Subtrochanteric fractures - current treatment, pearls and pitfalls

Søren Kring AOT Advanced Principles Course

Learning outcomes

• Define subtrochanteric fracture and biomechanical

characteristics

• Determine factors that influence decision making

• Outline surgical reduction techniques

• Outline surgical fixation techniques (plating, fixed-angle

devices, IM nailing)

• Contrast outcomes and complications with plate fixation

versus IM nailing

Subtrochanteric fractures— main classification systems

Classification

Ligger mellem 31A og 32 frakturerne

Fracture anatomy

Understanding the fracture pattern and its

inherent deformity is a key to success

Counteract deforming forces during fracture

reduction and fixation

Biomechanics

Tensile

forces

Compressive

forces

High bending loads and lack of medial support

Biomechanics

Our implants must be

mechanically strong and

tolerate bending forces

Current treatment options

• Conservative/traction

• External fixation

• Internal fixation

– Plates

– IM nails

Plating

• Blade

Plating

• Blade

• Locking Plate

Plating

• Blade

• Locking Plate

• DHS/SHS

Nailing

• Nails with or without

circumferential wires

Surgical technique

• Positioning ( )

• Reduction

• Proximal Fragment: • Gluteus medius + Iliopsoas

• Distal Fragment: • Adductors

Surgical technique

Deforming forces?

Surgical technique

Satisfied?!

Surgical technique

Better?

Entry point

• Femoral nailing with excessively

medial starting point

– Compromises vascularity of head

– Produces a stress riser in the neck

of the femur

• A lateral portal directs nail toward

medial cortex

Varus angulation

Medial comminution

compromising fixation

• RTFM!

NB

Entry point

Check your guidewire in AP and

Lateral before reaming!

Nails versus Plates

Miedel 2005

Sadowski 2002

Ekstrom 2007

Pooled RR 0.29 (0.06-1.33)

Study of subtrochanteric fractures of the femur—plates versus IM nails

Surgical decision making—fracture pattern

• Plates or nails are both

good options

• Trochanteric extensions

may favor plating

"Simple" fractures

• Favor nailing

• If you plate, use a

strong plate and

”biologic” techniques

"Complex" fractures

Surgical decision making—fracture pattern

Plate or nail?

Take home messages

• Analyze the Fracture • Stable/Unstable

• Simple/Complex

• Plan A and B!

• Plate or Nail?

• Positioning and Reduction • Open/Closed

• Deforming Forces

• Reduction before reaming/nail insertion • Reduction Forceps etc.

• Circumferential wires

• RTFM • Entry point

• Procedure