Fractures of The Proximal Part of The Femur .20

Fractures of the Proximal Part of the Femur
BY RICHARD F. KYLE. M.D.t. MINNEAPOLIS. MINNESOTA
WITH CONTRIBUTIONS FROM MIGUEL E. (AIJANELA. M.D.. THOMAS A. RUSSELL. M.D.. MARC F. SWIONTKOWSKI. M.D..
ROBERT A. WINOtJIST. MI).. JOSEPH D. ZIJCKERMAN. M.D.. A. H. SCHMIDT. M.D.. AND K. J. KOVAL. M.D.
ilii Iiz.structiona/ Course Lecture, The Aniericati Acadenzv of Orthopaedic Surgeons
Prevalence and Prevention

derly patients are generally the result of a single fall and
The worldwide prevalence of fractures of the proxi- are more common in women than in men4. The absolute
mal part of the femur is increasing as the average age of rate of fracture is highest for white women, followed by
the population increases. The actual number of these white men, black women, and black men4. These rates
fractures in the United States doubled from the mid- are thought to reflect a difference in bone density be-
1960s through the 1980s. Frandsen and Kruse predicted tween black and white people. Alffram reported that
that the number of such fractures will triple that of today patients who have intertrochanteric fractures are, as a
by the year 2050. Thus. fractures of the proximal part of group. slightly older and have higher rates of morbidity
the femur are an important cause of morbidity and mor- and mortality compared with patients who have frac-
tality in all age-groups, especially the elderly. tures of the femoral neck.
Approximately 250,000 fractures of the proximal Since falls are the single most common cause of
part of the femur occur in the United States each year. fractures of the proximal part of the femur. the preven-
resulting in annual health-care costs of more than 8.7 tion of falls is a primary way to control the increasing
billion dollars75. Extensive debate continues with regard prevalence of these injuries4. Alterations in living con-
to the cost-effectiveness of various medical and opera- ditions to eliminate obstacles that can cause tripping,
tive therapies. including the treatment of fractures of such as throw rugs and poor lighting. are practical steps
the proximal part of the femur. Using the concept of that can be taken. The treatment of conditions that
quality-adjusted life-years, Parker et al. determined that cause weakness and imbalance is another way to de-
operative treatment is the most cost-effective approach crease the prevalence of these fractures42.
for displaced intracapsular fractures and all extracapsu-
lar fractures75. Thus, the proper treatment of fractures of Pertinent Anatomy
the proximal part of the femur is important not only for Most of the vascular supply to the femoral head
the continued health and vitality of the population but comes from the posterior medial and lateral femoral
also for the health of the economy. circumflex arteries that form an extracapsular ring
Fractures of the proximal part of the femur occur about the femoral neck (Fig. 1). Ascending cervical
predominantly as low-energy injuries in elderly patients branches arise from this network and enter the capsule
and as high-energy injuries in younger patients. The high at its insertion. Fractures of the femoral neck have been
prevalence of these fractures in the elderly is related to shown, both by injection techniques and by histological
numerous factors, including osteoporosis, malnutrition, study. to disrupt this vascular supply to the femoral
decreased physical activity, impaired vision, neurologi- head997. Experimental study has shown that. if both
cal impairment, poor balance, altered reflexes, and mus- the medial circumflex and the lateral epiphyseal vessels
cular weakness. Firooznia et al. showed. however. that have been disrupted, the collateral circulation maintains
elderly patients who sustained fractures of the proximal viability of the femoral head in less than 20 per cent of
part of the femur did not have a higher rate of osteopo- specimens99. However, Claffey showed that displaced
rosis than age-matched control subjects32. fractures of the femoral neck can occur without corn-
Fractures of the proximal part of the femur in el- plete disruption of the medial femoral circumflex or
lateral epiphyseal systems. These vessels may only be
*Printed with permission of The American Academy of Ortho- kinked; therefore, early anatomical reduction and inter-
paedic Surgeons. This article will appear in Instructional Course nal fixation of displaced fernoral-neck fractures is advo-
Lectures, Vo/utiie 44, The American Academy of Orthopaedic Sur- cated in order to restore blood flow.
geons. Rosemont. Illinois. 1995.
tDepartment of Orthopaedic Surgery. Hennepin County Medi- The osseous anatomy of the proximal end of the
cal Center, 701 Park Avenue South. Minneapolis. Minnesota 55415. femur dictates where the internal fixation device should
924 THE JOURNAL OF BONE ANI) JOINT SURGERY

FRA(FURES OF TIlE PROXIMAL PART OF THE FEMUR 925
Anastomosis
between medial
and lateral
circumflex
arteries
Deep
femoral a. circumflex a.
Fto. I
Drawing showing the blood supply to the proximal end of the femur. The major sources are the lateral and medial circumflex arteries. which
traverse the capsule to become the lateral retinacular arteries supplying the femoral head. (Reprinted, with permission. from: Kyle. R. F.:
Fractures of the hip. In Fractures and Dislocations. edited by R. B. Gustilo. R. F. Kyle. and D. C. Templeman. Vol. 2. p. 789. St. Louis. Moshy-Year
Book. 1993.)
be placed for maximum purchase in the femoral head. rnal joint-reaction force can be as much as four to seven
Maximum bone density is found in the area where the times body weight. and in women, 2.5 to four times body
compression and tension trabeculae coalesce in the cen- weight737t. Stair-climbing causes peak hip forces of as
ter of the head (Fig. 2). Careful evaluation of the trabec- much as seven times body weight25. The mechanics of the
ular patterns allows the surgeon to estimate the degree hip are such that implants designed for the fixation of
of osteoporosis and to gauge the likelihood of success fractures or for prosthetic replacement must withstand
of internal fixation: however, the subjective nature of extremely high loads and bending moments. The activi-
the grading systems used for this purpose limits their ties of a bedridden patient can produce forces on the
reliability. implant equivalent to those that occur during walking
The ball-and-socket configuration of the hip joint is with the use of external supports73. Even when the struc-
inherently stable and allows an excellent range of mo- tural integrity of the hip has been restored, the major
tion in all directions. The two major forces acting on the muscle forces continue to test the stability of the frac-
hip joint are abductor muscle tension and body weight, ture fixation or of the prosthetic replacement. Using
as defined by the joint-reaction force. In men, the nor- instrumented nail-plate implants, Nordin and Frankel
Principal compressive
Greater trochanter group

Principal tensile group
Secondary co
3econdary tensile group
Fi;. 2
Drawing showing the internal trabecular pattern of the proximal third of the femur. The primary compressive and tension trabeculae
coalesce in the center of the head. W = Wards triangle. (Reprinted. with permission. from: Rockwood. C. A.. Jr.: Green. D. P.: and Bucholz.
R. W. leditorsl: Fractures in Adults. Ed. 3, vol. 2. p. 1488. Philadelphia. J. B. Lippincott. 1991.)
VOL. 76-A. NO. . JUNE 1994

926 R. F. KYLE ET AL.
An improved understanding of fracture patterns,

along with advancements in internal fixation, have led
to greater expectations of good results and to the need
for a more critical review of the results of treatment of
these injuries. Many factors conspire to make general-
izations about treatment difficult, and comparisons of
the results of treatment are nearly impossible. There
have been few prospective, randomized comparative
studies. Most clinical reviews are incomplete because of
poor follow-up. Rapid developments in implant technol-
ogy make the standardization of operative procedures
Type I. Incomplete fracture Type II. Complete fracture,
non-displaced
an elusive task. Finally, the age and poor health of the
patients who sustain fractures of the proximal part of
the femur make it difficult to conduct comprehensive,
long-term follow-up studies.
Fractures of the Femoral Neck
Clinical Presentation and Classification

Fractures of the femoral neck occur in two distinctly
different populations: the elderly and younger adults. In
an elderly patient. the fracture usually results from a fall,
while in a younger patient, it is generally caused by an
accident involving a motor vehicle or by another high-
energy pattern of injury. Because of the intracapsular
nature of the fracture, an elderly patient is usually stable
Type Ill. Complete fracture, Type IV. Complete fracture,
disolaced less than 50% dlsolaced more than 50% on initial presentation, unless transport has been de-
FIG. 3 layed or overriding medical problems are present. This
Drawings showing the classification of Garden353 for fractures of the is often not true for young adults. Fifty per cent of the
femoral neck. The rates of both osteonecrosis and non-union. as well as time, a younger patient has sustained multiple trauma
the method of treatment. are based on the amount of displacement.
and may have other serious injuries95. Twenty per cent
(Reprinted. with permission, from: Kyle, R. F.: Fractures of the hip. In
Fractures and Dislocations. edited by R. B. Gustilo, R. F Kyle. and D. C. of young patients who have a femoral neck fracture also
Templeman. Vol. 2. p. 795. St. Louis, Mosby-Year Book. 1993.) have a fracture of the ipsilateral femoral shaft79#{176}.Be-
cause the surgeon focuses on the femoral shaft fracture,
showed that only one-fourth of the total load is borne the femoral neck fracture may be missed in as many as
by the fixation device73. 40 per cent of these patients.
Highly sophisticated procedures and techniques can
Clinical Signs oflntracapsular Fractures ofthe Hip
now guide the surgeon to a more accurate placement of
internal fixation devices, optimizing impaction and sta- Clinical signs and symptoms at presentation may be
bilization of the fracture. Image intensification has re- minor in a patient who has an incomplete, impacted, or
duced operating time and has allowed the surgeon the non-displaced fracture of the femoral neck. Internal ro-
opportunity for immediate evaluation of the reduction tation of the limb almost always elicits pain in the region
and of the placement of the fixation device. This has of the hip and groin when a femoral neck fracture is
led to fewer complications and better results in pa- present. In displaced femoral-neck fractures, there is
tients who have an intracapsular or extracapsular frac- shortening and external rotation of the limb, with the
ture. New, high-strength stainless-steel and titanium hip usually held in slight abduction. The patient is in
alloys and computer-assisted designs ensure maximum severe pain, and any attempt to move the hip causes
strength of the implant by the reduction of stress-risers pain. If a femoral neck fracture is suspected, the patient
and the elimination of weak areas42. The use of these will be most comfortable with a pillow placed beneath
materials and designs has reduced the frequency of the knee and the hip moderately flexed. This position
breakage of the implant to less than 1 per cent; failures allows relaxation of the hip capsule and reduces pres-
of the implant that do occur are usually associated with sure on and pain in the hip joint.
a failure of fracture-healing and are indicative of non-
Radiographic Evaluation
union57. The one fracture pattern that still poses a great
problem is the displaced intracapsular fracture with Standard anteroposterior and lateral radiographs of
compromised blood supply to the femoral head. This the hip are essential for the evaluation of a femoral neck
fracture, so aptly named by Speed, remains today the fracture. Any discontinuity in the cortical outline or over-
unsolved fracture. lapping of the trabecular pattern of the head and neck
THE JOURNAL OF BONE AND JOINT SURGERY

FRACTURES OF THE PROXIMAL PART OF THE FEMUR 927
Principal compressive trabeculae describes subcapital fractures37. Types I through IV

are based on the degree of displacement evident on an
anteroposterior radiograph of the hip (Fig. 3). These
grades correspond to both the prognosis for healing and
the rate of osteonecrosis. Displaced fractures (types III
and IV) are associated with a higher prevalence of os-
teonecrosis and non-union than are non-displaced frac-
tures (types I and II).
An alternative classification system, in which the
type of femoral neck fracture is based on the angle
formed by the fracture line and the horizontal plane,
was proposed by Pauwels77. Fractures that are more ver-
FIG. 4 tical are subject to higher shear stresses and are associ-
Rotational malalignment
of the femoral head may be determined ated with a correspondingly poorer prognosis. and they
on the basis of observation
of the malalignment of the compressive
trabeculae. (Reprinted. with permission. from: Kyle. R. F.: Fractures
are given a higher classification77. The closer the fracture
of the hip. In Fractures and Dislocations, edited by R. B. Gustilo, R. E line to the horizontal, the less shear force exerted on the
Kyle. and D. C. Templeman. Vol. 2. p. 796. St. Louis, Mosby-Year fracture or on any device used to fix the fracture.
Book. 1993.)
The rotation of the femoral head and the amount of
comminution of the femoral neck must also be consid-
should be noted. Displaced femoral-neck fractures are ered when the severity of the fracture is estimated. Nei-
quite obvious; the surgeon should pay particular atten- ther of the classification systems just described takes
tion to the lateral radiograph to evaluate the amount of into account the rotational alignment of the head or the
posterior comminution because the greater the degree degree of posterior comminution. Rotational malalign-
of comminution, the greater the instability of the frac- ment is difficult to diagnose, but its presence should be
ture. Non-displaced fractures that cannot be seen on suspected when the major compressive trabeculae in the
plain radiographs are apparent on a magnetic resonance head and neck are not aligned accurately, even if there
image immediately and on a bone scan after three days. is over-all good alignment of the cortical shells (Fig. 4).
A negative result on the magnetic resonance image as- All patients must be evaluated thoroughly and their
sures the surgeon that no fracture of the hip is present5. medical condition must be stabilized before they are
Gardens classification, which is the most widely ac- taken to the operating room. The optimum timing for
cepted classification of femoral neck fractures, primarily internal fixation of femoral neck fractures remains con-
Fio. 5
Flowchart showing the various methods of treatment for fractures of the femoral neck. as determined by the amount of displacement of the
fracture. the age of the patient. and whether there is a history of hip disease. (Reprinted. with permission. from: Kyle. R. F.: Fractures of the
hip. In Fractures and Dislocations. edited by R. B. Gustilo. R. F. Kyle. and D. C. Templeman. Vol. 2, p. 8fX). St. Louis. Mosby-Year Book. 1993.)
VOL. 76-A. NC). (. JUNE 1994

Fio. 6-A
Figs. 6-A and 6-B: Lateral radiographs of a fracture of the femoral neck.
Fig. 6-A: The radiograph shows posterior comminution.
-.
. .
:k..
FIG. 6-B
Radiograph made after fixation. The screws have been placed along the posterior cortex to buttress the comminuted region.
troversial47. Several authors have reported lower the displacement of the fracture remains unchanged39.
rates of osteonecrosis and non-union in patients who Thus, these fractures are best treated with internal fix-
had reduction and rigid internal fixation of the fracture ation to prevent displacement and to decrease the at-
on an emergent basis7. In contrast, Barnes et al., in tendant risks of osteonecrosis and non-union45.
one of the largest over-all series of femoral neck frac- A patient who has a displaced femoral-neck frac-
tures, did not identify a significant increase in the rate ture is at high risk for both osteonecrosis and non-
of osteonecrosis or non-union when fixation had been union. Several authors, in studies of more than 100
delayed for as long as a week. Swiontkowski et al. patients, reported an average rate of non-union of 20
showed, in animal studies, that a minimum increase in per cent (range, 6 to 40 per cent) and an average rate
intracapsular pressure occludes the blood supply to the of osteonecrosis of 25 per cent (range, 10 to 43 per
femoral headix. We believe that there is a theoretical cent)59#{176}2#{176}23#{176}43997.
Arnold et al., in a study of 1000 non-
advantage, on the basis of the pathophysiology of the pathological fractures, including 670 displaced fractures,
fracture, to reduction and stabilization of the fracture as reported an over-all rate of non-union of 15 per cent5.
soon as the patient is medically stable. In the patients who had a displaced fracture, the rate of
The treatment of the fracture depends primarily on osteonecrosis was 12 per cent, and in those who had a
the age of the patient and the degree of displacement non-displaced fracture, it was 7 per cent. Barnes et al.,
(Fig. 5). A patient who has a non-displaced or a mini- in a study of 1503 subcapital fractures, reported that 289
mally displaced femoral-neck fracture is at low (0 to (19 per cent) were ununited and 183 (12 per cent) had
10 per cent) risk for osteonecrosis or non-union if late segmental collapse after three years of follow-up0.

C-ARM VIEWS
LATERAL ANTEROPOSTERIOR
FIG. 7
Diagrams showing the proper placement of the guide-pins. The cannulated screws are driven over one-eighth-inch (0.32-centimeter)
guide-pins to within five millimeters of the subchondral bone. Three screws, placed in a triangular pattern. provide optimum stability. The distal
screw lies against the medial cortex. to resist varus forces on the femoral head. The proximal screws are spread out and placed anterior and
posterior. to resist displacement and rotation. (Reprinted. with permission, from: Kyle. R. F.: Fractures of the hip. In Fractures and Dislocations.
edited by R. B. Gustilo. R. F. Kyle. and D. C. Templeman. Vol. 2. p. 807. St. Louis, Mosby-Year Book. 1993.)
Treatment of displaced femoral-neck fractures is based lar prosthesis with cement has been used. with excel-
on the age and the physical demands of the patient. In lent results. A modular hemiprosthesis, with a solid,
a younger. healthy, physically active patient, every effort exchangeable head on the femoral stem. is currently
should be made to preserve the femoral head. In an available; however, there have been no long-term corn-
elderly, physically debilitated patient, a second opera- parative studies of its clinical success. to our knowledge.
tion can be avoided by the use of primary prosthetic A total hip replacement is the treatment of choice for
replacement. There is. however, no documentation as to femoral neck fractures associated with severe osteo-
the exact age at which open reduction and internal fix- arthrosis. rheumatoid arthritis, or cancer.
ation to preserve the femoral head should be aban-
Treatment ofFractures of the
doned in favor of prosthetic replacement. In a patient
who is physiologically less than seventy to seventy-five Femoral Neck in Younger Adults
years old and is capable of withstanding a second oper- Protzman and Burkhalter reported disastrous re-
ation if the fixation fails, the treatment of choice is open sults, including very high rates of osteonecrosis and non-
reduction and internal fixation. A patient who is physi- union (nineteen patients [86 per cent] and thirteen
ologically more than seventy to seventy-five years old patients [59 per cent], respectively), in twenty-two pa-
should be considered a candidate for primary prosthetic tients who had a fernoral neck fracture and were less
replacement to avoid a second operation. A persons than fifty-five years old7. In more recent series, how-
physiological age is dependent on concurrent medical ever, the rates of osteonecrosis (20 to 30 per cent) and
problems that result in a change in activities of daily non-union (15 to 20 per cent) have been found to be the
living; it is not always the same as the chronological age. same as those in elderly patients. Swiontkowski et al., in
Prosthetic replacement may also be chosen for a patient a study of twenty-seven patients who were less than fifty
who has severe, pre-existing hip disease. such as os- years old, reported no non-unions; osteonecrosis devel-
teoarthrosis. compounded by a femoral neck fracture. oped in five patients (19 per cent)0. In a study by the
Various options for prosthetic replacement are Orthopaedic Trauma Hospital Association, the rates of
available. The choice of the prosthesis depends on the osteonecrosis and non-union in 1 12 patients who were
walking requirements of the patient and the degree of less than fifty-five years old were consistent with those
associated hip disease. In a patient who cannot walk or that have been reported in elderly patients.
transfer from bed to chair. a one-piece herniprosthe-
Evaluation ofReduction, and Acceptable Guidelines
Sis without cement may be used. This type of prosthesis
is best suited for sedentary patients because weight- A poor reduction of a femoral neck fracture pre-
bearing on the prosthesis is associated with a high prey- vents re-establishment of the blood supply to the femo-
alence of both pain in the thigh and later acetabular ral head and decreases the amount of apposition of
protrusion. In a patient who has moderate functional bone between the proximal and distal fragments, leav-
requirements. such as one who lives in a nursing home ing poor mechanical stability after fixation. Garden and
or who is restricted to walking about the house, a bipo- others have shown that reduction in more than 20 de-
VOL. 76-A. NO. . JUNE 1994

..-- - -
- - 20
Schematic drawings showing the technique for a valgus osteotomy of the proximal end of the femur in the treatment of a non-union of a
femoral neck fracture. The osteotomy has changed the vertical orientation of the fracture line from 55 to 20 degrees. (Reprinted, with
permission. from: Wehe. B. G.. and Cech. 0.: Pseudoarthrosis. Bern, Hans Huber, 1976.)
grees of valgus is associated with a higher rate of os- screws at an angle of 130 to 135 degrees in relation to
teonecrosis50. Any varus deformity after reduction is the femoral shaft. If they are positioned at a higher (140
also associated with increased rates of osteonecrosis and to 145-degree) angle, the holes will be created in the
non-union. Anterior or posterior angulation of more lateral cortex, at or distal to the level of the lesser tro-
than 10 degrees should not be accepted. particularly in chanter. Holes at this location have been associated with
osteoporotic bone: such angulation increases the poten- a 20 per cent prevalence of subtrochanteric fracture5.
tial for redisplacement of the fracture because the bone
Operative Technique with the
is weak. The surgeon should pay particular attention
Use of Three Cannulated Screws
to the degree of posterior comminution seen on the
lateral radiograph. Both Garden and Banks have shown A one-eighth-inch (0.32-centimeter) guide-pin is
that fractures with marked posterior comminution have laid along the anterior aspect of the fernoral neck at an
a higher prevalence of non-union73. When treating
fractures with a large amount of posterior comminu-
tion, the surgeon should place the superior and poste-
nor screws along the calcar femorale to resist posterior
collapse (Figs. 6-A and 6-B). In some patients, bone-
grafting of the posterior aspect of the femoral neck may
be considered.
A displaced fracture that cannot be reduced in a
closed fashion in an elderly patient who has high func-
tional requirements and is able to walk about the corn-
munity (generally, a patient who is less than seventy-five
years old and has few medical problems) or in a younger
patient should be treated with open reduction and in-
ternal fixation. In a more fragile. elderly patient, the
surgeon should proceed with prosthetic replacement.
The use of multiple pins, such as Knowles pins, or of
screws is a simple and effective technique for fixation of
well reduced femoral-neck fractures. This technique can
be done percutaneously with use of a local anesthetic,
or it can be performed with an open technique with the
patient under general or spinal anesthesia. Stability at Fio. 9
the site of the fracture is maximized by the placement Multiple-screw of a fracture
fixation of the femoral neck and
of three pins in a triangular configuration. Mechanical plating of a fracture of the femoral shaft. (Reprinted, with permis-
sion, from: Kyle, R. F.: Fractures of the hip. In Fractures and Disloca-
studies have not proved the effectiveness of the use of tions, edited by R. B. Gustilo, R. F. Kyle. and D. C. Templeman. Vol.2,
more pins. Care must be taken to place the pins or p. 810. St. Louis, Mosby-Year Book, 1993.)

angle of 135 degrees. according to the technique of be tightened simultaneously. to apply uniform compres-
Tronzo. This guide-pin should appear. on image inten- sion across the fracture and to avoid tipping of the fem-
sification. to lie adjacent to the medial cortex of the oral head into varus angulation. The guide-pins are then
femoral neck. A 3.8-millimeter drill-hole is made in the removed, and image intensification is used to confirm
mid-part of the lateral cortex, parallel to the anterior the proper position of all three screws.
guide-pin. The position of the drill-bit is checked on the
anteroposterior and lateral radiographs. The drill is then Complications
removed, and the guide-pin is placed in the drill-hole. Non-union: Non-union of femoral neck fractures.
Under image intensification, the guide-pin is tapped which usually becomes apparent within one year. was
into place along the medial cortex of the fernoral neck reported in thirty-four (1 1 per cent) of 301 patients in
and into the head to within five millimeters of the sub- one series7, in thirty-nine (33 per cent) of 119 patients
chondral bone. The guide-pin should lie slightly inferior in another series2, and in none of five patients in a
in the femoral head on the anteroposterior radiograph third series. Arnold et al. reported a 15 per cent rate
and in the center of the head on the lateral radiograph. of non-union in 1000 patients who had a displaced
After this guide-pin has been placed. two more guide- fracture5. This range of occurrence may be explained
pins are inserted with use of image intensification. On by differences in the types of fractures and in the meth-
the anteroposterior radiograph, these pins lie slightly ods used for reduction and fixation. Non-union may
superior in the femoral head; on the lateral radiograph, or may not be accompanied by osteonecrosis. If non-
one lies slightly anterior and the other, slightly posterior, union occurs, a magnetic resonance image must be
forming a triangular pattern of guide-pins. Next, the made to evaluate the viability of the femoral head be-
length of the screws to be implanted is determined by fore the options for treatment are considered. In an
direct measurement of the guide-pins, each of which lies elderly patient who is able to walk about the commu-
within five millimeters of the subchondral bone of the nity, a non-union is treated with a total hip replace-
fernoral head (Fig. 7). Cannulated screws are then ment; in a younger patient, a Pauwels valgus osteotomy
driven over the guide-pins. The inferior screw is placed and repeat fixation are used. In a younger patient who
first. followed by the superior screws. The screws should has collapse of the fernoral head concurrent with a
FIG. 10-A FIC;. 10-B FI;. 10-C
Radiographs showing various problems with the older. solid fixation devices. The bone has impacted to a stable position. causing the implant
to break (Fig. 10-A). to penetrate the hip joint (Fig. 10-B). and to cut out of the femoral head (Fig. 10-C). (Reprinted. with permission. from:
Kyle. R. F.: Fractures ofthe hip. In Fractures and Dislocations. edited by R. B. Gustilo. R. F. Kyle. and D. C. Templeman. Vol. 2. p. 845. St. Louis.
Mosby-Year Book. 1993.)
VOL. 76-A. NO. 6. JUNE 1994

wt433 M434
4 1
Osteotomy
OsteotomyL-
rn
wi4
WI. 434
Fio. 11-A
Figs. 1 I-A and 1 I-B: Drawings depicting two techniques of a stabilizing osteotomy for the treatment of an unstable intertrochanteric
fracture. (Reprinted. with
permission. from: Kyle. R. F.: Fractures of the hip. In Fractures and Dislocations, edited by R. B. Gustilo, R. F. Kyle.
and D. C. kmpleman. Vol. 2. p. 530. St. Louis. Mosby-Year Book. 1993.)
Fig. I 1-A: The medial displacement technique of Dimon and Hughston27. Wt. = weight.
non-union, a total hip replacement is indicated. Most tramedullary fixation. The femoral neck should be re-
non-unions have drifted into some varus angulation. duced. and it may be pinned temporarily with three one-
and a valgus intertrochanteric osteotomy allows corn- eighth-inch (0.32-centimeter) Kirschner wires, placed
pression loads to occur at the fracture site to promote anteriorly to avoid interference with the intrarnedullary
healing (Fig. 8). Another option for treatment is the nail. The intramedullary nail can then be introduced
use of a posterior muscie-pedicle graft. The success of through the piriformis fossa. The fernoral shaft should
this treatment is difficult to assess since the reported be overrearned by two millimeters to facilitate driving
series have been so smalI49. of the nail without excessive force, which could displace
Osteonecrosis: Over-all, the reported rate of osteo- the fernoral neck fracture. After the fracture of the fern-
necrosis in patients who have had a displaced femoral- oral shaft has been reduced and fixed with the nail, the
neck fracture has ranged from 4 to 40 per cent72 temporary fixation of the neck is removed, and three
Fielding et al. reported osteonecrosis in forty guide-wires are placed around the intramedullary nail
(16 per cent) of 256 patients3. The wide range in rates and into the femoral head under image intensification.
may. again. be explained. at least in part. by differences Cannulated screws are driven over the guide-wires,
in the types of fracture and in the respective authors with use of the technique described earlier. The intra-
chosen methods of reduction and fixation. Osteonecro- medullary nail must be locked to prevent rotation and
Sis is usually partial and does not involve the entire shortening at the site of the fracture of the shaft.
femoral head. In many patients. the head does not col- Alternatively, a second-generation locking nail (one
lapse. If a patient is asymptomatic. no additional treat- with two proximal locking screws, which are inserted
ment is indicated. If the osteonecrotic fragment has into the greater trochanter and angled into the femoral
collapsed and the patient is symptomatic but is able to head) may be used to stabilize the fernoral neck. but
walk about the community, total hip arthroplasty is proper placement of the locking screws in the femoral
indicated. head may be difficult, since the screws must be driven
through the nail. If there is a problem with placement
Operative Technique for Fractures of the Femoral Neck
of the screws through the second-generation nail, addi-
(111(1 the Ipsilateral Femoral Shaft
tional screws can be used outside of the nail. Swiont-
Special considerations may be necessary for a pa- kowski et al., as well as Sanders et al., described a
tient who has a fracture of the ipsilateral fernoral shaft. method in which a nail is inserted. after reaming, retro-
The injury of primary importance in this fracture com- grade from the medial fernoral condyle295. This tech-
plex is the femoral neck fracture. which must be reduced nique requires the use of a very flexible nail, and it may
and stabilized before fixation of the femoral shaft is result in valgus deformity at the site of the femoral shaft
attempted. fracture if it is not performed properly.
The fracture of the shaft may be treated with in- An acceptable, and recently more popular, alter-

and solid stabilization with multiple-point fixation. with

use of pins or cannulated screws, is the best way to
prevent osteonecrosis and non-union. In an elderly pa-
tient, a hemiprosthetic replacement is a good option.
Total hip replacement should be reserved for a patient
who has concomitant hip disease or in whom fixation
Slightly
oblique
1.. . ; Inferior spike of bone
has failed.
,__#Iv, [z; removed If necessary
osteotomy
Intertrochanteric Fractures
The treatment of intertrochanteric fractures has ad-

vanced greatly in the last few decades. In the 1930s,
Jewett introduced the triflanged nail. which allowed the
surgeon to achieve immediate stability of the fracture
and early mobilization of the patient4#{176}. However, use
of the Jewett nail for the fixation of unstable intertro-
chanteric fractures has been problematic and loss of
135 I-beam nail is fixation has been common. Such a rigid implant does not
driven over guide-pin allow the impaction of comminuted fracture fragments
to occur. As a result, there is increased stress on the
implant if union does not occur rapidly: the implant will
ultimately fatigue and fail, or it will penetrate and cut
out ofthe fernoral head2 (Figs. 10-A, 10-B,and 10-C).
Fracture is again
reduced and impacted
Plate is fixed to shaft
. Medial
cortices
apposed
Fl. Il-B
Il#{236}e
valgus osteotomy technique of Sarmiento and Williams03.
native is the routine stabilization and fixation of the

femoral neck fracture with multiple pins, followed by
plating of the femoral shaft fracture (Fig. 9). This ap-
proach allows the surgeon to stabilize the more critical
femoral-neck fracture adequately in a standard fashion.
The femoral shaft may then be exposed and plated with-
out fear of disruption of the femoral neck fixation. This
is the easiest and most reliable way of treating this corn-
plex pattern of injury in most patients.
In summary. proper treatment of fernoral neck frac-
tures depends on the age of the patient and the degree
of displacement of the fracture. A suggested algorithm
for treatment has been developed (Fig. 5). Concomitant
injuries and medical problems must also be evaluated.
A non-displaced femoral-neck fracture should be fixed
in situ for the best results. A displaced fernoral-neck Radiograph showing migration of Ender nails in an intertrochan-
fracture remains, in some ways, the unsolved frac- teric fracture. Nail migration is associated with high rates of varus
deformity and knee pain. (Reprinted. with permission. from: Kyle.
ture.7 Reduction and fixation should be performed as
R. F.: Fractures of the hip. In Fractures and Dislocations. edited by
soon as the patient is medically stable, to restore the R. B. Gustilo, R. F. Kyle. and D. C. Templeman.Vol. 2. p. t3l . St. Louis.
blood supply to the femoral head. Anatomical reduction Moshy-Year Book, 1993.)
VOL.. 76-A, NO. . JUNE 1994

the guide-pin in the center of the femoral head (Fig. 16).

A small drill-bit should be used to allow rapid reposi-
tioning of the guide-hole for accurate placement of the
pin. The drill-bit should be advanced at a high angle
LU
0 across the fracture site to the subcapital level of the
0 femoral head. During advancement, the position of the
U.
LU drill-bit should be checked under image intensification
(:, on both anteroposterior and lateral radiographs to en-
:i sure proper aim toward the center of the head. The
cl) drill-bit should lie at the highest angle anatomically pos-
Li
sible along the medial cortex of the neck fragment, yet
w it should be in the center of the femoral head on both
Cl)
anteroposterior and lateral radiographs. After drilling

has been accomplished, the drill-bit should be removed
U.
0 and the guide-pin should be passed into the drill-hole,
0
to the level of the subchondral bone. The exact nail-
plate angle that is required for fixation should be deter-
mined with use of a variable-angle guide.
If posterior sag of the fracture occurs, the fracture
should be reduced with upward pressure applied to the
130 140 150
buttock or femur. Pressure must be reapplied during
NAIL-PLATE ANGLE
each passage of the instruments across the fracture to
Fi;. 17
prevent jamming of the instruments on the guide-pin.
Graph in which the ease of sliding of the device is plotted against
the nail-plate angle. The higher the angle. the greater the ease of After insertion of the screw, the plate should be
sliding. The closer the nail-plate angle to the resultant force across fixed to the lateral aspect of the shaft with at least four
the hip. the more force available to assist impaction of the sliding
cortical-bone screws. In osteoporotic bone, six screws
screw. (Reprinted. with permission. from: Kyle. R. F.: Fractures of the
hip. In Fractures and Dislocations. edited by R. B. Gustilo. R. F. Kyle.
are necessary. Medial fragments may be secured with a
and D. C. Templeman. Vol. 2. p. 835. St. Louis. Mosby-Year Book. lag-screw technique if they can be captured without
1993.) extensive dissection or periosteal stripping. Biomechan-
ical studies have shown increased stability of the frac-
across the subtrochanteric region of the femur5ou. ture after fixation of large medial fragments4. Image
intensification should be used during the final seating
Clinical Signs
of the nail or screw to ensure that the implant is well
A patient who has a displaced intertrochanteric within the femoral head and lying within five millirne-
fracture is typically seen in the emergency room with ters of the subchondral bone. This placement ensures
the affected limb externally rotated and shortened. adequate purchase in the femoral head and solid fixa-
Since movement of the limb causes severe pain, a forced tion of the femoral head and neck fragment to the shaft
range of motion should not be attempted. Kenzora et al. fragment.
showed that medical stabilization of the patient is essen- Successful treatment of intertrochanteric fractures
tial before an operation and that the timing of the op- depends on stable osteosynthesis. The ability of the fix-
eration should be dictated by the patients medical ation device to obtain firm purchase in the proximal and
condition, which must be evaluated very carefully. distal fracture fragments depends on the degree of os-
teoporosis of the bone, the fracture pattern, and the
Radiographic Evaluation
correct use of the fixation device. The ability of severely
Standard anteroposterior and lateral radiographs of osteoporotic bone to bear a substantial segment of the
the hips are made for evaluation. A fracture between load is impaired even when a collapsible device is used
the greater and lesser trochanters can be seen on the properly. For this reason, many of these fractures must
anteroposterior radiograph. The larger the fracture of be protected with limited weight-bearing postopera-
the lesser trochanter, the more unstable the fracture. tively. The purchase of the cortical-bone screws through
The surgeon should note the amount of posterior corn- the side-plates may also be impaired in osteoporotic
minution on the lateral radiograph. The greater the de- bone and may result in the plate pulling away from the
gree of posterior comminution. the more unstable the femoral shaft. This problem may be corrected by the use
fracture (Figs. 15-A and 15-B). of either a longer plate and more screws or supplemen-
tal cerclage wiring. A patient who has severe arthritis of
Operative Techii ique for Fixation
the acetabulum can be managed with an arthroplasty:
The most important step in the fixation of an in- however, primary arthroplasty is difficult and is associ-
tertrochanteric fracture is the proper placement of ated with a high rate of dislocation. In most patients who

FRA(IIJRES OF THE PROXIMAL PART OF THE FEMUR 937
TABLE I
Tt tt RII..&F1oNsI 111 I3FF\VEEN 1111 Rxii o1 FAIE.LJRF OF FIxvrIoN 5NI) rilE PosirloN oi IHE NAIl. IN TvlI.I II FRsc1t RlS
Distance of Nail-Tip from

Position of Nail Prevalence Suhchondral Bone Failures
on AP/Lat. Radiographsi Position of Nail No. Per Cent on AP/Lat. Radiographst No. Per Cent
(miii)
2/2 34 46 11/12 (1 0
2/3 22 30 14/7 1 5
2/1 4 5 9/5 0
1/2 6 8 12/IS 2
1/3 4 14/11 1
3/3 4 5 15/16 1
Modified. with
permission. from: Kyle. R. F.: Fractures of the hip. In Fractures and Dislocations. edited b R. B. Gustilo. R. F. Kyle. and
I). C. Templeman. Vol. 2. p. 535. St. Louis. Moshy-Year Book. 1993.
lAP = anteroposterior.
)lhe center position (2) is associated with the lowest rate of failure. A = anterior and P = posterior.
have an intcrtrochanteric fracture with associated mild withstand. In 1935, Pauwels concluded that the forces
degenerative changes. internal fixation is the procedure acting on the hip in single-limb stance are equivalent to
of choice. If a patient is symptomatic after the fracture approximately three times the body weight, applied at
has healed. an arthroplasty can be performed more eas- an angle of 159 degrees to the vertical plane77. These
ily later than when the fracture was fresh. data were confirmed later by numerous authors47.
The value of prophylactic use of antibiotics has been These same forces act on any hip-fixation device that is
proved. The rates of infection have been reduced from placed across the fracture site.
5 per cent to less than 1 per cent with the use of broad- A sliding device with a screw-plate angle closest to
spectrum antibiotics. begun before the operation and the combined force vector allows optimum sliding and
given for at least one day postoperatively. impaction. The closer the nail-plate angle to the resul-
tant vector of the forces across the hip. the more force
Biomechanics Sliding
of Devices in
available to assist impaction (Fig. 17). A device that is
the Fixatioiz of Fractures of the Hip placed at a lower angle has less force working parallel
To use a sliding device correctly in a patient who has to the sliding axis and more force working perpendicu-
a fracture of the hip. it is essential to understand the lar to the sliding axis. This perpendicular force acts to
mechanics of the device and the forces that it must jam or bend the device, thereby preventing impaction.
Fi;. 18-A Fio. 18-B

Anteroposterior (Fig. 18-A) and lateral (Fig. 18-B) radiographs showing the proper placement of a sliding device allowing spontaneous
impaction and medial displacement of the fracture to a stable position.
vol.. 76-A. NO. (. JtNE/ 1994

Technically. however, the surgeon cannot place the slid- lowed. If the fixation is unstable, as when the bone is
ing device at a high angle in a small hip or in a hip with osteoporotic, only partial weight-bearing is permitted.
a varus deformity. Mechanically. it is desirable to place
Postoperative Care
the sliding device at as high an angle as clinically possi-
ble while still maintaining the placement of the device The patient is allowed to sit, if doing so is comfort-
in the center of the head. A device that is placed at a able, on the day after the operation. If solid fixation has
lower angle may he used effectively in a stable fracture been obtained, the patient is allowed to walk between
because controlled collapse is not important for impac- parallel bars, bearing weight on the injured extremity
tion of the fracture and early weight-bearing. However, as tolerated, on the second or third postoperative day.
an accurate assessment of the stability of the fracture is Weight-bearing is progressed as tolerated. If the bone is
sometimes difficult. In these questionable situations, osteoporotic or if only poor fixation has been obtained,
placement of the device at a higher angle will allow delayed weight-bearing with use of toe-touch only is
impaction. regardless of the degree of stability of the necessary until callus has formed. If there is a subtro-
fracture. chanteric component to the fracture, weight-bearing
The ideal position for the nail or screw in the femo- should be delayed until callus is seen on the radiograph.
ral head is apparent from a radiograph of the proximal Radiographs should be made at weekly intervals for
part of the femur. The point of coalescence of the ten- the first two weeks to ensure that proper impaction of
sion and compression trabeculae results in a dense pat- the fragments occurs. Additional radiographs should
tern of cancellous bone in the center of the fernoral be made at four and six weeks after the fracture. The
head. This is where the best purchase in the bone can be final radiographs should be made six months after the
obtained for a fixation device. When these trabeculae fracture.
are absent, the surgeon can expect a higher rate of fail- Low-dose heparin is not effective in the prevention
ure with use of the device. Placement in the center of of thromboembolic disease in patients who have a hip
the femoral head, within five millimeters of the sub- fracture2. Coumadin (warfarin) is the most effective
chondral bone, has resulted in the lowest rate of clinical drug in the prevention of thromboembolic disease, but
failure in patients who have an unstable intertrochan- formation of a hernatoma can complicate treatment
teric fracture3 (Table I). After anatomical reduction, a with anticoagulants if the prothrombin time is not kept
properly placed sliding device allows spontaneous irn- within the recommended range of fifteen to eighteen
paction and medial displacement of all intertrochan- seconds. Continuous passive motion and intermittent
teric fractures into a stable configuration (Figs. 18-A use of a positive-pressure splint may be of value in the
and 18-B) This allows early mobilization ofthe patient. prevention of thromboembolic complications, but both
If a patient has good fixation, full weight-bearing is al- require a specialized apparatus, which may interfere
FIG. 19-A
Figs. 19-A, 19-B. and I9-(: Radiographs showing a combined intertrochanteric-subtrochanteric fracture of the proximal part of the right
femur.
Fig. I 9-A: Radiograph showing involvement of the piriformis fossa.

with the mobilization of the patient. Stable fixation of reported to be 90 per cent, although Boyd and Lipinski
the fracture. which allows rapid mobilization of the pa- found that, of twenty-eight non-unions, twenty-two (79
tient, is the most effective method for the prevention of per cent) united after operative treatment3.
thromboembolic disease. The most common mode of failure of fixation is the
hip-screw cutting out of osteoporotic bone. allowing the
Complications
fracture to collapse into varus angulation. If little bone
The complications of fixation of intertrochanteric is left in the femoral head after this has occurred, a
fractures are minimum. compared with those associated blade-plate can be used to restore stability. The plate
with fixation of other fractures of the hip. if the surgeon provides more surface area to resist cutting out through
uses the appropriate device correctly and pays attention the femoral head. If the acetabulurn has been injured by
to accepted mechanical principles. The rate of failure the protruding nail. a total hip replacement is the treat-
with use of a collapsible hip-screw or nail of contempo- ment of choice.
rary materials and design is less than S per cent. With
prophylactic use of antibiotics, the rate of infection is Type-IV Fractures
less than 1 per cent. Osteonecrosis is extremely rare, A sliding hip-screw or a second-generation locking
occurring in less than 1 per cent of patients. nail may be used in the treatment of intertrochanteric-
The rate of non-union is less than 10 per cent. If subtrochanteric fractures that have a femoral shaft cx-
non-union does occur. the rate of success after simple tension. The second-generation locking nail is an
removal of the device, renailing in a more valgus posi- excellent form of fixation if the piriformis fossa is intact.
tion, and insertion of a cancellous bone graft has been When the piriformis fossa is not intact, treatment with
Fio. 19-B FIG. 19-C
Fig. 19-B: Fixation is best accomplished with a sliding hip-screw, as it is very difficult to use an intramedullary nail when the piriformis fossa
is fractured.
Fig. 19-C: Six months postoperatively. the fracture has healed.
VOL. 76-A. NO. (. JUNE 1994

Fio. 20-A FIG. 20-B
Figs. 20-A and 20-B: Schematic drawings of a reverse oblique fracture. These fractures are difficult to reduce and to fix because of the forces
that displace the distal fragment medially.
Fig. 20-A: In this fracture. a low-angle nail has been used. The barrel of the screw is placed through the lateral cortex of the proximal
fragment. thus preventing displacement.
Fig. 20-B: If the piriformis fossa is not involved, a second-generation nail (with two locking screws) may be used to prevent displacement of
the distal fragment.
a hip-screw with a long side-plate. combined with lim- Large fragments between the proximal and distal seg-
ited intcrfragmentary fixation and supplementary bone- ments are stabilized with interfragrnentary fixation and
grafting. is advisable (Figs. 19-A, 19-B, and 19-C). In placement of bone-screws through the side-plate, if the
subtrochanteric fractures that extend quite distally into fragments can be retrieved and fixed without additional
the shaft and that are combined with an intertrochan- periosteal stripping. Anatomical restoration of all corn-
teric fracture and involvement of the piriformis fossa, a minuted fragments is not necessary. Grafting of the me-
second-generation intramedullary nail may be the only dial defects with autogenous bone should be done to
option; however, the surgeon should anticipate difficulty promote early healing if medial comminution is present.
in its use because the starting point has been destroyed. A reverse oblique fracture3 needs special consider-
ation, because the major fracture line extends from
Operative Technique
proximal-medial to distal-lateral through the intertro-
For type-IV intertrochanteric-subtrochanteric frac- chanteric-subtrochanteric region (Figs. 20-A and 20-B).
tures, a one-eighth-inch (0.32-centimeter) guide-wire is While this type of fracture should be fixed in a manner
first placed into the proximal neck-and-head fragment, similar to that used for a type-IV fracture, it may be
as is done for routine type-I, II, and III fractures. The difficult to reduce, because the adductors and iliopsoas
distal aspect of the shaft is then exposed by dissection are intact and they pull the distal fragment medially
of the vastus lateralis from the lateral aspect of the shaft while the proximal fragment is abducted, flexed, and
with a periosteal elevator. The posterior sag is reduced pulled laterally. These fractures should be fixed with a
by traction and with pressure applied directly under the screw-plate placed at a lower angle so that the fixation
buttocks or femur at the site of the fracture. The frag- device does not have to be placed directly along the
ments are aligned by traction applied through the soft- fracture site. The fracture is reduced with manual trac-
tissue attachments with use of the principles of indirect tion and is held in place with a bone-clamp. Excessive
reduction as described by Kinast et al.2. The side-plate traction may cause additional displacement; often, the
is then applied to the distal aspect of the shaft and is traction must be released and the fragments must be
secured with a Verbrugge bone-clamp. The proximal rotated slightly and reduced manually to the side-plate.
fragment is well fixed by placement of the hip-screw in A longer side-plate is recommended for these fractures
the center of the head. The distal fragment is fixed by because of their distal extension. Some authors, such as
capture of at least eight cortices with four bone-screws. Kinast et al., have advocated the use of a right-angle

nail2. However, this device places high stresses on the internal fixation again became more popular, although
nail-plate junction. A second-generation locking nail complications remained frequent. Fielding and Magliato
may also be used for stabilization5. An advantage of the reported complications in association with sixteen (25
intramedullary position of this device is that it prevents per cent) of sixty-four subtrochanteric fractures that had
medial displacement of the distal fragments. been consecutively treated with a Jewett nail. The treat-
ment was a failure in ten (40 per cent) of the twenty-five
Postoperative Treatment fractures that were distal to the lesser trochanter.
A patient who has a type-IV fracture is allowed to KUntscher, in 1939, reported on the concept of in-
sit the day after the operation. Unlike the protocol for tramedullary fixation of subtrochanteric fractures with
a patient who has a type-I, II. or III fracture, weight- a Y nail. However, this double nail. the large trian-
bearing is delayed until callus has formed. The patient gular metal wedge of which was driven into the head
is then allowed to increase weight-bearing gradually as and neck fragment, proved difficult to use, and it did not
tolerated. gain general acceptance.
In summary, the treatment of unstable and complex
intertrochanteric and intertrochanteric-subtrochanteric
fractures has been simplified by the development of 5
newer techniques and devices, which, in general, have

been highly successful. Solid fixation of the proximal
fragment to the distal fragment with use of a sliding
device and a side-plate allows bone impaction and the
restoration of medial stability, with few complications.
Nevertheless, complications can result because intertro-
chanteric fractures frequently occur in osteoporotic
bone and in patients who are quite ill. With a thorough
understanding of the biornechanics of these fractures,
meticulous attention to operative technique, and mod-
em medical management, union can be achieved in
most patients, with minimum morbidity.
Subtrochanteric Fractures
Subtrochanteric fractures of the femur account for

10 to 15 per cent of all fractures of the hip and are among
the most problematic ones to treat. These fractures occur
in the most highly stressed region of the skeleton.
Koch described compressive forces of greater than 1200
pounds per square inch (8,274,()00 pascals) in the medial
cortex distal to the lesser trochanter and tensile stresses
FIG. 21
of 1000 pounds per square inch (6,895,000 pascals) in the Compressive forces of more than 1200 pounds per square inch
lateral cortex353 (Fig. 21). Such high stresses predispose (8,274,0(X) pascals)3 may occur along the medial cortex of the femur,
internal fixation ofthese fractures to a high rate of failure one to three inches (approximately two and one-half to seven and
one-half centimeters) distal to the lesser trochanter. This is the most
and account for the great difficulty in both operative and highly stressed region in the body. (Reprinted, with permission. from:
non-operative treatment. Kyle. R. F.: Fractures of the hip. In Fractures and Dislocations, edited
In 1891, Allis described the difficulty involved in by R. B. Gustilo. R. F. Kyle. and D. C. Templeman. Vol. 2. p. 814. St.
Louis, Mosby-Year Book. 1993.)
the treatment of these fractures in traction, and the re-
sultant high rates of varus deformity and non-union3.
Because of these problems, Lambotte, in 1907, recorn- The first intramedullary device known to be used
mended open reduction and internal fixation with a successfully was developed by Zickel in the 1960s
combination of hip-nails and cerclage wiring5. Hibbs, (Figs. 22-A and 22-B). He reported very low rates of
in 1902, advocated traction followed by use of a cast#{176}. failure in several clinical series: none of five devices
Because of the mechanical problems with early devices, failed in a preliminary report; two of eighty-four, in
most surgeons, before the 1950s, took the advice of 1976; and three of 184, in 198011112. The Zickel nail was
Hibbs and treated these fractures with traction followed a great advance in the treatment of subtrochanteric frac-
by immobilization of the limb in a plaster cast. Most of tures, and the device was the most effective one used
the fractures healed, but with shortening and varus de- through the early 1980s. However, it could not be in-
formity. In addition. prolonged treatment in bed pro- serted with a closed technique. and it did not stabilize
duced a high rate of medical complications. the fracture against compressive forces. Shortening of
After the development of the triflanged nail-plate, the femur occurred unless cerclage wiring or inter-
VOL. 76-A, NO. ti. JUNE 1994

fragmentary fixation was used. There were also techni- teric fractures with an intramedullary nail and lock-
cal difficulties during insertion, and refracture of the ing screws was introduced. More recent advances in
femur occurred occasionally during extraction of the both technique and design have made possible the intra-
nai 74.I0) medullary fixation of subtrochanteric fractures that ex-
The AO angled blade-plate. introduced in the 1970s, tend into the shaft. Although it was believed that locking
was effective if the medial buttress could be restored nails might predispose a fracture to non-union because
and the plate could be used as a tension band. This they maintain distraction of the fracture fragments, din-
technique required accurate realignment and stable fix- ically this has not been the case. All known reported
ation of all medial fragments5. series of closed interlocking intramedullary nailing have
The sliding hip-screw or nail device, popularized by shown a high rate of union, a low rate of infection, and
Clawson3 and by Massie in the 1960s, was used in excellent maintenance of alignment25. The high
proximal subtrochanteric-intertrochanteric fractures, rate of mechanical failure noted with use of the Jewett
but the rate of failure was high in comminuted fractures nail has not been demonstrated with these newer devices.
with extension into the femoral shaft#{176}.The develop- The rapid rate of healing is attributed to the closed
ment of higher-strength metals, such as cold-worked operative technique, which gives excellent stabilization
stainless steel and titanium, markedly reduced the rate of the fracture and, through reaming, provides autoge-
of failure of these telescoping screw devices. The success nous bone graft to the area of the fracture. With reaming,
of these devices in the treatment of both subtrochan- larger (stronger) nails can be placed in the shaft of the
teric and comminuted intertrochanteric-subtrochanteric femur. The intramedullary position of the nail, as with the
fractures was improved further by the use of bone- Zickel device, greatly reduces the lever arm at the screw-
grafting about the highly stressed medial cortex. This nail junction, contributing to the decrease in the rate of
technique. which is used in conjunction with the method mechanical failure (Figs. 23-A and 23-B). The walls of
of indirect reduction advocated by Kinast et al.5, re- these nails are thicker than those of standard intra-
quires little or no periosteal stripping in the area of medullary nails, in order to reduce the stress-riser effect
comminution, and soft-tissue tension is used to realign of holes placed through them, and the increased thick-
the bone fragments. ness enhances their rigidity. For this reason, proper oper-
In the early 1980s, closed treatment of subtrochan- ative technique is critical to ensure that the wall of the
I2
FI;. 22-A
Radiographs showing a subtrochanteric fracture (Fig. 22-A) fixed with a Zickel nail (Fig. 22-B). (Reprinted, with permission, from: Kyle, R.
F.: Fractures of the hip. In Fractures and Dislocations. edited by R. B. Gustilo, R. F. Kyle. and D. C. Templeman. Vol. 2. p. 821. St. Louis,
Moshy-Year Book. 1993.)

femur is not fractured inadvertently during insertion of

the nail.
tvhchamusm of Injury
The cause of subtrochanteric fractures is related to
the age of the patient. In most series, including those
that we reviewed at the Hennepin County Medical Cen-
ter, approximately one-half of the injuries were the re-
sult of a high-energy trauma, such as an automobile
accident or a fall from a height, usually in young peo-
plc. The other half were the result of a low-energy fall
in elderly patients7. A combination of a direct blow on
the lateral
along
aspect
the femur.
of the greater
and muscular
trochanter,
pull creates
axial force
various pat-
m = Fxd
terns of subtrochanteric fractures. These deforrning
muscle forces were reported by Froimson35, who clearly
described the proximal fragment being abducted by the FIG. 23-A
gluteal muscles, flexed by the iliopsoas, and externally
rotated by the short external rotators and the distal
fragment being displaced medially by the strong pull of
the adductors.
Classification
There have been multiple systems of classification

of subtrochanteric fractures. Some are complex and oth-
ers are simple, but few have taken into account the
mode of treatment or the prognosis. The classification
of Fielding and Magliato describes three types of frac-
tures on the basis of the location of the primary fracture xd
line in relation to the lesser trochanter5. In type I, the
fracture line is one inch (approximately two and one-
half centimeters) distal to the lesser trochanter; in type
II. two inches (approximately five centimeters) distal; FIG. 23-B
and in type III. three inches (approximately seven and Figs. 23-A and 23-B: Diagrams depicting the moment on the nail.
one-half centimeters) distal5. Zickel, in 1976, described An intramedullary position reduces the moment (m) on the angle of
six types of subtrochanteric fractures: four oblique and the nail by reducing the distance (d) over which the bending force (F)
acts.
two transverse. The classification of Seinsheirner in-
eluded four types. with type I being the most proximal lesser trochanter). Both types of fracture may be either
and type IV, the most distal. He further classified each simple or comrninuted, with extension into the shaft.
type into subtypes A, B, and C, with subtype A being In a type-I fracture in which the piriforrnis fossa is
the most stable and subtype C, the most unstable and fractured, a sliding hip-screw is used because the central
comminuted. The AO group developed a classification entry point for insertion of an intrarnedullary nail has
system that is based on the degree of comminution; been lost. In a type-I fracture in which the piriforrnis
however, in their system, the region of the lesser tro- fossa is intact, a second-generation locking nail is used
chanter is always intact72. because the entry point for the intramedullary nail is
The classification system currently used by us at undisturbed.
the Hennepin County Medical Center is based on the On occasion, in a very distal type-I fracture of the
method of treatment. with the fractures divided into two ipsilateral fernoral shaft, despite involvement of the pir-
types (Fig. 24). In type I, or high subtrochanteric frac- iformis fossa, we use a second-generation locking nail.
tures. the fracture line extends into the lesser trochanter. In a type-Il fracture in which the lesser trochanter and
Since the lesser trochanter is broken off, fixation must the piriformis fossa are intact, we use a first-generation
be obtained with either a sliding hip-screw or a second- locking nail.
generation locking nail. In type II,or low subtrochanteric
fractures, the lesser trochanter remains intact, and the Clinical Signs and Symptoms
fractures can be treated with a first-generation locking On presentation, the affected limb is markedly short-
nail (a nail, with a single proximal locking screw, that is ened and externally rotated. In a younger patient who
positioned retrograde from the greater trochanter to the has sustained high-energy trauma, the surgeon must be
VOL. 76-A. NC). (. JUNE 1994

TYPE I - HIGH TYPE II - LOW

F
J;)
.#-,-. V
t;)
COMMINUTED COMMINUTED SIMPLE COMMINUTED

DISTAL FRACTURE
A. Simple B. (omminuted (. Piriformis Fossa Intact
.5Ii1ii,t2 IIij .S(rea Sliding 1/i1; Siren cit/i I)isiai .5/taft 1.ciensio,s
IiieriuiI Iicatits t !iP5. .StcOI(I(;(fl(raIlO?z
(;r(iIi I.O(kW5 .\(IIl
FIG. 24
(lassification of subtrochanteric fractures (top). used at the Hennepin County Medical Center, and a flowchart (bottom) showing the
various methods of treatment. A type-I simple. high fracture involves the lesser trochanter and is treated with a sliding hip-screw or a
second-generation locking nail. In a type-I comminuted fracture that involves the piriformis fossa, the sliding hip-screw is preferred because
of the difficulty encountered with insertion of an intramedullary nail. In a type-Il simple or comminuted low fracture, a first-generation
locking nail (with a single locking screw) is used. (Modified, with permission. from: Kyle, R. F.: Fractures of the hip. In Fractures and
Dislocations. edited by R. B. Gustilo, R. F. Kyle. and D. C. Templeman. Vol. 2, p. 819. St. Louis, Mosby-Year Book. 1993.)
aware of accompanying injuries to the pelvis. axial spine, formed within forty-eight hours after the injury.
and other long bones. Associated pelvic and long-bone
Operative Techniquefor the Use of
fractures were found in 46 per cent of such patients who
Locking Intramedullary Nails
were evaluated at the Hennepin County Medical Cen-
ter7. The patient must also be evaluated for hernody- The surgeon may elect to perform the intramedullary
namic instability because of the loss of blood due to the nailing with the patient in either the supine or the lateral
high-energy fracture. position. The supine position is preferable, since it facil-
After being stabilized in the emergency room, the itates radiographic visualization of the hip in both the
patient is taken to the radiology suite for evaluation of anteroposterior and the lateral planes and makes posi-
the bone injuries.The fracture is splinted in Buck traction tioning of the patient easier. A patient who has sustained
or in a Thomas splint with a Pearson attachment during multiple trauma should always be placed in the supine
transfer. In a patient who has sustained multiple trauma, position to allow ease of access to the airway as well as
the fracture should be stabilized on an emergency basis. to facilitate treatment of the other injuries. The supine
If the patient has an isolated subtrochanteric fracture. position also facilitates reduction of the fracture and
stabilization may be delayed, but it should still be per- obtainment of an acceptable rotational alignment of the

guide-wire must lie at the base of the femoral neck,

just medial to the greater trochanter on the antero-
posterior radiograph and just anterior to the piniformis
fossa on the lateral radiograph.
After the guide-wire has been positioned correctly
and driven into the femur, the proximal end of the
femur is opened with use of a one-half-inch (1.27-
centimeter) diameter drill-bit. Alternatively, an awl
may be used to broach the proximal end of the femur
(Fig. 29). A T-handled reamer is then used to ream the
proximal part of the medullary canal.
A bulb-tipped guide-wire with a 35-degree curved
tip is then inserted into the medullary canal and passed
across the fracture site into the distal fragment. If the
PIRIFORMIS FOSSA
FIG. 25
Figs. 25-32: Drawings showing the operative technique for the use
of locking intramedullary nails.
Fig. 25: The patient is positioned on the fracture-table with the hip
in adduction and the torso away from the fracture, to aid in exposure
of the insertion site. (Reprinted. with permission, from: Kyle, R., and
Chadwick. R., Jr.: Operative technique for second-generation inter-
locking femoral nails. Op. Tech. Orthop.. 1(4): 288, 1991.)
femur (Fig. 25). However, with the supine position, it is

difficult to gain access to the tip of the greater trochanter
for insertion of the intramedullary nail. In these proximal FIG. 26
fractures of the femur, the proximal fragment is flexed The intramedullary nail must be inserted precisely: in the pirifor-
and abducted, making access to the greater trochanter mis fossa, beneath the flare of the tip of the greater trochanter in the
even more difficult. The lateral position may be used in posterior aspect of the femoral neck. (Reprinted, with permission.
from: Kyle, R. F.: Fractures of the hip. In Fractures and Dislocations.
patients who have an isolated subtrochanteric fracture. edited by R. B. Gustilo, R. F. Kyle, and D. C. Templeman. Vol. 2, p. 815.
Although this position allows easy access to the greater St. Louis, Mosby-Year Book, 1993.)
trochanter for insertion of the nail, reduction of the
fracture and radiographic visualization of the head-and-
neck fragment are more difficult. Good visualization of
the proper entry point for an intramedullary nail must be
obtained on both the anteroposterior and the lateral
radiographs. The point of entry should be in line with the
medullary canal on the anteroposterior radiograph and
should lie just anterior to the piriformis fossa on the
lateral radiograph (Fig. 26).
An incision is made beginning just distal to the flare
of the greater trochanter and extending proximally nine
to ten centimeters (Fig. 27). The fascia of the gluteus
maximus is incised in line with its fibers. The subfascial
plane of the gluteus medius is identified, and the pin-
formis fossa is palpated. This may be difficult in an
obese patient. especially if flexion and abduction of the
proximal fragment cause the tip of the trochanter to lie
against the ilium. Adduction of the limb and positioning
of the torso away from the affected extremity can help FIG. 27
to expose the tip of the trochanter. The skin incision should be in line with the femur and should
extend proximally from the greater trochanter. (Reprinted, with
A one-eighth-inch (0.32-centimeter) guide-wire is
permission, from: Kyle, R., and Chadwick, R., Jr.: Operative tech-
inserted into the piriformis fossa, and its correct posi- nique for second-generation interlocking femoral nails. Op. Tech.
tion is verified with image intensification (Fig. 28). The Orthop.. 1(4): 288. 1991.)
VOL. 76.A. NO. 6. JUNE 1994

After the guide-wire has been placed, the femur is

reamed according to the operative technique associated
with the particular device being used. Reaming should
proceed in one-millimeter increments until contact with
the cortical wall has been made, and it should then
continue in one-half-millimeter increments. If a second-
generation locking nail is used, it must be aligned
correctly with the anteversion of the femur. The fe-
mur should be reamed one to one and one-half milli-
meters more than the diameter recommended by the
manufacturer to allow free rotation of the nail within
the femur and easy accommodation for any anteversion
encountered.
The reaming nail is then exchanged for a driving
FIG. 28
wire with use of a plastic exchange tube. The proper
A guide-wire and step-drill are used to create the insertion site.
length of the intramedullary nail is determined by meas-
(Reprinted. with permission. from: Kyle. R.. and Chadwick, R., Jr.: urernent of the length of the guide-wire extending from
Operative technique for second-generation interlocking femoral the femur (Fig. 30) and subtraction of this length from
nails. Op. Tech. Orthop.. 1(4): 289. 1991.)
the total length. Preoperatively, direct radiographic
measurement of the contralateral, intact femur allows
the surgeon to select a nail of the proper length. This
step is particularly useful in the treatment of commi-
nuted fractures.
The nail is inserted over the driving wire, and its
proper rotation is estimated by careful assessment of
the anteversion as seen on the lateral radiograph of
the proximal part of the femur under image intensifi-
FIG. 29
cation. The proximal targeting device is used to insert
An alternative method for opening of the femur with use of an awl.
(Reprinted. with permission. from: Kyle, R., and Chadwick, R.. Jr.: two screws through the nail into the femoral neck and
Operative technique for second-generation interlocking femoral head. Cane must be taken to place the distal screw
nails. Op. Tech. Orthop., 1(4): 289, 1991.)
tightly against the medial cortex to prevent vanus de-
formity as well as to allow roorn for insertion of the
proximal screw (Fig. 31). This may be difficult in a
FIG. 30
Method of measurement of the correct size for the intramedullary

nail. If the two nails are of identical length, then the length X-Y can
be calculated easily. (Reprinted. with permission. from: Kyle, R., and
Chadwick, R., Jr.: Operative technique for second-generation inter-
locking femoral nails. Op. Tech. Orthop.. 1(4): 289, 1991.)
passing of the guide-wire proves difficult, pressure on

the anterior aspect of the proximal fragment, applied
either with the hand or directly with an instrument, may
aid in reduction. A small (ten on eleven-millimeter) nail,
inserted into the medullary canal, may also be used to
manipulate the proximal fragment into alignment with
the shaft fragment. Preliminary reaming of the proxi-
mal fragment to twelve millimeters to accommodate the
eleven-millimeter guide-nail is necessary. The guide-
wire is then passed through the nail and into the distal
pant of the femur, and the small nail is removed. FIG. 31
The surgeon should not attempt to place the guide- Placement of the guide-wires for the proximal screws. The guide-
wires should lie adjacent to the calcar cortex and in the appropriate
wire with the closed technique for more than twenty to
amount of anteversion. (Reprinted. with permission. from: Kyle. R.,
thirty minutes. After such an interval, the fracture site and Chadwick, R., Jr.: Operative technique for second-generation
should be opened for placement of the guide-wire. interlocking femoral nails. Op. Tech. Orthop.. 1(4): 290. 1991.)

small patient or in a patient who has a varus hip. Cane-

ful attention to the amount of anteversion, and the use
of guide-wires before insertion of the screws, will help
to ensure correct placement of the screws in the fem-
oral head and neck.
Attention is then turned to the distal aspect of the
femur and to the placement of locking distal screws to
prevent rotational deformity. I have found a modified
freehand technique to be the easiest way to insert the
distal screws (Fig. 32). After perfectly round distal holes
have been visualized under image intensification, a one-
centimeter incision is made oven the lateral aspect of the
thigh and a one-eighth-inch (0.32-centimeter) Kirschner FIG. 32
wire, secured to a radiolucent holder, is inserted down Freehand technique for distal locking. Care should be taken to align
to the femur to the center of the proximal hole. The wine the image so that both holes in the nail are collinear before placement
of the Kirschner wire. (Reprinted, with permission, from: Kyle, R., and
is then aligned in both planes under image intensifi-
Chadwick, R., Jr.: Operative technique for second-generation interlock-
cation and is driven through the hole in the nail with a ing femoral nails. Op. Tech. Orthop., 1(4): 290, 1991.)
mallet. Proper placement of the Kirschnen wine through
the proximal hole is verified with image intensification. ods of treatment of subtnochantenic fractures. When
The wire is then removed, and a hole of proper size is such a deformity occuns and the patient is symptomatic,
drilled through the nail, following the track made by either an open on a closed denotation osteotomy, with
the wire. A distal locking screw of correct length is in- insertion and locking of an intramedullany nod, should
serted. A second screw may be used to provide addi- be performed. A patient who has a symptomatic vanus
tional fixation. malunion should be managed with an intentrochanteric
valgus osteotomy and fixation with a blade-plate or hip-
Operative Techniquefor the Use ofSliding Hip-Screws
screw device.
If the piniformis fossa is involved in a proximal (type- Non-union: Non-unions of the shaft of the femur are
I) subtrochantenic-intentnochanteric fracture, a sliding treated with repeat reaming and insertion and locking
hip-screw should be used. The technique for placement of a larger intramedullany rod. Non-unions in the sub-
of the screw is the same as that descnibed earlier for tnochantenic region are treated with valgus osteotomy,
the treatment of intentrochanteric-subtnochantenic frac- bone-grafting, and refixation. Osteonecrosis is rare in
tures. Indirect reduction with minimum peniosteal strip- patients who have a subtrochantenic fracture.
ping should be used. Bone-grafting of the medial cortex In summary, the orthopaedic surgeon has a multitude
is done if this area is comminuted. of internal fixation devices and techniques available for
use in the treatment of subtnochantenic fractures of the
Postoperative Care proximal part of the femur. The successful use of second-
Strengthening exercises for the entire lower extrem- generation locking nails is technically demanding. Close
ity and range-of-motion exercises are begun immedi- attention to positioning of the patient, reduction of the
ately. Regardless of the device that is used, the patient is fracture, placement of the guide-wire, and insertion of
allowed to walk with use of crutches and toe-touching the nail and of the proximal and distal locking screws
until good formation of callus has been observed on is mandatory. The newer, high-strength hip-screws al-
radiographs. After this has occurred, progressive weight- low good fixation of a fracture that extends into the
bearing is started. The fracture callus is allowed to ma- piriformis fossa. If medial comminution is present, this
ture completely. If complete healing is observed, the technique is best performed in conjunction with indirect
fixation device may be removed fifteen to eighteen reduction and bone-grafting. With proper technique,
months postoperatively in a young and active patient or these devices allow the surgeon to manage predictably
in one who is symptomatic. a complex subtrochantenic fracture that previously had
to be treated with traction on extensive dissection and
Complications with (frequently inadequate) internal fixation.
Varus and rotational deformities: Rotational de-
Norr: The author thanks Laura C. Carroll and Sara J. Campbell for their assistance with
fonmity is uncommon with use of contemporary meth- the manuscript.
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Fractures of the Proximal Part of the Femur

BY RICHARD F. KYLE. M.D.t. MINNEAPOLIS. MINNESOTA

ilii Iiz.structiona/ Course Lecture, The Aniericati Acadenzv of Orthopaedic Surgeons

Prevalence and Prevention

924 THE JOURNAL OF BONE ANI) JOINT SURGERY

Greater trochanter group

3econdary tensile group

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An improved understanding of fracture patterns,

Fractures of the Femoral Neck

Clinical Presentation and Classification

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Principal compressive trabeculae describes subcapital fractures37. Types I through IV

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FIG. 10-A FIC;. 10-B FI;. 10-C

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and solid stabilization with multiple-point fixation. with

The treatment of intertrochanteric fractures has ad-

reduced and impacted

Plate is fixed to shaft

native is the routine stabilization and fixation of the

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the guide-pin in the center of the femoral head (Fig. 16).

anteroposterior and lateral radiographs. After drilling

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Distance of Nail-Tip from

Fi;. 18-A Fio. 18-B

vol.. 76-A. NO. (. JtNE/ 1994

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Fio. 19-B FIG. 19-C

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Fio. 20-A FIG. 20-B

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newer techniques and devices, which, in general, have

Subtrochanteric fractures of the femur account for

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femur is not fractured inadvertently during insertion of

There have been multiple systems of classification

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TYPE I - HIGH TYPE II - LOW

COMMINUTED COMMINUTED SIMPLE COMMINUTED

A. Simple B. (omminuted (. Piriformis Fossa Intact

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guide-wire must lie at the base of the femoral neck,

femur (Fig. 25). However, with the supine position, it is

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After the guide-wire has been placed, the femur is

Method of measurement of the correct size for the intramedullary

passing of the guide-wire proves difficult, pressure on

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small patient or in a patient who has a varus hip. Cane-

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