Subtrochanteric Femur Fractures

(1) The strong muscular envelope of the proximal femur contributes to the deforming forces on a subtrochanteric femur fracture, and must be fully understood in order to achieve an appropriate intraoperative reduction and prevent fixation failure. (2) The surgical stabilization of subtrochanteric femur fractures is primarily performed with antegrade medullary nails. (3) Multiple options for patient positioning during reduction may be appropriate; however, it is important to understand the effects of patient positioning on the surgeon’s ability to obtain and maintain an appropriate reduction. (4) Although many subtrochanteric fractures can be reduced through closed manipulative methods, the surgeon should be prepared to perform an open reduction of the subtrochanteric fracture. An appropriate open reduction is nearly always superior to a percutaneous malreduction. (5) Multiple designs of antegrade medullary nails exist (e.g., interlocking options, entry portals) and are all potentially appropriate for treatment of a subtrochanteric fracture. It is imperative to understand the specific advantages and drawbacks of each nail design to ensure appropriate fracture stabilization and avoid introducing iatrogenic malreduction. (6) Plate fixation may still be appropriate, or even preferred, in specific situations. These instances may include fracture comminution that extends into the antegrade medullary nail starting point, the presence of prior implants or preexisting anatomic abnormalities, or implants that prevent placement of a medullary nail. (7) Appropriate plate fixation may include the use of a 95° angled blade plate or proximal femoral locking plate. A surgeon using this technique must understand and respect the potential biomechanical drawbacks of plate fixation. Patients typically must be kept on protected weight bearing for a more prolonged period of time with plate fixation than with medullary nailing. (8) Most studies have demonstrated superior union rates and lower malreduction rates with the use of antegrade medullary nails than with plate fixation of subtrochanteric fractures. (9) The majority of complications after surgical treatment of subtrochanteric fractures pertain to malreduction or loss of reduction and failure of fixation. These complications can typically be mitigated by avoiding common pitfalls in fracture reduction, which include varus and apex anterior angulation. (10) Subtrochanteric nonunion can often be salvaged through correction of the deformity and compression of the nonunion. This is often best accomplished through use of a 95° angled blade plate or a revision medullary nail