Beaty JH, Fractures and Dislocations of the Hip. In: Lavelle DG Editor. Campbell’s operative orthopaedics. 11th ed. Mosby Elsevier. 2007;3262- 70.
Jiang LS, Shen L, Dai LY. Intramedullary fixation of Subtrochanteric fractures with a long proximal femoral nail or a gamma nail: Technical notes and preliminary results. Ann Acad Med Singapore. 2007;36:821-26.
Russell TA, Taylor JC. Skeletal Trauma. Philadelphia: WB Saunders. 1992;2:1499–501.
Gupta RK, Sangwan K, Kamboj P, Punia SS, Walecha P. Unstable trochanteric fractur: the role of lateral wall reconstruction. Int Orthop. 2010;34(1): 125-129.
Kyle RF, Cabanela ME, Russel TA. Fractures of the proximal part of the femur. Inst course lect. 1995;44:227-53.
Schipper IB, Marti RK, Van der Werken C. Unstable trochanteric femoral fractures: extramedullary or intramedullary fixation. Review of literature, Injury. 2004;35:142-51.
Giannoudis PV. Surgical priorities in damage control in polytrauma, J Bone Joint Surg Br. 2003;85:478-83.
Parker M, Johansen A. Hip fracture. BMJ. 2006;333:27–30.
Conn KS, Parker MJ. Undisplaced intracapsular hip fractures: Results of internal fixation in 375 patients. Clin Orthop Relat Res. 2004;249–254.
Parker MJ, Handoll HH. Conservative versus operative treatment for extracapsular hip fractures. Cochrane Database Syst Rev. CD000337; 2000.
British Orthopaedic Association. The care of patients with fragility fractures. Currie, C., editor. British Orthopaedic Association. London; 2007.
Zuckerman JD. Hip fracture. N Engl J Med. 1996;334:1519–1525.
Ravinath T, Madhan J, Kartavya C, Ravi W A, Sabarish K, et al. Surgical Management of Proximal Femoral Fractures by Proximal Femoral Nailing-An Institutional Experience. Ortho Res Online J. 2019;5(2):OPROJ.000610.
Chou DT, Taylor AM, Boulton C, Moran CG. Reverse oblique intertrochanteric femoral fractures treated with the intramedullary hip screw (IMHS). Injury. 2012;43(6):817-821.
Cornell CN. Internal fracture fixation in patients with osteoporosis. J Am Acad Orthop Surg. 2003;11:109‑19.
Sadowski C, Lubbeke A, Saudan M, Riand N, Stern R, Hoffmeyer P. Treatment of re-verse oblique and transverse intertrochanteric fractures with use of an intramedullary nail or a 95 degrees screw-plate: a prospective, randomized study. J Bone Joint Surg Am. 2002;84(3):372-381.
Utrilla AL, Reig JS, Munoz FM, Tufanisco CB. Trochanteric gamma nail and compres¬sion hip screw for trochanteric fractures: a randomized, prospective, comparative study in 210 elderly patients with a new design of the gamma nail. J Orthop Trauma. 2005;19(4):229-233.
Platzer P, Thalhammer G, Wozasek GE, Vecsei V. Femoral shortening after surgical treatment of trochanteric fractures in nonge¬riatric patients. J Trauma. 2008;64(4):982-989.
Mavrogenis A, Panagopoulos G, Megaloikonomos P, Igoumenou V, Galanopoulos I, Vottis C, Karabinas P, Koulouvaris P, Kontogeorgakos V, Vlamis J, Papagelopoulos P. Complications after hip nailing for fractures. Orthopaedics. 2016;39:e108-e116.
National Institute for Health and Clini¬cal Excellence. The management of hip fracture in adults (clinical guideline CG124). Available:http://guidance.nice.org.uk/CG124
Turner IG, Rice GN. Comparison of bone screw holding strength in healthy bovine and osteoporotic human cancellous bone. Clin Mater. 1992;9:105‑7.
Klinger HM, Baums HM, Eckert M, Neugebauer R. A comparative study of unstable per and intertrochanteric femoral fractures with DHS and PFN and TSP. Zantralbl Chir. 2005;130(4):301-306.
Chakraborty MK, Thapa P. Fixation of subtrochanteric fracture of the femur: our experience. J Clin Diag Research. 2012;2: 76-80.
Yarnold BD. Hip fracture: Caring for a fragile population. Arn J Nurs. 1999;99:36-41.
Haentjens P, Autier P, Barette M, Venken K, Vanderschueren D, Boonen S. Survival and functional outcome according to hip fracture type: A one-year prospective cohort study in elderly women with an intertrochanteric or femoral neck fracture. Bone. 2007;41(6):958–964.
Leibson CL, Tosteson ANA, Gabriel SE, Ransom JE, Melton LJ III. Mortality, disability and nursing home use for persons with and without hip fracture: A population-based study. Journal of the American Geriatrics Society. 2002;50(10): 1644–1650.
Hershkovitz Z. Kalandariov, Hermush V, Weiss R, Brill S. Factors affecting short-term rehabilitation outcomes of disabled elderly patients with proximal hip fracture. Archives of Physical Medicine and Rehabilitation. 2007;88(7):916–921.
Lumbers M, Driver LT, Howland RJ, Older MWJ, Williams CM. Nutritional status and clinical outcome in elderly female surgical orthopaedic patients. Clinical Nutrition. 1996;15(3):101–107.
Koval KJ, Skovron ML, Polatsch D, Aharonoff GB, Zuckerman JD. Dependency after hip fracture in geriatric patients: A study of predictive factors. Journal of Orthopaedic Trauma. 1996;10(8):531–535.
Radosavljevic N. The effects of balneo-physical therapy on the quality of life of patients who underwent surgery for hip fractures. PhD thesis. Faculty of Medicine, University of Belgrade; 2013.
Momsen AM, Rasmussen JO, Nielsen CV, Iversen MD, Lund H. Multidisciplinary team care in rehabilitation: An overview of reviews. J Rehabil Med. 2012;44:901-912.
Gregersen M, Morch MM, Hougaard K, Damsgaard EM. Geriatric intervention in elderly patients with hip fracture in an ortopedic ward. J Inj Violence Res. 2012;4:45-51.
Lindelöf N, Littbrand H, Lindström B, Nyberg L. Weighted belt exercise for frail older women following hip fracture: a single subject design. Advances in Physiotherapy. 2002;4:54-64.
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