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Duke Orthopaedics
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Wheeless' Textbook of Orthopaedics

Proximal Femoral Shaft Fractures


- See:  - Subtrochanteric Fractures

- Discussion:
    - failure of nail to fill IM canal of either the proximal or distal fragment, may lead to postoperative instability;
    - tend to migrate into a varus deformity
    - requires abduction and traction for reduction;
    - tends to have an accentuated anterior bow;
    - internal rotation tends to improve this;
    - proximal 1/3 frx tend to angulate in varus w/ pt supine on table, & adjustments in pt positioning including switching to lateral position may be necessary;

- Indications for IM Nail in Proximal Frx:
    - consider nail if frx is 2.5 cm distal to lesser troch, or even more proximal fractures if the lesser trochanter is intact;
    - IM nails are well suited for proximal 1/3 shaft frx & subtrochanteric frx in which lesser trochanter is not comminuted off proximal femur;
    - if oblique bolt gains good purchase on medial cortex around lesser trochanter, excellent stability of the fracture is achieved;
    - femoral recon nails are required w/ comminution of the lesser troch;

- Reduction:
    - in subtrochanteric fractures, esp when the lesser trochanter is still attached to the proximal fragment, reduction can be achieved only be extreme
              abduction and external rotation of the leg;
    - consider placing a Steiman pin percutaneously into greater trochanter to act as a handle & thereby reduces frx much easier intraoperatively;
    - consider use of the Synthese trochanteric reduction clamp;

- Nail Insertion:
    - an accurate insertional point for the nail is critical;
    - Kuntscher among many, have advocated insertional point lateral to tip of greater trochanter to avoid risks of intra-capsular infection, AVN, and iatrogenic femoral neck fracture;
    - lateral insertion point however, may result in comminution of medial femoral cortex of proximal frag, esp in more proximal fractures;
    - lateral entry hole position (ie, in greater troch), will contribute to varus deformity;
          - this tends to be more common with the supine position;
    - note that in proximal fractures the proximal fragment is pulled into flexion, abduction, and external rotation;
          - common pitfall is to place the entry hole too far anterior, which will result in posterior comminution




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

Last updated by Data Trace Staff on Monday, April 29, 2013 10:39 am