AO basic course

1. AOTrauma Principles Course
Subtrochanteric fractures
Martin van der Elst, NL

2. Subtrochanteric fractures
• Fractures
• Patients
• Therapeutic options
• Tips and tricks
• Conclusions

3. Müller AO Classification
31-A3
32-A1
32-A2
32-A3

4. A biomechanical challenge

5. Biomechanical problems
• Short proximal segment
• Long lever-arm
• Strong musculature
• Eccentric load

6. Typical dislocation

7. Gluteal muscles → abduction
Iliopsoas muscle → flexion + external
rotation

8. Two separate populations
• High-energy trauma—often seen in polytrauma
• Elderly—usually with osteoporosis and co-morbidities

9. Therapeutic options

11. Therapeutic option 1
• Traction?
- Very difficult to obtain and maintain reduction due to
strong muscular deforming forces
• Conventional plating
Therapeutic option 2

12. 29-year-old male 40-year-old female

13. 17-year-old women
Cons:
• Approach
• Cosmetic
• Devascularization
• Bone-grafting
• Demanding surgery
• Plate removal
• Refracture after
plate removal

14. Therapeutic option 3
• Biological plating
0
Postop3 m

15. Biology and biomechanics
• Preservation of viability is more important than
restoration of stability

16. Therapeutic option 4
Intramedullary nailing (IM),
antegrade or retrograde
Gerhard Küntscher 1900–1972
Accurate fitting
Reaming medullary canal

17. Conventional nailing
Simple/stable fracture
Narrow part medullary canal
Isthmus

18. Reamed nailing of shaft fractures
Cons:
• Massive interruption to endosteal blood supply
• Adds to the trauma by the fracuture

19. Nailing of subtrochanteric fractures
The solid femoral nail
1
2
2
3
1
2
3

20. Nailing of subtrochanteric fractures
• Essential in unreamed femoral nailing:
• Sufficient reduction
• Correct entry point

21. Nailing of subtrochanteric fractures
• Poor reduction
• Wrong entry point

22. Therapeutic option 5
• Proximal femoral nail (PFN, standard size)

23. Long PFN
• Long PFN
- proximal angle
- oval locking hole
- hip screw for locking

24. Long PFN

25. Long PFN
59y m

26. Tips and tricks

27. Fracture fragments are devitalized by
Trauma
Surgery
Impaired healing
Risk of infection

28. Positioning

29. Typical dislocation of proximal fragment
Patient positioning
abduction
nail introduction
is problematic
!
leg in strong
adduction

30. Nailing
UFN
Insertion point
Fossa piriformis
Long PFN
Insertion point
Trochanter tip

31. Nailing
Open reduction Temporary fixation
- forceps, cerclage wires

32. Use of IM nail as a reduction tool

33. Conclusion
Option 1: IM nail
• Closed reduction will be difficult
• Don’t be afraid to open fracture
to obtain a reduction
• Correct entry point is crucial
• Long PFN has some
advantages

34. Summary
• Good reduction is essential
• Correct entry point
• Open reduction is often required
• Plating is better than poor nailing