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Duke Orthopaedics
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Wheeless' Textbook of Orthopaedics

IM Nailing for Subtrochanteric Frx


- Discussion
     - IM nailing of Intertrochanteric fractures
     - Synthes Trauma Menu / Proximal Femoral Products
     - nails designed for trochanteric entry and rigid fixation into the femoral head are optimally used;
     - indications:
            - interlocking nails have been used for subtroch frx when lesser trochanter remains attached to the proximal fragment;
                   - depending upon pattern of frx, its comminution, & shape of medullary canal, frx > 2 cm below lesser troch may be fixed w/ standard nail;
                   - when lesser troch is fractured, reconstruction nail w/ femoral head and neck fixation is required;
     - risks of IM nailing:
            - varus angulation:
                   - varus mal-alignment must be avoided in the initial stabilisation of subtrochanteric fractures.
                   - in frxs involving subtrochanteric region, medullary canal & trochanteric area do not provide good stable purchase on proximal fragment;
                          - this results in varus angulation of the proximal fragment and, frequent  rotational instability of the distal fragment;
                          - this is particularly true in high subtrochanteric fractures;
                   - be aware of pending non union and hardware failure;
                          - distal locking screw failure is predictive of future fracture non-union and nail breakage
                   - references:
                          - Avoiding varus malreduction during cephalomedullary nailing of intertrochanteric hip fractures 
                          - Subtrochanteric fracture non-unions with implant failure managed with the "Diamond" concept
            - iatrogenic fracture of proximal fragment:
                   - some restrict IM nailing for fractures w/ an intact ring of cortical bone on proximal fragment 2 cm below the lesser trochanter;
                   - some will insert the nail even if frx is up to proximal edge of trochanter;
                   - in either case, great care must be taken not to shatter the proximal fragment during nail insertion;
                   - w/ significant flexion of the proximal fragment, consider open reduction prior to nail insertion;
                   - if the proximal fragment does fracture during the nailing, all good options for fixation are lost;

- Technical Considerations:
    - IM hip screw for peritrochanteric fractures
    - IM nail in proximal femoral shaft frx
    - technique of IM nailing
    - nail length and diameter:
           - it is important to estimate length of proximal diaphyseal fragment on lateral view, becuase flexion foreshortens it on AP view;
           - consider insertion of a smaller diameter flexibile nail (Synthese titanium) to help avoid shattering the proximal fragment during nail insertion;
                  - overreaming the canal will help avoid fracturing the proximal fragment;
    - reduction: need to reduce calcar avoid varus and avoid hip flexion;
           - note that the proximal fragment is often severely flexed which can complicate the reduction, and may increase the chance of fracturing the proximal fragment;
           - w/ significant flexion of the proximal fragment, consider open reduction prior to nail insertion;
           - direct clamp fixation is the most straight forward technique;
           - blocking screws:
                  - lateral to medial blocking (Poller) screw is inserted dorsal to the desired path of the nail in the proximal fragment in order to help adress flexion deformity;
                  - second screw in an anterior to posterior direction over the medial aspect of the proximal end cortex (medial to desired direction of nail);

           - references:
                   - Clamp-Assisted Reduction of High Subtrochanteric Fractures of the Femur
                   - Clamp-assisted reduction of high subtrochanteric fractures of the femur: surgical technique.
                   - Subtrochanteric hip fractures treated with cerclage cables and long cephalomedullary nails: A review of 17 consecutive cases over 2 years.
                   - Functional and radiographic outcomes of intertrochanteric hip fractures treated with calcar reduction, compression, and trochanteric entry nailing.
                   - Comparison of reduction methods in intramedullary nailing of subtrochanteric femoral fractures
                   - "Subtrochanteric Fractures: Treatment with cerclage wire and long intramedullary nail" 
                   - Use of blocking screws in intramedullary fixation of subtrochanteric fractures.
                   - Techniques of Obtaining and Maintaining Reduction During Nailing of Femur Fractures
                   - Open reduction and intramedullary stabilisation of subtrochanteric femur fractures: A retrospective study of 56 cases

    - entry point:
                       - w/ a trochanteric entry nail, start slightly medial to the specific tip of the greater trochanter;
                       - lateral entry will end up causing a high lag-screw position in the femoral head (leads to cut out)
                       - lateral entry will end up causing the fracture to reduce into varus (leads to non union and or malunion);
                       - entry thru piriformis fossa risks shattering proximal fragement, especially in cases where frx procedes close to piriformis fossa;
                       - difficult starting point:
                               - rongeur is used at the starting point to remove medial bone to the anterolateral piriformis fossa to avoid varus
                                        malreduction with passage of the nail;

                       - references:
                              - A critical analysis of the eccentric starting point for trochanteric intramedullary femoral nailing
     - reaming
           - do not ream an unreduced fracture;
           - reaming an unreduced fracture in this situation will help reenforce the malreduction after the nail is inserted;
    - proximal fixation:
           - if there is any risk of propagating a fracture into the piriformis fossa, or if there is any risk of the proximal fragment slipping into varus, consider use of prophylactic cerclage wires;
    - distal fixation: (interlocking screws)
    - adjunctive fixation:
          - w/ long spiral or long oblique configurations, or with wide open canals look for inadequate reduction at fracture site; 
          - place a single cerclage cable around the fracture through a lateral incision;

     - case example: this unfortunate prisoner sustained a subtrochanteric frx, as well as having AVN;

           

    - case example: reverse obliquity frx;
             



Subtrochanteric fractures treated with interlocking nailing.

Subtrochanteric fractures of the femur. Results of treatment by interlocking nailing.

Reconstruction nailing for pathological subtrochanteric fractures with coexisting femoral shaft metastases.

Unreamed femoral nail with spiral blade in subtrochanteric fractures: experience of 55 cases.



Iatrogenic subtrochanteric fracture: a complication of Zickel nails.

Prophylactic femoral stabilization with the Zickel nail by closed technique.

Intraoperative and postoperative subtrochanteric fracture of the femur associated with removal of the Zickel nail.

The Gamma nail for peritrochanteric fractures.

Subtrochanteric fracture of the femur. Fixation using the Zickel nail

Gamma nails and dynamic hip screws for peritrochanteric fractures. A randomised prospective study in elderly patients.

A biomechanical evaluation of the Gamma nail.
Ensuring Correct Placement of Proximal Fixation in Reconstruction Intramedullary Nailing for Subtrochanteric Femur Fractures



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Monday, February 10, 2014 11:19 am