Reducing Subtrochanteric Femur Fractures

Abstract

Treatment of subtrochanteric fracture remains a challenge, but evolution of strategy has allowed for reliable results with low complications. Although several fixation options exist, reamed, antegrade intramedullary nailing (IMN) has evolved as the standard of care. Cognizant effort to achieve anatomic reduction before IMN passage allows for desired outcomes. Several reduction techniques can be used to overcome the deforming forces present in the proximal femur to allow for proper IMN placement. The purpose of this article is to review the tips, tricks, and pitfalls to avoid in the treatment of subtrochanteric femur fractures with IMN.

Common complications in hip fracture surgery: Tips/tricks and solutions to avoid them

“…Subtrochanteric fracture reduction poses specific difficulties due to the deforming forces exerted in the proximal and distal fragments. In most of the cases supine position in the fracture table with ipsilateral foot traction is preferable to floppy lateral position with free prepped lower extremity [52]. Occasionally distal femoral skeletal traction might be more beneficial instead of foot traction.…”

“…Along with techniques previously described for intertrochanteric fracture reduction additional techniques to ease the insertion of the nail in the correct corridor is the use of poller screws to the proximal short segment, reaming the proximal fragment with flexible reamers using the rigid over-reamer only for the enlargement of the entry point, use of the ''reduction tool'' to manipulate the proximal fragment and direct the guide wire away from the medial cortex (Figs. 7 and 8) [52,[72][73][74]. Clamp (collinear and pointed) or wire assisted reduction and are also useful techniques with recent evidence in the literature suggesting good results provided that are carefully used without disturbing the periosteal blood supply [75][76][77][78][79].…”

“…Poor vascularity and inherent low healing potential, increased stress concentration, significant deforming forces that predispose to malreduction are unique characteristics of the subtrochanteric area and have been recognised as aetiologic factors to nonunion. Additionally medial cortex comminution and poor fracture reduction have and been associated with problematic healing of subtrochanteric fractures [52].…”

Study of management of subtrochanteric fractures of femur with reconstruction nail

“…2 Intramedullary nailing has developed as the best method of subtrochanteric fracture fixation and can lead to reliable reproducible results. 10 Reconstruction or cephalomedullary nails are specialized, antegrade, femoral, intramedullary nails designed to provide fixation into the femoral head and neck for selected, complex, proximal-femoral fractures. 11 Reconstruction intramedullary nails are the preferred design because the cephalomedullary component increases device-to-bone contact points in the proximal fracture fragment.…”

Role of percutaneous cerclage wire in the management of subtrochanteric fractures treated with intramedullary nails

“…Decreased contact area, less vascularity of cortical bone, and strong deforming muscular forces acting in this region further add to the woes. 1 , 2 …”