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An 82-year-old man with right hip trauma
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An 82-year-old man had a syncopal episode due to an ischemic stroke. He subsequently fell from standing height onto his right lateral thigh. The patient’s medical history was significant for coronary artery disease, diabetes mellitus, Parkinson’s disease and dementia. The patient’s chief orthopedic complaint was lateral thigh pain and an inability to bear weight on his right lower extremity.
Physical examination of the right lower extremity revealed a closed injury with visible shortening of the limb. There was pain with any motion about the right hip. The patient had palpable pulses and an intact neurological examination. AP (Figure 1a) and lateral (Figure 1b) radiographs of the right proximal femur obtained as part of the patient’s initial trauma evaluation demonstrated a displaced comminuted fracture of the right proximal femur.
AP (a) and lateral (b) femur radiographs obtained at time of injury demonstrate a right comminuted proximal femur fracture.
Images: Conti Mica MR, Bernstein M
What is the diagnosis?
See answer on next page.
Subtrochanteric femur fracture
The patient was diagnosed with a right subtrochanteric femur fracture with two distinct fracture lines. As seen on the AP and lateral femur radiographs (Figure 1), there is an oblique, coronal plane fracture traversing the subtrochanteric region with a separate fracture line extending into the greater trochanter. This produces three fracture fragments: a proximal head/neck fragment, a posterior-based fragment of the greater and lesser trochanters, and the remainder of the shaft. Intraoperative traction films more clearly define the fracture pattern (Figure 2).
Michael R. Conti Mica
Mitchell Bernstein
Diagnosis of the fracture pattern
Various classification systems for subtrochanteric femur fractures have been proposed. The most notable was developed by Thomas A. Russell and J. Charles Taylor, who described it to aid in selecting the optimal biomechanical construct based on principles of intramedullary fixation. The first designation is based on involvement of the piriformis fossa: in type I fractures there is no involvement, whereas type II fractures involve extension into the piriformis fossa and greater trochanter. This distinction was made to address fractures with piriformis extension, which were thought to be a contraindication to the use of piriformis-start intramedullary nails. A greater trochanteric starting point is preferred in these cases. The subclassification of A or B is based on the on the involvement of the lesser trochanter. Discontinuity of the lesser trochanter from the proximal fragment limits bicortical fixation with a standard interlocking device and would be more appropriately treated with a cephalomedullary nail.
Given that our fracture falls within the subtrochanteric region of the femur with proximal extension into the piriformis fossa, with discontinuity between the proximal fragment and the lesser trochanter, this fracture most closely represents a type IIB. This type of fracture is best treated with a cephalomedullary device.
Intraoperative fluoroscopic images with traction are shown. AP of the proximal femur (a) demonstrates three separate fragments: 1) femoral head-neck fragment, 2) intertrochanteric fragment; and 3) shaft fragment. The arrow demonstrates the basicervical fracture. Lateral of the proximal femur (b) demonstrates the coronal plane and subtrochanteric fracture indicated by the arrow. Open reduction was performed and maintained with a ball spike and collinear clamp (c).
AP (a) and lateral (b) fluoroscopic images taken after placement of the nail.
Background
Subtrochanteric fractures can be a challenging pattern to treat. This is largely attributed to the deforming forces imparted on the individual fragments. Typically, as a result of the gluteus minimus and medius, the short external rotators, and iliopsoas muscles, the proximal fragment becomes flexed, abducted and externally rotated whereas the distal fragment is typically shortened and adducted by the adductor muscle group. This is important to recognize because closed reduction alone is not always able to reduce the fragments. Percutaneous reduction aids, such as ball-spikes, unicortical Schanz pins and Steinmann pins, can be used. Open reduction and clamp application is often required to neutralize the aforementioned deforming forces prior to intramedullary nailing. Furthermore, compared to intertrochanteric femur fractures, subtrochanteric femur fractures have a protracted healing time and, as a result of the energy required to fracture this dense region, are typically comminuted in younger patients.
Lateral fluoroscopic image demonstrates cerclage and interfragmentary fixation of sagittal displacement.
Final AP (a) and lateral (b) radiographs are shown.
It is therefore critical to appropriately differentiate this fracture from that of an intertrochanteric fracture. It is worth noting that the insertion of an intramedullary nail should not proceed until the reduction is obtained. In addition, the reduction must be maintained during reaming and final nail insertion.
Discussion and management
The patient presented with a coronal subtrochanteric fracture with proximal extension through the piriformis fossa that resulted in an additional head-neck fragment. Nonoperative management of hip fractures in the elderly has been associated with significant morbidity and a high incidence of mortality, and is typically reserved for patients who are medically unable to undergo the standard risks associated with surgery. Surgical management of the fracture was indicated in this patient to restore function and limit pain. Treatment options include open reduction and internal fixation with a plate-screw construct. This includes 95° blade-plates and proximal femoral plates. Alternatively, closed vs. open reduction and intramedullary nailing with a cephalomedullary device is a reliable option. The proximal extension of this fracture, resulting in a free head neck fragment, made a cephalomedullary device the best implant option.
The patient’s most recent follow-up at 4 months demonstrates a healed fracture and stable hardware.
The patient was positioned supine on a radiolucent spine table with an ipsilateral bump that spanned the entire torso. The use of a bump clears the ipsilateral femur from the contralateral femur on lateral intraoperative radiographs. The torso was abducted to unencumber the approach of the starting pin and ultimately the implant. The lateral position is also an excellent alternative. Distal femoral traction with 25 lbs. of weight was utilized throughout the case to facilitate reduction of length and gross alignment. Fluoroscopic images with traction (Figures 2a and 2b) best demonstrated the proximal basicervical fracture. It is this author’s belief that all subtrochanteric femur fractures treated with an intramedullary device require some sort of percutaneous or open assisted reduction. A lateral approach to the proximal femur was made and an open reduction was performed and maintained utilizing a ball spike and collinear clamp (Figure 2c). Aids for reduction included the use of ball spikes, collinear clamps, and bone hooks. It is critical that the femur be reduced prior to insertion of the nail. The femur was reamed and the cephalomedullary nail was then passed down the femoral shaft. Proximal locking screws were utilized to compress the head-neck component to the trochanteric fragment and prevent rotation. Next, the distal interlocking screws were placed under fluoroscopic guidance. Evaluation of the reduction on the AP (Figure 3a) fluoroscopic image demonstrated restoration of near anatomic alignment and length. Persistent displacement of the subtrochanteric fracture in the coronal plane was reduced (Figure 3b) and maintained utilizing a cerclage wire augmented by a single interfragmentary screw (Figure 4). Final radiographs are shown (Figure 5).
Postoperatively, the patient was made weight-bearing as tolerated. At 4 months of follow-up, the patient has no pain, is ambulating with his walker and his fracture is radiographically healed (Figure 6).
References:
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Browner BD. Skeletal Trauma. 1998, Philadelphia: W.B. Saunders Company.
Gardner MJ. Harborview Illustrated Tips and Tricks in Fracture Surgery. 2011, Baltimore: Lippincott Williams and Wilkins.
Kennedy MT. Injury. 2011; doi: 10.1016/j.injury.2011.03.023.
Moran CG. J Bone Joint Surg Am. 2005; doi: 10.2106/JBJS.D.01796.
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Stannard JP. Surgical Treatment of Orthopaedic Trauma. 2007, New York: Thieme.
For more information:
Michael R. Conti Mica, MD; and Mitchell Bernstein, MD, FRCSC, can be reached at Loyola University Medical Center, 2160 S. First Ave., Maywood, IL 60153. Conti Mica’s email: micontimica@lumc.edu; Bernstein’s email: mitchell.bernstein@lumc.edu.
Disclosures: Conti Mica and Bernstein report no relevant financial disclosures.