Subtrochanteric Fractures of the Femur Marvin L.
Shelton,
MD
Subtrochanteric fractures of the femur comprise only 5% to 7% of hip fractures, but are important because of the difficulty in management. They combine the problem of instability to varus deformation common to comminuted intertrochanteric fractures and the problem of delayed union common to diaphysial fractures of the femur. While the benefits of open reduction and internal fixation in decreasing morbidity and mortality have been well established, formidable operative complications have occurred when this fracture is treated like an intertrochanteric fracture. Improved results have been obtained by utilizing a fixation device that can control the intertrochanteric instability and that has sufficient strength to withstand deforming
forces that may be present for up to a year while the fracture is uniting. Bone grafting has been found very useful in shortening the overall period of healing.
fracture of the femur has received con¬ siderable attention in the surgical literature in the two decades. It represents 5% to 7% of fractures about the hip but, unlike subcapital fracture, shows no predilection for females. Prior to the early 1950s, when open treatment for fractures of the hip and femoral shaft came into wide acceptance, the problems encountered with closed management of this fracture were well recog¬ nized. Uncontrolled flexion, abduction, and external rota¬ tion of the proximal fragment made alignment with trac¬ tion or plaster difficult and uncertain. Comminution, especially of the medial cortex, made varus deformity, shortening, and delayed union the rule rather than the ex¬ ception. A significant contribution was made by Russell Hibbs as a young resident, when he presented a treatise before the Academy of Medicine in New York describing the principle of bringing the distal fragment into align¬ ment with the proximal fragment to achieve reduction. This effort merited a gold medal. Despite meticulous at¬ tention to traction details, however, all of the problems could not be solved, and, frequently, interposed tissue proved an absolute barrier to union. As a natural evolution, beginning in the early 1950s, a greater number of surgeons undertook to treat this frac¬ ture by open reduction and internal fixation. Unfortu¬ nately, it was not long before reports appeared indicating a substantial percentage of mechanical failures requiring reoperation. At the same time, several detailed studies on the results of operative treatment of intertrochanteric fractures were published that identified certain fracture types as being unstable after reduction and fixation with the usual blade plate devices. These reports increased our appreciation of the complex biomechanical forces oper¬ ating around the hip joint and the upper part of the fem-
Subtrochanteric past
Accepted for publication July 25, 1974. From the Department of Orthopedic Surgery, Harlem Hospital Center and Columbia University College of Physicians and Surgeons, New York. Reprint requests to Department of Orthopedic Surgery, Harlem Hospital Center, 506 Lenox Ave, New York, NY 10037 (Dr. Shelton).
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Watson et al,'- in their 1964 study of 100 subtrochanteric fractures, classified their patients by fracture cause and described the fractures numerically by a rather compli¬ cated system. Their method required accurate measure¬ ments that
are often difficult on poor quality x-ray films. The authors did not relate the classification to the method of treatment or to the results. Fielding and Magliaio,1 in 1966, proposed a simple classification in which three 2.5-cm segments were made by a series of four transverse lines beginning at the top of the lesser trochanter (Fig 2). They believed that this 2.5cm zone was an area of stress concentration, based on the work of Koch.4 It seems that the bone would fracture more commonly where there is an area of stress concentration. Since intertrochanteric fractures are far more common than subtrochanteric fractures, this concept is open to question. Their report indicated that they^ could predict the result of treatment to a large degree based on this classification, noting that the incidence of nonunion in¬ creased strikingly between type 1 and type 3 fractures. They recognized the difficulty in applying this classifica¬ tion to oblique and comminuted fractures. The typing of comminuted fractures is somewhat arbitrary and variable among different observers.
ANATOMY AND BIOMECHANICS
Fig 1.—Boyd and Griffin' classi¬ fication of trochanteric fractures.
oral shaft. As a result, within the last five years, impor¬ tant advances have been made in the management of this fracture and these have resulted in an overall improve¬ ment in the end results. Nevertheless, a number of prob¬ lems remain to be solved. CLASSIFICATION
Fractures of the femur that occur in the 7.6-cm zone be¬ top of the lesser trochanter and 5 cm below the lesser trochanter are commonly referred to as subtrochanteric fractures. While many are simple, rela¬ tively transversely oriented, and easy to describe anatom¬ ically, other fractures are comminuted with major compo¬ nents extending obliquely upward toward the greater trochanter and down into the upper third of the femur. This latter type of fracture has been classified inconsist¬ ently, appearing in some reports as pertrochanteric or as a shaft fracture rather than a subtrochanteric fracture. The classificiation proposed by Boyd and Griffin' origi¬ nally in 1949 has been useful because of the great fre¬ quency with which the mixed type of fracture occurs. Types 1 and 2 are pure intertrochanteric fractures, type 3 is pure subtrochanteric, and type 4 is subtrochanteric but extends up into the trochanteric area and down into the upper part of the femoral shaft (Fig 1). tween the level of the
The femur has been studied extensively from the ana¬ tomical, mechanical, and biomechanical viewpoints. Nils Rydell·' summarized many important observations in a re¬ cent review. He stressed that the hip resembles a ball-andsocket type joint but is more complex due to the limited contact area. The neck in cross section changed in shape from cylindrical near the head to elliptical near the base, with a gradual increase in cortical thickness. The elliptical shape developed after birth under load bearing, and the cortical thickening is much more marked along the infe¬ rior or medial cortex. The angles formed by the femoral neck and shaft are crucial to analysis of the forces acting on the upper part of the femur. Backman" described them in 1957 as illustrated in Fig 3. The important axes, planes, and angles seem to be (1) the cervical axis OHC; (2) the ideal axis AOK; (3) the frontal plane of the femur AOKD; (4) the anteversion plane AOKC; (5) the antetorsion angle T, between planes AOKB and AOKC; (6) the cervical diaphysial angle between OHC and OD; (7) angle A, formed by ADK and AOK (the axis OKD, similar to the femur, forms a ventroconvex curve that is unsatisfactory for geometrical calculations, so the ideal axis AOK is used in most instances); and (8) the principal plane, which is laid through the head and neck coincident with the cervi¬ cal axis and the major axis of the section area. This last plane intercepts the femoral shaft medially and distally just anterior to the lesser trochanter. It forms an angle with the cervical diaphysial plane of 25° and with the an¬ tetorsion plane of 15°. These angles and planes have been interpreted mechanically in several studies. The cervical diaphysial angle is about 150° at birth and, if subjected to normal loading, will decrease to about 130° in adults. Like¬ wise, paresis of the abductor muscles causes the center of
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gravity to shift over the head of the femur in gait, making
the load on the femur more vertical. The femoral neck de¬ in a valgus position under these circumstances. The ventral deviation of the neck begins early in fetal life and increases until delivery, probably depending on torsion of the upper part of the femur. It amounts to 35° at birth and decreases to around 14° at the completion of bony growth. Most of this decrease occurs before the age of 8 years. The measurement and calculation of the forces acting on the upper part of the femur and femoral head have brought to light several important facts. RydelP inserted a prosthetic device provided with strain gauges in the femoral head to measure forces acting in the hip. He found that standing on one leg created a force about the hip joint of about 2% times body weight. The direction of the force was parallel to the principal plane and to the tra¬ becular system of the femoral head. With walking, the force on the hip during the stance phase was relatively low because the body rolled over the femoral head and the abductors did not have to work. During the swing phase, the force was larger than expected because of the muscu¬ lar activity required to accelerate and decelerate the leg. While running, forces of 4% to five times body weight were recorded. Walking upstairs increased the load on the hip to about three times body weight, while walking downstairs loaded the hip about the same or less than level walking (slightly more than body weight). When the leg was completely off the floor, the force on that hip was one half times body weight, but flexion to 90° at the hip and knee increased the force to almost body weight. In bed, straight leg raising gave a force of llA times body weight in the other hip. Standing on one leg with a cane in the opposite hand reduced the force to slightly more than body weight. Sitting put very little force on the hip. Rydell concluded that it was difficult to reduce the load on the hip and the most effective method was a cane in the opposite hand.
velops
Fig 2.—Fielding and Magliato' clas¬ sification of subtrochanteric fractures.
INCIDENCE
TREATMENT
Subtrochanteric fractures have a reported incidence of between 5% and 29% of trochanteric fractures.1-3 Authors reporting the lower incidences generally exclude fractures with comminution extending up into the trochanteric area and down the shaft. Boyd and Anderson7 found that 12% of type 1 and 2 intertrochanteric fractures were converted to type 3 subtrochanteric fractures by intraoperative frac¬ ture around the nail hole. Subtrochanteric fractures occur in all age groups. In the elderly, they generally are related to natural thinning of the bone in the upper part of the femur; in the young, they are primarily due to violent trauma; and they occur at any age when a disease state weakens bone structure, ie, ma¬ lignant neoplasms, osteomalacia, Paget disease, fibrous dysplasis. While females predominate in the incidence of subcapital fractures, they show no predominance in inter¬ trochanteric fractures. In the experience at Harlem Hos¬ pital Center, where violent trauma is the most common cause, males predominate (68%).
The question of the method of treatment of choice for this injury is not an easy one, partly because there are no recent references to results of nonoperative treatment of subtrochanteric fractures. It is a fair assumption that the mortality is basically the same for subtrochanteric frac¬ tures and intertrochanteric fractures occurring in pa¬ tients of comparable age. The reported mortality for nonoperatively treated intertrochanteric fractures ranged from 3% to 66%.s-'2 Most reports of surgically treated pa¬ tients indicate a mortality of approximately 20%.S,MS-15 Unless there is some bias favoring the operative cases, viz, being the better risk patients, this would tend to favor open treatment. While open treatment usually will shorten hospitalization, it seems unwise to use a shortened hospital stay and early ambulation as the sole grounds for advising operative treatment. John Charnley,'" long an advocate of closed treatment for most fractures, has con¬ ceded that the operative treatment of intertrochanteric fractures is superior to closed management. Most authors
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and managed preoperatively and postoperatively. The brittleness of the elderly patient is generally appreciated; however, the unwary surgeon may underrate the risks in¬ volved by failing to appreciate the magnitude of the trauma in the younger patient with a subtrochanteric fracture. Control of hypovolemia and its sequels and rec¬ ognition of associated injuries are essential to avoid post¬ operative complications. The operative procedure must also provide sufficient fixation to allow early range of hip and knee joint motion, permit ambulation with support, and carry with it a low risk of infection and death. The re¬ ported mortality after operative treatment of subtro¬ chanteric fractures varies between 10% and 30% with an average of 20% and serves as a reminder that these are se¬ rious injuries.'1" It is quite sobering that these figures have not changed during the past 15 years despite im¬ provements in the methods of fixation. SUBTROCHANTERIC FRACTURES IN CHILDREN Plaster Immobilization
Fig 3.—Critical angles and planes of up¬ part of femur. (Adapted from Backman.")
per
who have studied the mortality after hip fracture believe that the overall mortality is related more to the general health, both physical and mental, of the patient and to the skill and adequacy of nursing and supportive medical care, than it is to whether operative or nonoperative treatment is rendered. Fitts et al'7 have shown that the survival rate for a patient with an intertrochanteric fracture is the same as for the general population six months after in¬ jury. One cannot dismiss closed treatment lightly, partic¬ ularly in view of reports by Horn and Wang12 from Peking who treated 170 patients with intertrochanteric fractures in traction with a-5.3% mortality with no reported inci¬ dence of pneumonia, decubitus ulcers, or pulmonary em¬ boli and no nonunions. On the other hand, we were naturally impressed by work of men such as Sevitt1" in England, who examined 154 patients with femoral neck fractures and found 27% had clinically detectable venous thrombosis and 7.9% de¬ veloped fatal pulmonary emboli. This certainly suggests that pulmonary embolism is a substantial risk for a pa¬ tient immobilized for a subtrochanteric fracture. Pre¬ vention of pulmonary embolism after hip surgery can be effected by administration of antithrombotic agents.19 Yet, if one then considers the problems of prophylactic anticoagulation, particularly the interference with fracture healing and the prolonged hospitalization, especially in crowded urban centers where beds are in short supply and hospital charges astronomically high, then operative treatment does seem to be more advantageous. It is clear, however, that operative treatment should only be carried out in patients who are carefully evaluated
Plaster immobilization is the treatment of choice in in¬ fancy and can be used successfully for undisplaced, stable fractures in the older child and young adult. The major drawbacks of this treatment are fracture deformity and prolonged hospitalization. Flexion, abduction, and slight external rotation of the involved thigh may help prevent deformity during the healing phase. A 3.8-cm hip spica should be used to control the pelvis. Skeletal Traction This method is frequently used and is the treatment of choice for displaced fractures in childhood. The main prob¬ lems are flexion, abduction, and external rotation of the proximal fragment, so the leg should be positioned with the hip and knee joint in 90° of flexion (90-90 position), with the traction pin placed through the distal part of the femur rather than the upper part of the tibia to prevent anterior subluxation of the knee. In the 90-90 position the iliopsoas is relaxed, diminishing the external rotation forces so that neutral rotation is usually satisfactory for reduction and alignment. The period of immobilization is quite variable. Some of the important factors concerning the rate of healing are the age of the patient, the level of the fracture, and whether anticoagulants are used. Frac¬ tures that are basically diaphysial in location usually will take longer and traction must be maintained in order to prevent deformity. Also, the accuracy of reduction must be greater in adults than in children and in diaphysial fractures than those more proximal because of the poor blood supply in the former instances. Anteroposterior and lateral roentgenograms are essential to evaluate the posi¬ tion of the fragments and progress of union. I have not seen a subtrochanteric fracture unite in traction in a pa¬ tient receiving anticoagulants. OPERATIVE TREATMENT and internal fixation is the most fre¬ method of treatment in this country. Most authors indicate inability to control the fracture de-
Open reduction quently employed
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formity,
the threat of
delayed union, and prolonged bed hospitalization as reasons for preferring open over closed treatment. Nail plate devices are most com¬ monly employed. Many surgeons did not appreciate the special problems of the subtrochanteric fracture until the report by Boyd and Anderson in 1961.7 In analyzing 100 fractures of the hip, they found that 20% were type 3, 9% rest and
type 4, and 12% of the types 1 and 2 were converted type 3 during the open reduction and internal fixation. Twenty-six percent of their subtrochanteric fractures were
to
needed
supplemental
fixation such
as
buttress
plates,
screws, and circumferential wire bands. The high failure rate of open treatment has been further documented by the reports of Watson et al,2 Aronsson," and, most re¬
cently, by Fielding and Magliaio1 who found the union ranged from 90% in type 1
4.—Unstable intertrochanteric fractures according Hughston22: (1) head fragment, (2) shaft, (3) lesser trochanter and portion of calcar, (4) posterior fragment including portion of greater trochanter.
Fig
to Dimon and
rate in 46 fractures studied
fractures to 66% in type 2 and 43% in type 2 subtrochan¬ teric fractures. All of these fractures were treated by Jew¬ ett nails with supplementation by anterior plates, cancellous screws, and primary bone grafting. As a group, 26% required additional surgery to obtain bony union. Watson et al2 reported on 100 subtrochanteric fractures and found 19 failures, mostly due to mechanical causes such as bending and breaking of the nail and plate or me¬ dial moderation of the shaft with penetration of nail through the head. Following these reports, stronger nails were introduced for fixation of these fractures in an attempt to overcome this cause of failure. Typical of these was the Holt nail2" reported in 1963, which can withstand static loads of 452 kg. Despite the increased metal strength, failures contin¬ ued to be reported due to cyclic loading and metal fatigue. It is interesting that most of these failures occurred be¬ tween three and 12 months after fixation at a time when most intertrochanteric fractures have healed. This points out the basic difference between intertrochanteric and subtrochanteric fractures, namely, a slower rate of heal¬ ing of the subtrochanteric fracture rather than any sub¬ stantial difference in the nature or magnitude of the forces operating at the fracture site. It became increas¬ ingly clear that diminishing the cyclic loading and in¬ creasing the rate of union would be necessary to eliminate these failures. Most authors have recommended achieving a more stable reduction to allow the fracture to support it¬ self rather than having the entire strain on the metallic fixation device as the most rational solution to this prob¬ lem. Similar fixation failures have been reported after open treatment of unstable intertrochanteric fractures, and several solutions have been suggested for this problem. Among the more widely accepted concepts is that of Sar¬ miento,2' which proposes that the reduction of the medial cortex is the key to fracture stability. He recommends an oblique osteotomy of the femoral shaft just below the lesser trochanter, an anatomical reduction of the medial cortices, and fixation with a 130° nail inserted at 90° into the neck of the femur to obtain a valgus reduction of the head and a more horizontal fracture line. This exact rela¬ tionship is difficult to obtain surgically and several of the
cases he illustrated showed some medial displacement of the shaft. One must be careful that the osteotomy does not result in excessive neck valgus because this will be as¬ sociated with a corresponding genu valgum deformity and may cause avascular necrosis of the femoral head. Dimon and Hughston22 believe that comminution is re¬ sponsible for unstable reductions, particularly when there is a lesser trochanteric fragment that includes a substan¬ tial portion of the medial cortex and a greater trochanter fragment that includes a substantial posterior fragment (Fig 4). They recommend performing a transverse os¬ teotomy at the level of the lesser trochanter and placing the medial spike of neck into the distal shaft. They also obtain a valgus reduction using a 150° Jewett nail and plate and stress contact between fragments medially to prevent collapse and metal failure. They expect 1.3- to 1.9cm shortening. Too much medial displacement may be a problem and lead to delayed union and plate breakage. Certain subtrochanteric fractures, ie, Boyd type 4 and Fielding type 1, have intertrochanteric components and tend to collapse into varus and bend the nail or penetrate the head. These solutions are helpful in their management but fail to adequately fix the fracture lines below the lesser trochanter. Even extra strong and extra long side plates tend to bend or break prior to fracture consoli¬ dation. None of the nail plates manufactured in this coun¬ try are recommended by the manufacturers for subtro¬ chanteric fractures. The Swiss Association for the Study of Internal Fix¬ ation (ASIF) technique, which requires anatomical reduc¬ tion or primary bone grafting and interfragmentary or longitudinal compression of each fracture fragment, has considerable appeal and is favored by many surgeons, but to me it seems ill suited for comminuted subtrochanteric fractures. Even when one is clever enough to reassemble the fragments, the weakness of the side plate and its sus¬ ceptibility to failure due to cyclic loading is disturbing. An alarming rate of failure has been noted when single-plate fixation has been used in fractures with the middle third of the femur, and I would anticipate that this would occur also with subtrochanteric fractures of the femur, partic¬ ularly if early weight bearing is instituted. Successes that
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Fig 5.—A 45-year-old man with Boyd 3 and Fielding 3 subtrochan¬ teric fractures three months after Zickel nailing with supplemental Parham bands; full weight bearing.
Fig 6.—A 45-year-old man with Boyd 4 subtrochanteric fracture immediately after nail plate fixation (left) and six months later (right) when plate broke despite crutch-protected ambulation. Frac¬ ture went on to heal without reoperation.
Fig 7.—Left, A 44-year-old woman with Boyd 4 and Fielding 3 sub¬ trochanteric fracture. Note flexed, abducted position of proximal fragment and medial position of lateral butterfly fragment; early weight bearing allowed. Right, At three months, when Parham bands were removed, there was clinical union.
Fig 8.—A 34-year-old man with Boyd 3 and Fielding 3 subtro¬ chanteric fracture at time of injury (left) and three months postinjury (right); weight bearing with crutches.
Fig 9.—Ninety-ninety distal femoral traction for controlling flexed, abducted, and externally rotated proximal fragment. Results of 37 Adult Subtrochanteric Fractures of the Femur Treated at Harlem Hospital Center, 1967 to 1973* Method of Treatment Zickel nail Zickel nail with supplemental fixation Nail plate Schneider nail KUntscher nail Rush pins
Nonoperative
Primary Union
Nonunion
_10
•
Includes 24 males and 13 females; average age, 53 years. There were four open reductions and three deaths.
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have been reported with this technique are probably at¬ tributable to the relatively rapid union that is possible when the fracture line is reduced to minimum width by
compression.
Intramedullary Nail Fixation
Intramedullary nailing has been recommended for many years for the transverse femoral fractures between 5 and 7.6 cm below the lesser trochanter. These fractures at the isthmus of the femur are usually rigidly fixed by an in¬ nail of proper size. Banks and Davis,2' Aufranc,24 and Aronoff et al21 were among the early reporters describing the superior results after intramedullary nail¬ ing of subtrochanteric fractures. They expanded the indi¬ cations somewhat to include certain comminuted fractures and those located a little closer to the lesser trochanter. Watson et al2 and Fielding26 have also cited the usefulness of intramedullary nail fixation for certain subtrochanteric fractures. Many surgeons, however, are justifiably reluc¬ tant to attempt nailing of a comminuted subtrochanteric fracture. Zickel,27 in 1967, reported on a new fixation device that combined the principles of intramedullary fixation of the femoral shaft with nail fixation in the neck to obtain bet¬ ter control of the proximal fragment. Credit for the origi¬ nal idea should probably be given to Küntscher, who re¬ ported a series of 100 pertrochanteric fractures treated with a Y nail in 1940.2S The Zickel device is contoured to achieve a valgus reduction and maintain apposition of the medial cortex. The expanded upper end of the intramedul¬ lary nail is perforated to accept a triflanged crossbar in¬ serted through the intramedullary nail and into the fem¬ oral neck. This provides superb control of the proximal part of the fragment. The intramedullary nail is also curved anteriorly to obtain three-point fixation in the shaft. This device lends itself well to supplemental inter¬ nal fixation with circumferential wire bands or Parham bands and does not require supplemental external plaster support (Fig 5). It appears to be particularly useful in con¬ junction with methyl methacrylate for pathological frac¬ tures2" and after resection of bone tumors in the subtro¬ chanteric area. Zickel's personal series is now more than 67 cases, with only one instance of metal breakage and failure of union. There are many hazards in performing this type of sur¬ gery that are inherent to any intramedullary nailing. No¬ table among these are exploding the shaft during inser¬ tion of the nail and exposure of the medullary canal to extensive infection should this occur postoperatively.
tramedullary
CURRENT TREATMENT AT HARLEM HOSPITAL CENTER
At Harlem Hospital Center between 1964 and 1970 we employed nail plate fixation for Boyd type 4 and Fielding type 1 and 2 fractures. We noted metal failure with the blade plate when we did not obtain a stable relationship between the medial cortex of the shaft and the interior neck of the proximal part of the fragment (Fig 6). Placing the fracture line under compression by tilting the head and neck into a valgus position, with or without os-
Fig 10.—A 62-year-old woman with comminuted segmental sub¬ trochanteric and femoral fracture. Extensive soft tissue avulsion of popliteal fossa prevented open reduction (left). Treated with long leg cast and tibial traction 20 hours per day and with weight bearing for four hours per day. Clinical union at 12 weeks (top right) and solid union with full weight bearing at 20 weeks (bottom right). our rate of successful unions, but we unable to allow early ambulation or weight bearing because of fear of hardware failure. Since 1967, we have favored the Zickel nail usually sup¬ plemented by circlage Parham bands for Boyd type 3 and Fielding type 3 fractures (Fig 7). We have used it also for Boyd type 4 and Fielding type 1 and 2 fractures since 1970. In several instances, intramedullary nailing using the Schneider device without the crossbar has been ade¬ quate (Fig 8). This is especially true of spiral fractures at the isthmus of the femur. We found that the routine use of primary iliac bone graft to replace any defects in the cortical tube to be helpful in achieving rapid union of these fractures. Fracture healing is still a race between union of the fracture and failure of the hardware. The pa¬ tients have been kept on crutches until the fracture healed and the Parham bands have been routinely removed after three months to prevent ring sequestra formation. They
teotomy, improved
were
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were always loose at that time, so we did not believe we lost any fixation. Our experiences are summarized in the Table. We have treated children with skeletal traction. If the lesser trochanter is intact and the fracture line is proxi¬ mal to the gluteus maximus insertion into the distal part of the fragment, the proximal part of the fragment gen¬ erally flexed, abducted, and externally rotated. We place the leg and thigh in a 90-90 position using femoral trac¬ tion to avoid injury and subluxation of the knee (Fig 9). Other types of subtrochanteric fractures not exhibiting this particular pattern of displacement initially have been treated with conventional tibial tubercle traction and bal¬ anced suspension. Overriding of at least 1 cm should be al¬ lowed in the children under 11 years because considerable
stimulation of
growth in the ipsilateral femur and tibia usually occurs. Recently, following an unpublished report by E. Dehne, MD, and B. Follette, MD, we managed an adult woman with skeletal traction by incorporating a tibial pin in a snug long leg cast and allowing her to ambulate four hours a day weight bearing on the fractured extremity. Union was achieved in 12 weeks and adequate reduction
maintained. We believe that this method is useful for Fielding type 3 fractures (Fig 10), especially when open reduction and internal fixation are not feasible. Fracture bracing, in my opinion, will be used more and more fre¬ quently in the future. With it, we can achieve most of the goals of surgery without the many risks of an invasive
procedure.
References 1. Boyd HB, Griffin LL: Classification and treatment of trochanteric fractures. Arch Surg 58:853-866, 1949. 2. Watson HK, Campbell RD, Wade PA: Classification, treatment, and complications of the adult subtrochanteric fracture. J Trauma 4:457-480, 1964. 3. Fielding JW, Magliato HJ: Subtrochanteric fractures. Surg Gynecol Obstet 122:555-560, 1966. 4. Koch JC: The laws of bone architecture. Am J Anat 21:177\x=req-\ 298, 1917. 5. Rydell NW: Forces acting on the femoral head-prosthesis: A study on strain gauge supplied prostheses in living persons. Acta Orthop Scand 37(suppl 88):1-132, 1966. 6. Backman S: The proximal end of the femur. Acta Radiol, suppl 146, pp 1-166, 1957. 7. Boyd HB, Anderson LD: Management of unstable trochanteric fractures. Surg Gynecol Obstet 112:663-668, 1961. 8. Kennedy JC, McFarlane RM, McLaughlin AD: The Moe plate in intertrochanteric fractures of the femur. J Bone Joint Surg 39\x=req-\
B:451-457, 1957. 9. Robey LR: Intertrochanteric and subtrochanteric fractures of the femur in the Negro. J Bone Joint Surg 38-A:1301-1312, 1956.
10. Evans EM: The treatment of trochanteric fractures of the femur. J Bone Joint Surg 31-B:190-203, 1949. 11. Murray RC, Frew JF: Trochanteric fractures of the femur. J Bone Joint Surg 31-B:204-219, 1949. 12. Horn JS, Wang YC: The mechanism, traumatic anatomy and non-operative treatment of intertrochanteric fracture of the femur. Br J Surg 51:574-580, 1964. 13. Cleveland M, Bosworth DM, Thompson FR: Management of the trochanteric fracture of the femur. JAMA 37:1186-1190,1948. 14. Aronsson H: Osteosynthesis of intertrochanteric and pertrochanteric fractures of the femur. J Bone Joint Surg 29-B:37-43, 1948. 15. Bickel WH, Jackson AE: Intertrochanteric fractures of the
femur: An analysis of the end results of 126 fractures treated by various methods. Surg Gynecol Obstet 91:14-24, 1950. 16. Charnley J: Closed Treatment of Common Fractures. Baltimore, Williams & Wilkins Co, 1971, p 160. 17. Fitts WT Jr, Lehr HB, Schor S, et al: Life expectancy after fracture of the hip. Surg Gynecol Obstet 108:7-12, 1959. 18. Sevitt S: Modern Trends in Accident Surgery and Medicine. London, Butterworth, 1959, p 257. 19. Clagett GP, Salzman EW: Prevention of venous thromboembolism in surgical patients. N Engl J Med 290:93-96, 1974. 20. Holt EP Jr: Hip fractures in the trochanteric region: Treatment with a strong nail and early weight-bearing. J Bone Joint Surg 45-A:687-705, 1963. 21. Sarmiento A: Unstable intertrochanteric fractures of the femur. Clin Orthop 92:77-85, 1972. 22. Dimon JH III, Hughston JC: Unstable intertrochanteric hip. J Bone Joint Surg 49-A:440-450, 1967. 23. Banks TE, Davis PM: Treatment of subtrochanteric fractures of the femur.Bull Tulane Med Fac 19:77-97, 1960. 24. Aufranc OE: Subtrochanteric fracture in a patient with Paget's disease. JAMA 177:908-911, 1961. 25. Aronoff PM, David PM Jr, Wickstrom JK: Intramedullary nail fixation as treatment of subtrochanteric fractures of the femur. J Trauma 11:637-650, 1971. 26. Fielding JW: Subtrochanteric fractures. Clin Orthop 92:86\x=req-\
99, 1972.
27. Zickel RE: A
new
fixation device for subtrochanteric frac-
femur, abstracted. J Bone Joint Surg 49-A: 1251, 1967. 28. K\l=u"\ntscherG: Practice of Intramedullary Nailing. Springfield, Ill, Charles C Thomas Publisher, 1967, p 179. 29. Schurman DJ, Amstutz HC: Orthopedic management of patient with metastatic carcinoma of the breast. Surg Gynecol Obstet 137:831-836, 1973. tures of the
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Shelton,
MD
Subtrochanteric fractures of the femur comprise only 5% to 7% of hip fractures, but are important because of the difficulty in management. They combine the problem of instability to varus deformation common to comminuted intertrochanteric fractures and the problem of delayed union common to diaphysial fractures of the femur. While the benefits of open reduction and internal fixation in decreasing morbidity and mortality have been well established, formidable operative complications have occurred when this fracture is treated like an intertrochanteric fracture. Improved results have been obtained by utilizing a fixation device that can control the intertrochanteric instability and that has sufficient strength to withstand deforming
forces that may be present for up to a year while the fracture is uniting. Bone grafting has been found very useful in shortening the overall period of healing.
fracture of the femur has received con¬ siderable attention in the surgical literature in the two decades. It represents 5% to 7% of fractures about the hip but, unlike subcapital fracture, shows no predilection for females. Prior to the early 1950s, when open treatment for fractures of the hip and femoral shaft came into wide acceptance, the problems encountered with closed management of this fracture were well recog¬ nized. Uncontrolled flexion, abduction, and external rota¬ tion of the proximal fragment made alignment with trac¬ tion or plaster difficult and uncertain. Comminution, especially of the medial cortex, made varus deformity, shortening, and delayed union the rule rather than the ex¬ ception. A significant contribution was made by Russell Hibbs as a young resident, when he presented a treatise before the Academy of Medicine in New York describing the principle of bringing the distal fragment into align¬ ment with the proximal fragment to achieve reduction. This effort merited a gold medal. Despite meticulous at¬ tention to traction details, however, all of the problems could not be solved, and, frequently, interposed tissue proved an absolute barrier to union. As a natural evolution, beginning in the early 1950s, a greater number of surgeons undertook to treat this frac¬ ture by open reduction and internal fixation. Unfortu¬ nately, it was not long before reports appeared indicating a substantial percentage of mechanical failures requiring reoperation. At the same time, several detailed studies on the results of operative treatment of intertrochanteric fractures were published that identified certain fracture types as being unstable after reduction and fixation with the usual blade plate devices. These reports increased our appreciation of the complex biomechanical forces oper¬ ating around the hip joint and the upper part of the fem-
Subtrochanteric past
Accepted for publication July 25, 1974. From the Department of Orthopedic Surgery, Harlem Hospital Center and Columbia University College of Physicians and Surgeons, New York. Reprint requests to Department of Orthopedic Surgery, Harlem Hospital Center, 506 Lenox Ave, New York, NY 10037 (Dr. Shelton).
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Watson et al,'- in their 1964 study of 100 subtrochanteric fractures, classified their patients by fracture cause and described the fractures numerically by a rather compli¬ cated system. Their method required accurate measure¬ ments that
are often difficult on poor quality x-ray films. The authors did not relate the classification to the method of treatment or to the results. Fielding and Magliaio,1 in 1966, proposed a simple classification in which three 2.5-cm segments were made by a series of four transverse lines beginning at the top of the lesser trochanter (Fig 2). They believed that this 2.5cm zone was an area of stress concentration, based on the work of Koch.4 It seems that the bone would fracture more commonly where there is an area of stress concentration. Since intertrochanteric fractures are far more common than subtrochanteric fractures, this concept is open to question. Their report indicated that they^ could predict the result of treatment to a large degree based on this classification, noting that the incidence of nonunion in¬ creased strikingly between type 1 and type 3 fractures. They recognized the difficulty in applying this classifica¬ tion to oblique and comminuted fractures. The typing of comminuted fractures is somewhat arbitrary and variable among different observers.
ANATOMY AND BIOMECHANICS
Fig 1.—Boyd and Griffin' classi¬ fication of trochanteric fractures.
oral shaft. As a result, within the last five years, impor¬ tant advances have been made in the management of this fracture and these have resulted in an overall improve¬ ment in the end results. Nevertheless, a number of prob¬ lems remain to be solved. CLASSIFICATION
Fractures of the femur that occur in the 7.6-cm zone be¬ top of the lesser trochanter and 5 cm below the lesser trochanter are commonly referred to as subtrochanteric fractures. While many are simple, rela¬ tively transversely oriented, and easy to describe anatom¬ ically, other fractures are comminuted with major compo¬ nents extending obliquely upward toward the greater trochanter and down into the upper third of the femur. This latter type of fracture has been classified inconsist¬ ently, appearing in some reports as pertrochanteric or as a shaft fracture rather than a subtrochanteric fracture. The classificiation proposed by Boyd and Griffin' origi¬ nally in 1949 has been useful because of the great fre¬ quency with which the mixed type of fracture occurs. Types 1 and 2 are pure intertrochanteric fractures, type 3 is pure subtrochanteric, and type 4 is subtrochanteric but extends up into the trochanteric area and down into the upper part of the femoral shaft (Fig 1). tween the level of the
The femur has been studied extensively from the ana¬ tomical, mechanical, and biomechanical viewpoints. Nils Rydell·' summarized many important observations in a re¬ cent review. He stressed that the hip resembles a ball-andsocket type joint but is more complex due to the limited contact area. The neck in cross section changed in shape from cylindrical near the head to elliptical near the base, with a gradual increase in cortical thickness. The elliptical shape developed after birth under load bearing, and the cortical thickening is much more marked along the infe¬ rior or medial cortex. The angles formed by the femoral neck and shaft are crucial to analysis of the forces acting on the upper part of the femur. Backman" described them in 1957 as illustrated in Fig 3. The important axes, planes, and angles seem to be (1) the cervical axis OHC; (2) the ideal axis AOK; (3) the frontal plane of the femur AOKD; (4) the anteversion plane AOKC; (5) the antetorsion angle T, between planes AOKB and AOKC; (6) the cervical diaphysial angle between OHC and OD; (7) angle A, formed by ADK and AOK (the axis OKD, similar to the femur, forms a ventroconvex curve that is unsatisfactory for geometrical calculations, so the ideal axis AOK is used in most instances); and (8) the principal plane, which is laid through the head and neck coincident with the cervi¬ cal axis and the major axis of the section area. This last plane intercepts the femoral shaft medially and distally just anterior to the lesser trochanter. It forms an angle with the cervical diaphysial plane of 25° and with the an¬ tetorsion plane of 15°. These angles and planes have been interpreted mechanically in several studies. The cervical diaphysial angle is about 150° at birth and, if subjected to normal loading, will decrease to about 130° in adults. Like¬ wise, paresis of the abductor muscles causes the center of
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gravity to shift over the head of the femur in gait, making
the load on the femur more vertical. The femoral neck de¬ in a valgus position under these circumstances. The ventral deviation of the neck begins early in fetal life and increases until delivery, probably depending on torsion of the upper part of the femur. It amounts to 35° at birth and decreases to around 14° at the completion of bony growth. Most of this decrease occurs before the age of 8 years. The measurement and calculation of the forces acting on the upper part of the femur and femoral head have brought to light several important facts. RydelP inserted a prosthetic device provided with strain gauges in the femoral head to measure forces acting in the hip. He found that standing on one leg created a force about the hip joint of about 2% times body weight. The direction of the force was parallel to the principal plane and to the tra¬ becular system of the femoral head. With walking, the force on the hip during the stance phase was relatively low because the body rolled over the femoral head and the abductors did not have to work. During the swing phase, the force was larger than expected because of the muscu¬ lar activity required to accelerate and decelerate the leg. While running, forces of 4% to five times body weight were recorded. Walking upstairs increased the load on the hip to about three times body weight, while walking downstairs loaded the hip about the same or less than level walking (slightly more than body weight). When the leg was completely off the floor, the force on that hip was one half times body weight, but flexion to 90° at the hip and knee increased the force to almost body weight. In bed, straight leg raising gave a force of llA times body weight in the other hip. Standing on one leg with a cane in the opposite hand reduced the force to slightly more than body weight. Sitting put very little force on the hip. Rydell concluded that it was difficult to reduce the load on the hip and the most effective method was a cane in the opposite hand.
velops
Fig 2.—Fielding and Magliato' clas¬ sification of subtrochanteric fractures.
INCIDENCE
TREATMENT
Subtrochanteric fractures have a reported incidence of between 5% and 29% of trochanteric fractures.1-3 Authors reporting the lower incidences generally exclude fractures with comminution extending up into the trochanteric area and down the shaft. Boyd and Anderson7 found that 12% of type 1 and 2 intertrochanteric fractures were converted to type 3 subtrochanteric fractures by intraoperative frac¬ ture around the nail hole. Subtrochanteric fractures occur in all age groups. In the elderly, they generally are related to natural thinning of the bone in the upper part of the femur; in the young, they are primarily due to violent trauma; and they occur at any age when a disease state weakens bone structure, ie, ma¬ lignant neoplasms, osteomalacia, Paget disease, fibrous dysplasis. While females predominate in the incidence of subcapital fractures, they show no predominance in inter¬ trochanteric fractures. In the experience at Harlem Hos¬ pital Center, where violent trauma is the most common cause, males predominate (68%).
The question of the method of treatment of choice for this injury is not an easy one, partly because there are no recent references to results of nonoperative treatment of subtrochanteric fractures. It is a fair assumption that the mortality is basically the same for subtrochanteric frac¬ tures and intertrochanteric fractures occurring in pa¬ tients of comparable age. The reported mortality for nonoperatively treated intertrochanteric fractures ranged from 3% to 66%.s-'2 Most reports of surgically treated pa¬ tients indicate a mortality of approximately 20%.S,MS-15 Unless there is some bias favoring the operative cases, viz, being the better risk patients, this would tend to favor open treatment. While open treatment usually will shorten hospitalization, it seems unwise to use a shortened hospital stay and early ambulation as the sole grounds for advising operative treatment. John Charnley,'" long an advocate of closed treatment for most fractures, has con¬ ceded that the operative treatment of intertrochanteric fractures is superior to closed management. Most authors
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and managed preoperatively and postoperatively. The brittleness of the elderly patient is generally appreciated; however, the unwary surgeon may underrate the risks in¬ volved by failing to appreciate the magnitude of the trauma in the younger patient with a subtrochanteric fracture. Control of hypovolemia and its sequels and rec¬ ognition of associated injuries are essential to avoid post¬ operative complications. The operative procedure must also provide sufficient fixation to allow early range of hip and knee joint motion, permit ambulation with support, and carry with it a low risk of infection and death. The re¬ ported mortality after operative treatment of subtro¬ chanteric fractures varies between 10% and 30% with an average of 20% and serves as a reminder that these are se¬ rious injuries.'1" It is quite sobering that these figures have not changed during the past 15 years despite im¬ provements in the methods of fixation. SUBTROCHANTERIC FRACTURES IN CHILDREN Plaster Immobilization
Fig 3.—Critical angles and planes of up¬ part of femur. (Adapted from Backman.")
per
who have studied the mortality after hip fracture believe that the overall mortality is related more to the general health, both physical and mental, of the patient and to the skill and adequacy of nursing and supportive medical care, than it is to whether operative or nonoperative treatment is rendered. Fitts et al'7 have shown that the survival rate for a patient with an intertrochanteric fracture is the same as for the general population six months after in¬ jury. One cannot dismiss closed treatment lightly, partic¬ ularly in view of reports by Horn and Wang12 from Peking who treated 170 patients with intertrochanteric fractures in traction with a-5.3% mortality with no reported inci¬ dence of pneumonia, decubitus ulcers, or pulmonary em¬ boli and no nonunions. On the other hand, we were naturally impressed by work of men such as Sevitt1" in England, who examined 154 patients with femoral neck fractures and found 27% had clinically detectable venous thrombosis and 7.9% de¬ veloped fatal pulmonary emboli. This certainly suggests that pulmonary embolism is a substantial risk for a pa¬ tient immobilized for a subtrochanteric fracture. Pre¬ vention of pulmonary embolism after hip surgery can be effected by administration of antithrombotic agents.19 Yet, if one then considers the problems of prophylactic anticoagulation, particularly the interference with fracture healing and the prolonged hospitalization, especially in crowded urban centers where beds are in short supply and hospital charges astronomically high, then operative treatment does seem to be more advantageous. It is clear, however, that operative treatment should only be carried out in patients who are carefully evaluated
Plaster immobilization is the treatment of choice in in¬ fancy and can be used successfully for undisplaced, stable fractures in the older child and young adult. The major drawbacks of this treatment are fracture deformity and prolonged hospitalization. Flexion, abduction, and slight external rotation of the involved thigh may help prevent deformity during the healing phase. A 3.8-cm hip spica should be used to control the pelvis. Skeletal Traction This method is frequently used and is the treatment of choice for displaced fractures in childhood. The main prob¬ lems are flexion, abduction, and external rotation of the proximal fragment, so the leg should be positioned with the hip and knee joint in 90° of flexion (90-90 position), with the traction pin placed through the distal part of the femur rather than the upper part of the tibia to prevent anterior subluxation of the knee. In the 90-90 position the iliopsoas is relaxed, diminishing the external rotation forces so that neutral rotation is usually satisfactory for reduction and alignment. The period of immobilization is quite variable. Some of the important factors concerning the rate of healing are the age of the patient, the level of the fracture, and whether anticoagulants are used. Frac¬ tures that are basically diaphysial in location usually will take longer and traction must be maintained in order to prevent deformity. Also, the accuracy of reduction must be greater in adults than in children and in diaphysial fractures than those more proximal because of the poor blood supply in the former instances. Anteroposterior and lateral roentgenograms are essential to evaluate the posi¬ tion of the fragments and progress of union. I have not seen a subtrochanteric fracture unite in traction in a pa¬ tient receiving anticoagulants. OPERATIVE TREATMENT and internal fixation is the most fre¬ method of treatment in this country. Most authors indicate inability to control the fracture de-
Open reduction quently employed
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formity,
the threat of
delayed union, and prolonged bed hospitalization as reasons for preferring open over closed treatment. Nail plate devices are most com¬ monly employed. Many surgeons did not appreciate the special problems of the subtrochanteric fracture until the report by Boyd and Anderson in 1961.7 In analyzing 100 fractures of the hip, they found that 20% were type 3, 9% rest and
type 4, and 12% of the types 1 and 2 were converted type 3 during the open reduction and internal fixation. Twenty-six percent of their subtrochanteric fractures were
to
needed
supplemental
fixation such
as
buttress
plates,
screws, and circumferential wire bands. The high failure rate of open treatment has been further documented by the reports of Watson et al,2 Aronsson," and, most re¬
cently, by Fielding and Magliaio1 who found the union ranged from 90% in type 1
4.—Unstable intertrochanteric fractures according Hughston22: (1) head fragment, (2) shaft, (3) lesser trochanter and portion of calcar, (4) posterior fragment including portion of greater trochanter.
Fig
to Dimon and
rate in 46 fractures studied
fractures to 66% in type 2 and 43% in type 2 subtrochan¬ teric fractures. All of these fractures were treated by Jew¬ ett nails with supplementation by anterior plates, cancellous screws, and primary bone grafting. As a group, 26% required additional surgery to obtain bony union. Watson et al2 reported on 100 subtrochanteric fractures and found 19 failures, mostly due to mechanical causes such as bending and breaking of the nail and plate or me¬ dial moderation of the shaft with penetration of nail through the head. Following these reports, stronger nails were introduced for fixation of these fractures in an attempt to overcome this cause of failure. Typical of these was the Holt nail2" reported in 1963, which can withstand static loads of 452 kg. Despite the increased metal strength, failures contin¬ ued to be reported due to cyclic loading and metal fatigue. It is interesting that most of these failures occurred be¬ tween three and 12 months after fixation at a time when most intertrochanteric fractures have healed. This points out the basic difference between intertrochanteric and subtrochanteric fractures, namely, a slower rate of heal¬ ing of the subtrochanteric fracture rather than any sub¬ stantial difference in the nature or magnitude of the forces operating at the fracture site. It became increas¬ ingly clear that diminishing the cyclic loading and in¬ creasing the rate of union would be necessary to eliminate these failures. Most authors have recommended achieving a more stable reduction to allow the fracture to support it¬ self rather than having the entire strain on the metallic fixation device as the most rational solution to this prob¬ lem. Similar fixation failures have been reported after open treatment of unstable intertrochanteric fractures, and several solutions have been suggested for this problem. Among the more widely accepted concepts is that of Sar¬ miento,2' which proposes that the reduction of the medial cortex is the key to fracture stability. He recommends an oblique osteotomy of the femoral shaft just below the lesser trochanter, an anatomical reduction of the medial cortices, and fixation with a 130° nail inserted at 90° into the neck of the femur to obtain a valgus reduction of the head and a more horizontal fracture line. This exact rela¬ tionship is difficult to obtain surgically and several of the
cases he illustrated showed some medial displacement of the shaft. One must be careful that the osteotomy does not result in excessive neck valgus because this will be as¬ sociated with a corresponding genu valgum deformity and may cause avascular necrosis of the femoral head. Dimon and Hughston22 believe that comminution is re¬ sponsible for unstable reductions, particularly when there is a lesser trochanteric fragment that includes a substan¬ tial portion of the medial cortex and a greater trochanter fragment that includes a substantial posterior fragment (Fig 4). They recommend performing a transverse os¬ teotomy at the level of the lesser trochanter and placing the medial spike of neck into the distal shaft. They also obtain a valgus reduction using a 150° Jewett nail and plate and stress contact between fragments medially to prevent collapse and metal failure. They expect 1.3- to 1.9cm shortening. Too much medial displacement may be a problem and lead to delayed union and plate breakage. Certain subtrochanteric fractures, ie, Boyd type 4 and Fielding type 1, have intertrochanteric components and tend to collapse into varus and bend the nail or penetrate the head. These solutions are helpful in their management but fail to adequately fix the fracture lines below the lesser trochanter. Even extra strong and extra long side plates tend to bend or break prior to fracture consoli¬ dation. None of the nail plates manufactured in this coun¬ try are recommended by the manufacturers for subtro¬ chanteric fractures. The Swiss Association for the Study of Internal Fix¬ ation (ASIF) technique, which requires anatomical reduc¬ tion or primary bone grafting and interfragmentary or longitudinal compression of each fracture fragment, has considerable appeal and is favored by many surgeons, but to me it seems ill suited for comminuted subtrochanteric fractures. Even when one is clever enough to reassemble the fragments, the weakness of the side plate and its sus¬ ceptibility to failure due to cyclic loading is disturbing. An alarming rate of failure has been noted when single-plate fixation has been used in fractures with the middle third of the femur, and I would anticipate that this would occur also with subtrochanteric fractures of the femur, partic¬ ularly if early weight bearing is instituted. Successes that
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Fig 5.—A 45-year-old man with Boyd 3 and Fielding 3 subtrochan¬ teric fractures three months after Zickel nailing with supplemental Parham bands; full weight bearing.
Fig 6.—A 45-year-old man with Boyd 4 subtrochanteric fracture immediately after nail plate fixation (left) and six months later (right) when plate broke despite crutch-protected ambulation. Frac¬ ture went on to heal without reoperation.
Fig 7.—Left, A 44-year-old woman with Boyd 4 and Fielding 3 sub¬ trochanteric fracture. Note flexed, abducted position of proximal fragment and medial position of lateral butterfly fragment; early weight bearing allowed. Right, At three months, when Parham bands were removed, there was clinical union.
Fig 8.—A 34-year-old man with Boyd 3 and Fielding 3 subtro¬ chanteric fracture at time of injury (left) and three months postinjury (right); weight bearing with crutches.
Fig 9.—Ninety-ninety distal femoral traction for controlling flexed, abducted, and externally rotated proximal fragment. Results of 37 Adult Subtrochanteric Fractures of the Femur Treated at Harlem Hospital Center, 1967 to 1973* Method of Treatment Zickel nail Zickel nail with supplemental fixation Nail plate Schneider nail KUntscher nail Rush pins
Nonoperative
Primary Union
Nonunion
_10
•
Includes 24 males and 13 females; average age, 53 years. There were four open reductions and three deaths.
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have been reported with this technique are probably at¬ tributable to the relatively rapid union that is possible when the fracture line is reduced to minimum width by
compression.
Intramedullary Nail Fixation
Intramedullary nailing has been recommended for many years for the transverse femoral fractures between 5 and 7.6 cm below the lesser trochanter. These fractures at the isthmus of the femur are usually rigidly fixed by an in¬ nail of proper size. Banks and Davis,2' Aufranc,24 and Aronoff et al21 were among the early reporters describing the superior results after intramedullary nail¬ ing of subtrochanteric fractures. They expanded the indi¬ cations somewhat to include certain comminuted fractures and those located a little closer to the lesser trochanter. Watson et al2 and Fielding26 have also cited the usefulness of intramedullary nail fixation for certain subtrochanteric fractures. Many surgeons, however, are justifiably reluc¬ tant to attempt nailing of a comminuted subtrochanteric fracture. Zickel,27 in 1967, reported on a new fixation device that combined the principles of intramedullary fixation of the femoral shaft with nail fixation in the neck to obtain bet¬ ter control of the proximal fragment. Credit for the origi¬ nal idea should probably be given to Küntscher, who re¬ ported a series of 100 pertrochanteric fractures treated with a Y nail in 1940.2S The Zickel device is contoured to achieve a valgus reduction and maintain apposition of the medial cortex. The expanded upper end of the intramedul¬ lary nail is perforated to accept a triflanged crossbar in¬ serted through the intramedullary nail and into the fem¬ oral neck. This provides superb control of the proximal part of the fragment. The intramedullary nail is also curved anteriorly to obtain three-point fixation in the shaft. This device lends itself well to supplemental inter¬ nal fixation with circumferential wire bands or Parham bands and does not require supplemental external plaster support (Fig 5). It appears to be particularly useful in con¬ junction with methyl methacrylate for pathological frac¬ tures2" and after resection of bone tumors in the subtro¬ chanteric area. Zickel's personal series is now more than 67 cases, with only one instance of metal breakage and failure of union. There are many hazards in performing this type of sur¬ gery that are inherent to any intramedullary nailing. No¬ table among these are exploding the shaft during inser¬ tion of the nail and exposure of the medullary canal to extensive infection should this occur postoperatively.
tramedullary
CURRENT TREATMENT AT HARLEM HOSPITAL CENTER
At Harlem Hospital Center between 1964 and 1970 we employed nail plate fixation for Boyd type 4 and Fielding type 1 and 2 fractures. We noted metal failure with the blade plate when we did not obtain a stable relationship between the medial cortex of the shaft and the interior neck of the proximal part of the fragment (Fig 6). Placing the fracture line under compression by tilting the head and neck into a valgus position, with or without os-
Fig 10.—A 62-year-old woman with comminuted segmental sub¬ trochanteric and femoral fracture. Extensive soft tissue avulsion of popliteal fossa prevented open reduction (left). Treated with long leg cast and tibial traction 20 hours per day and with weight bearing for four hours per day. Clinical union at 12 weeks (top right) and solid union with full weight bearing at 20 weeks (bottom right). our rate of successful unions, but we unable to allow early ambulation or weight bearing because of fear of hardware failure. Since 1967, we have favored the Zickel nail usually sup¬ plemented by circlage Parham bands for Boyd type 3 and Fielding type 3 fractures (Fig 7). We have used it also for Boyd type 4 and Fielding type 1 and 2 fractures since 1970. In several instances, intramedullary nailing using the Schneider device without the crossbar has been ade¬ quate (Fig 8). This is especially true of spiral fractures at the isthmus of the femur. We found that the routine use of primary iliac bone graft to replace any defects in the cortical tube to be helpful in achieving rapid union of these fractures. Fracture healing is still a race between union of the fracture and failure of the hardware. The pa¬ tients have been kept on crutches until the fracture healed and the Parham bands have been routinely removed after three months to prevent ring sequestra formation. They
teotomy, improved
were
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were always loose at that time, so we did not believe we lost any fixation. Our experiences are summarized in the Table. We have treated children with skeletal traction. If the lesser trochanter is intact and the fracture line is proxi¬ mal to the gluteus maximus insertion into the distal part of the fragment, the proximal part of the fragment gen¬ erally flexed, abducted, and externally rotated. We place the leg and thigh in a 90-90 position using femoral trac¬ tion to avoid injury and subluxation of the knee (Fig 9). Other types of subtrochanteric fractures not exhibiting this particular pattern of displacement initially have been treated with conventional tibial tubercle traction and bal¬ anced suspension. Overriding of at least 1 cm should be al¬ lowed in the children under 11 years because considerable
stimulation of
growth in the ipsilateral femur and tibia usually occurs. Recently, following an unpublished report by E. Dehne, MD, and B. Follette, MD, we managed an adult woman with skeletal traction by incorporating a tibial pin in a snug long leg cast and allowing her to ambulate four hours a day weight bearing on the fractured extremity. Union was achieved in 12 weeks and adequate reduction
maintained. We believe that this method is useful for Fielding type 3 fractures (Fig 10), especially when open reduction and internal fixation are not feasible. Fracture bracing, in my opinion, will be used more and more fre¬ quently in the future. With it, we can achieve most of the goals of surgery without the many risks of an invasive
procedure.
References 1. Boyd HB, Griffin LL: Classification and treatment of trochanteric fractures. Arch Surg 58:853-866, 1949. 2. Watson HK, Campbell RD, Wade PA: Classification, treatment, and complications of the adult subtrochanteric fracture. J Trauma 4:457-480, 1964. 3. Fielding JW, Magliato HJ: Subtrochanteric fractures. Surg Gynecol Obstet 122:555-560, 1966. 4. Koch JC: The laws of bone architecture. Am J Anat 21:177\x=req-\ 298, 1917. 5. Rydell NW: Forces acting on the femoral head-prosthesis: A study on strain gauge supplied prostheses in living persons. Acta Orthop Scand 37(suppl 88):1-132, 1966. 6. Backman S: The proximal end of the femur. Acta Radiol, suppl 146, pp 1-166, 1957. 7. Boyd HB, Anderson LD: Management of unstable trochanteric fractures. Surg Gynecol Obstet 112:663-668, 1961. 8. Kennedy JC, McFarlane RM, McLaughlin AD: The Moe plate in intertrochanteric fractures of the femur. J Bone Joint Surg 39\x=req-\
B:451-457, 1957. 9. Robey LR: Intertrochanteric and subtrochanteric fractures of the femur in the Negro. J Bone Joint Surg 38-A:1301-1312, 1956.
10. Evans EM: The treatment of trochanteric fractures of the femur. J Bone Joint Surg 31-B:190-203, 1949. 11. Murray RC, Frew JF: Trochanteric fractures of the femur. J Bone Joint Surg 31-B:204-219, 1949. 12. Horn JS, Wang YC: The mechanism, traumatic anatomy and non-operative treatment of intertrochanteric fracture of the femur. Br J Surg 51:574-580, 1964. 13. Cleveland M, Bosworth DM, Thompson FR: Management of the trochanteric fracture of the femur. JAMA 37:1186-1190,1948. 14. Aronsson H: Osteosynthesis of intertrochanteric and pertrochanteric fractures of the femur. J Bone Joint Surg 29-B:37-43, 1948. 15. Bickel WH, Jackson AE: Intertrochanteric fractures of the
femur: An analysis of the end results of 126 fractures treated by various methods. Surg Gynecol Obstet 91:14-24, 1950. 16. Charnley J: Closed Treatment of Common Fractures. Baltimore, Williams & Wilkins Co, 1971, p 160. 17. Fitts WT Jr, Lehr HB, Schor S, et al: Life expectancy after fracture of the hip. Surg Gynecol Obstet 108:7-12, 1959. 18. Sevitt S: Modern Trends in Accident Surgery and Medicine. London, Butterworth, 1959, p 257. 19. Clagett GP, Salzman EW: Prevention of venous thromboembolism in surgical patients. N Engl J Med 290:93-96, 1974. 20. Holt EP Jr: Hip fractures in the trochanteric region: Treatment with a strong nail and early weight-bearing. J Bone Joint Surg 45-A:687-705, 1963. 21. Sarmiento A: Unstable intertrochanteric fractures of the femur. Clin Orthop 92:77-85, 1972. 22. Dimon JH III, Hughston JC: Unstable intertrochanteric hip. J Bone Joint Surg 49-A:440-450, 1967. 23. Banks TE, Davis PM: Treatment of subtrochanteric fractures of the femur.Bull Tulane Med Fac 19:77-97, 1960. 24. Aufranc OE: Subtrochanteric fracture in a patient with Paget's disease. JAMA 177:908-911, 1961. 25. Aronoff PM, David PM Jr, Wickstrom JK: Intramedullary nail fixation as treatment of subtrochanteric fractures of the femur. J Trauma 11:637-650, 1971. 26. Fielding JW: Subtrochanteric fractures. Clin Orthop 92:86\x=req-\
99, 1972.
27. Zickel RE: A
new
fixation device for subtrochanteric frac-
femur, abstracted. J Bone Joint Surg 49-A: 1251, 1967. 28. K\l=u"\ntscherG: Practice of Intramedullary Nailing. Springfield, Ill, Charles C Thomas Publisher, 1967, p 179. 29. Schurman DJ, Amstutz HC: Orthopedic management of patient with metastatic carcinoma of the breast. Surg Gynecol Obstet 137:831-836, 1973. tures of the
Downloaded From: http://archsurg.jamanetwork.com/ by a UQ Library User on 06/17/2015
