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 Subtrochanteric Femoral Fracture

Subtrochanteric femoral fractures are difficult fractures to manage. It is widely accepted that the most optimal way of fixing it is by an intra-medullary device. Whilst intra-medullary devices have certain advantages to the plates (locking plate, DHS, reverse LISS), the main disadvantage of the intra-medullary devices is the lack of reduction unless we open the fracture. And if the fracture is already open, we certainly lose the advantage of "intact fracture haematoma".

Simple question: "Is fracture haematoma more important than anatomical reduction in subtrochanteric fractures?"

Answer is not that simple but basic guidelines can be found on AO website. For more details ask uncle Google (i.e. absolute stability vs relative stability fracture) or better senior colleagues. 

X-rays below present one of the typical examples of "subtrochanteric fracture fixation" using an intra-medullary device.

Subtrochanteric Femoral Fracture
Subtrochanteric Femoral Fracture
Subtrochanteric Femoral Fracture
Subtrochanteric Femoral Fracture
Subtrochanteric Femoral Fracture

Fracture looks relatively "straight forward" on the initial X-ray. Intra-medullary fixation is certainly a good option. But is it really?

Looking through the intra-operative  and post operative X-rays this fracture fixation stands relatively small chances to heal. Why?  In my understanding Stress/Strain is the answer.

Please read Perren's article published in BJJ(formerly known as JBJS (Br). Does it make sense?

Few examples from my practice are below.

 Subtrochanteric fracture....

Subtrochanteric Spiral fracture with butterfly segment
Subtrochanteric Femoral Fracture
Subtrochanteric Spiral fracture with butterfly segment
Subtrochanteric Spiral fracture with butterfly segment
Subtrochanteric Spiral fracture with butterfly segment
Subtrochanteric Femoral Fracture
Subtrochanteric Spiral fracture with butterfly segment
Subtrochanteric Spiral fracture with butterfly segment
Subtrochanteric Spiral fracture with butterfly segment
Subtrochanteric Spiral fracture with butterfly segment
Subtrochanteric Spiral fracture with butterfly segment

Periprosthetic fracture....

 Subtrochanteric Femoral Fracture
 Subtrochanteric Femoral Fracture
 Subtrochanteric Femoral Fracture
 Subtrochanteric Femoral Fracture
 Subtrochanteric Femoral Fracture
 Subtrochanteric Femoral Fracture
 Subtrochanteric Femoral Fracture
 Subtrochanteric Femoral Fracture
 Subtrochanteric Femoral Fracture
 Subtrochanteric Femoral Fracture
 Subtrochanteric Femoral Fracture
 Subtrochanteric Femoral Fracture

 Subtrochanteric Spiral fracture with butterfly segment....

Subtrochanteric Femoral Fracture
Subtrochanteric Femoral Fracture
Subtrochanteric Femoral Fracture
Subtrochanteric Femoral Fracture
Subtrochanteric Femoral Fracture
Subtrochanteric Femoral Fracture
Subtrochanteric Femoral Fracture
Subtrochanteric Femoral Fracture
Subtrochanteric Femoral Fracture

 Comminuted Subtrochanteric fracture....

Subtrochanteric Femoral Fracture
Subtrochanteric Femoral Fracture
Subtrochanteric Femoral Fracture
Subtrochanteric Femoral Fracture
Subtrochanteric Femoral Fracture
Subtrochanteric Femoral Fracture
Subtrochanteric Femoral Fracture
Subtrochanteric Femoral Fracture
Subtrochanteric Femoral Fracture

As you can see from the cases above I will plate vast majority of subtrochanteric fractures. One of the reasons is that I have to open the fracture to reduce it. And when it is opened I just put a plate on it.

​More important reason is that it has to be reduced, otherwise IT WILL NOT HEAL.

My conclusion for subrochanteric femoral fractures:

NO REDUCTION = NO HEALING

And I believe we all know what "NO HEALING" entitles. Not good.

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  • Home
    • Knee Surgery >
      • Symptomatic Osteoarthritis of the Knee >
        • Primary Care >
          • Initial Management
          • Intermediate Care
          • Referral Treshold
        • Secondary Care >
          • Total Knee Replacement
          • High Tibial Osteotomy
          • Knee Arthroscopy
          • Complex Primary Total Knee Replacement
          • Postoperative Management
        • Procedures recommended by NICE
        • Procedures with limitations by NICE
        • Procedures not recommended by NICE
        • Viscosupplementation
      • Trauma to the Knee >
        • Meniscal Injuries
        • ACL Injury
      • Partial v Total Knee replacement
    • Limb Lengthening >
      • Femoral lengthening over the nail
  • Orthopaedic Trauma
    • Complex Trauma Impact
    • Principles of fine wire frame fixation >
      • Indications for fine wire frame
      • Complications >
        • Predictable complications
        • Unpredictable complications
      • Pin sites management
      • Activities >
        • Videos
        • Photos
    • Poller or Blocking screw >
      • Mechanic of Poller screw
      • Without and With a Poller Screw
      • Third Generation Poller Screws >
        • Epicentric poller screws in osteoporotic bone
        • Epicentric poller screws in comminuted spiral fracture
      • Use of Poller Screw(s) in Complex Cases >
        • Segmental Femoral Fracture
        • Low Supracondylar Femoral Fracture
        • Low Supracondylar Femoral Fracture 2nd case
        • Femoral Non-union - Antegrade Nail
        • Femoral Non-union - Retrograde nail
        • Distal Tibia Spiral Fracture
    • VAC irrigation
    • Complex Cases >
      • Femoral diaphysis defect
      • Capitellum Fractures
      • Distal Femoral Fractures
      • Proximal Humerus Fractures
      • Subtrochanteric Femoral Fractures
  • Osseointegration
    • Osseointegration-Physiotherapy
    • Osseointegration-Surgery
    • Osseointegration-NHS Perspective
  • Medico-legal
    • PI Solicitors
  • Blog
  • Contact
    • About
    • CV