Nailing Proximal Femur Fractures

Abstract

Fractures of the proximal femur can be a challenging treatment dilemma for the orthopaedic surgeon. Complex mechanical forces and anatomic variables in this region combine to make treatment of these injuries difficult and can often result in serious complications. The decision to treat this fracture with an intramedullary device requires the surgeon evaluate many variables in the context of the specific fracture pattern. These include the choice of implant, starting portal location, and positioning of the patient. Assessment of the fracture pattern and its 3 dimensional orientation is usually accomplished with the aid of advanced imaging. The patient's physiological status, body habitus and bone quality must also be incorporated into the treatment algorithm. We review these issues and how they factor into the decision making process in order to develop a successful operative plan for these injuries. We will review the starting portal selection, reduction and insertion techniques and examine options for proximal locking screw configurations.

Does using different entrance points for intramedullary nails affect clinical outcomes for femoral shaft fractures? A retrospective clinical comparative study

“…By contrast, only one open reduction was performed among the 9 supraisthmal fractures in the GTE group. In the case of supraisthmal fractures, if an appropriate reduction with traction prior to nail entrance cannot be obtained, an open reduction followed by reduction with clamps or additional cables will ease the introduction of the nail and decrease the risk for an iatrogenic fracture [16]. In this study, no iatrogenic fractures were detected among isthmal and infra-isthmal fractures indicating that an intact long proximal segment prevents iatrogenic communition at the entrance point.…”

“…When choosing the appropriate starting site for these injuries, the surgeon should consider many potential factors, all of which contribute to appropriate portal location. Fully understanding all subtleties related to each particular starting point will help the surgeon individualize the entry portal for each fracture [16]. In this study, supraisthmal fractures constituted the majority of the TFE group, with open reductions performed in 28 of 40 supraisthmal fractures in this group.…”

“…3). In such cases we now use a short locking nail introduced from the hole aiming to the lesser trochanter, as recommended by Nicalaou et al [16].…”

Management of Subtrochanteric Proximal Femur Fractures: A Review of Recent Literature

“…In terms of the proximal entry point for an anterograde intramedullary nailing, the surgeon has a choice of a piriformis start point and a greater trochanteric start point. Advantages of the piriformis start point include reduction of the incidence of varus malreduction and medial cortex injury with reaming [ 17 ]. Disadvantages are difficulty in obtaining a proper start point in obese patients, patients with hypertrophic short external rotators, or greater trochanter overhang.…”