craig sivaji maffulli rev -...

35Bulletin • Hospital for Joint Diseases Volume 60, Number 1 2001

AbstractSubtrochanteric fractures of the femur were originallygrouped with comminuted intertrochanteric fractures. How-ever, they pose their own distinct management problemsmainly due to biomechanical differences in stability andare now considered separately. There are several classifi-cation systems but the most widely accepted is the one pro-posed by Seinsheimer in 1978. Many different methods havebeen employed in the management of this group of frac-tures with varying rates of success. The management hasaltered as new implants have been developed to try to over-come the shortfalls of the existing implants. This study is areview of the literature and was carried out using Medlineand the Cochrane Library to look at the management meth-ods employed in the past and today. Most of the publishedarticles are retrospective uncontrolled reports of the re-sults of management and it is difficult to suggest manage-ment principles from them. The other main shortcoming isthat, although there are several devices available on themarket for the management of these fractures, most of theliterature concerns one or two of them. The results reportedexamine union rates and failure of implants leading to re-operation. This is a crude outcome measure, and there isvery little in the literature regarding patient function. Inorder to provide evidence-based advice on the best man-

agement options for these difficult fractures, future studiesshould be designed as randomized controlled trials andplace more emphasis on studying patients’ outcomes.

Subtrochanteric femoral fractures as a group posemany management problems for the orthopaedicsurgeon. Much has been written on their

management. Unfortunately, most of the literature concernscohort studies of patients with crude outcome measures suchas re-operation and non-union rates. There is very littleinformation on patient satisfaction with the outcome of thevarious management options. Most healthcare professionalsare of the opinion that the way to further knowledge issoundly planned and well-executed studies reportedhonestly in peer reviewed journals. In writing this review itproved very difficult to find such information regardingmany of the management options. More research using theaccepted standards is needed before rational treatmentalgorithms can be produced. It is, however, worth trying totie together the available information as it stands at present.

Subtrochanteric fractures (STFs) were originallygrouped with comminuted intertrochanteric fractures,1 andBoyd and Griffin2 were the first to report on the problemsencountered in these injuries. The incidence of STFs var-ies between 11% and 44%, depending upon the classifica-tion system used.3 Many authors noted a bimodal age dis-tribution.4-7

In this article, we review the published literature on thesubject, in an effort to give evidence-based directions onthe management of these injuries.

Classification of Subtrochanteric FracturesBoyd and Griffin2 considered STFs as a variant of intertro-chanteric fractures. There is little uniformity in the classi-fication of STFs.2,8 A comprehensive review of the English-language literature revealed at least 15 different

Subtrochanteric FracturesA Review of Treatment Options

Niall J. A. Craig MBChB FRCS(Ed) Chellappan Sivaji MCh(Orth) FRCS and

Nicola Maffulli MD MS PhD FRCS(Orth)

Niall J.A. Craig, M.B.Ch.B., F.R.C.S.(Ed.), Chellappan Sivaji,M.Ch.(Orth.), F.R.C.S., are in the Department of OrthopaedicSurgery, University of Aberdeen Medical School, Aberdeen, Scot-land. Nicola Maffulli, M.D., M.S., Ph.D., F.R.C.S.(Orth.), Pro-fessor and Head, Department of Trauma and Orthopaedic Sur-gery, Keele University School of Medicine, North StaffordshireHospital, Staffordshire, England.Reprint requests: Nicola Maffulli, M.D., M.S., Ph.D.,F.R.C.S.(Orth.), North Staffordshire Hospital, Thornburrow Drive,Hartshill, Stoke on Trent, Staffordshire, ST4 7QB, England.

36 Bulletin • Hospital for Joint Diseases Volume 60, Number 1 2001

classification systems for STFs. Most classification sys-tems have been used only by the originating authors, andmost are totally descriptive, with little bearing on manage-ment and outcome9 (Table 1). In view of this, it is best totreat each injury on an individual basis. However, a widelyaccepted classification system was introduced in 1978 bySeinsheimer10 (Table 2).

Mechanisms of InjuryIn younger patients, STFs are caused by high-energytrauma, such as motor vehicle accidents, vehicular-pedes-trian accidents, falls from significant heights, or gunshotwounds (nearly 10% of STFs in the USA3). In the olderage group, STFs occur with low-energy trauma, as in asimple fall. Frequently, these patients have osteoporoticbones, with widened medullary canals and thin cortices.Bergman and colleagues11 noted an average age of 40.6years in the high-energy trauma group and of 76.2 years inthe low-energy trauma group. High energy STFs are fre-quently associated with significant other local and distant

injuries. Given the ageing population and a rising incidenceof hip fractures, a rise in the numbers of STFs in this olderage group can be expected.12 In another group of patients,the femur presents osteolytic defects, usually due to tumor,and the fracture is therefore pathological. This group hasnot been looked at in this review

Associated InjuriesPatients with low energy STFs tend not to have significantassociated injuries. Contusions and abrasions are common,but head injuries and other osteoporotic fractures can oc-cur.11,13 Levy and associates14 noted a high incidence of ip-silateral patellar and tibial fractures, and Lucas15 reporteda case of bilateral STF associated with fracture of the pu-bis. These injuries may limit the functional outcome ofSTFs.

Applied Anatomy and BiomechanicsSTFs are displaced by the forces exerted by the musclesattached to the upper end of the femur. The proximal frag-ment is abducted by the action of gluteus medius andminimus16 and, if the lesser trochanter is still attached, theiliopsoas flexes and externally rotates it. The adductors andhamstrings cause shortening and adduction of the distalfragment, producing a varus deformity. The unopposedactions of these muscles produce flexion, adduction, andexternal rotation. A functionally weakened abductor musclegroup is produced. If uncorrected, the shortening and varusdeformity will cause significant limp and abductor lurch.Fielding and coworkers17 called attention to the necessityof a medial cortical buttress to minimize the stresses on animplant. Higher forces are generated on extramedullary(EM) implants than on intramedullary (IM) orcentromedullary devices.18

Basic Biomechanics of ImplantsStatic interlocking IM nailing techniques reduce the rota-tional shear forces that may lead to implant failure fromcyclical loading. Tencer and coworkers,19 in a cadavericmodel, calculated the bending and torsional stresses, plusload to axial failure of a variety of internal fixation de-vices. In transverse osteotomies, interlocking IM nailing

Table 1 Main Classification Systems forSubtrochanteric Fractures

NumberProximal Distal of

Study Border Border Subdivisions

Boyd & Griffin (1949) NS NS 2Watson et al (1964) DBLT 10 cm > 10Fielding (1966) PBLT 5 cm 4Cech and Sosa (1974) NS NS 4Zickel (1976) PBLT 10 cm 6Seinsheimer (1978) DBLT 5 cm 7Pankovich et al (1979) DBLT 5 cm 4Waddell (1979) NS NS 3Harris (1980) DBLT 5 cm 6Malkawi (1982) NS NS 5Russell & Taylor (1987) NS NS 3AO Müller (1990) DBLT 3 cm 9Wiss & Brien (1992) DBLT 7.5 cm 3Parker & Pryor (1994) DBLT 5 cm

NS = Not stated; PBLT = Proximal border of lesser trochanter; DBLT= Distal border of lesser trochanter.

Table 2 Seinsheimer Classification of Subtrochanteric Fractures*

Type I: Non-displaced fractures or any fractures with less than 2 mm of displacement of the fracture fragments.Type II: Two-part fractures: (A) transverse fracture; (B) spiral fracture with the lesser trochanter attached to the proximal

fragment; (C) spiral fracture with the lesser trochanter attached to the distal fragment.Type III: Three part fractures: (A) spiral fracture in which the lesser trochanter is part of the third fragment, which has an

inferior spike of cortex of varying length; and (B) fracture of the proximal one- third of the femur with the thirdpart a butterfly fragment.

Type IV: Comminuted fractures with 4 or more fragments.Type V: Subtrochanteric-intertrochanteric fractures: any subtrochanteric fracture with an extension through the greater

trochanter.

In types II and III, A is the most stable and C the least stable. *This classification was published in 1978 and was based on the morphology ofthe subtrochanteric fractures.


and Zickel nails approached 75% to 80% of the relativebending stiffness, while Ender nails reached less than 50%of the bending stiffness. In fractures with a segmental de-fect, the compression hip screw, which allows free rotationof the screw shaft inside the plate barrel, resulted in markeddiminution of stiffness as a result of rotation of the femoralhead. With torsional testing, all of the slotted, open-sectionnails and the Ender nails restored less than 5% of the nor-mal femoral torsional stiffness. The plate and screw de-vices restored nearly 40% of the femoral torsional stiff-ness when tested in a single load to failure. TheGrosse-Kempf and Klemm-Schellmann devices failed atloads of 350% to 400% of body weight. Plate and screwsystems failed at 200% of body weight. Ender nails, bladeplate, and Brooker-Wills nails failed at less than 150% ofbody weight.

The 15 mm interlocked IM Russell-Taylor nail restoredthe bending stiffness to the intact femur,19 and reached 58%of the torsional stiffness of the intact femur. This implantreached a tenfold improvement over the torsional stiffnessof open-section interlocking nails. For axial load failure,the Russell-Taylor closed-section nail was the strongestimplant, and failed at 450% of the body weight. A 13 mmRussell-Taylor reconstruction nail, because of its greaterwall thickness, restored 96% of the bending stiffness. Tor-sional stiffness was similar to that achieved with a 15 mmnail, and axial load failure was 500% of the body weight.The stiffness of the Richards nail is 40% of the normalfemur as is the Zimmer reconstruction nail. The Synthesnail is 17% as stiff as the normal femur.

The present generation of compression dynamic hipscrews (DHS) have sufficient strength and fatigue life thatthey can be used in STFs.19 When the medial cortex is re-constituted, the lateral plate acts as a tension band and isnot subjected to bending load. In a low STF, the “dynamic”hip screw acts as a static implant preventing the collapse ofthe fracture, with the possibility of delayed union and im-plant failure. The Medoff axial compression screw behavesas a dynamic implant.

ManagementThe management of STFs is challenging. Many reports haveincluded other fractures of the proximal femur thus mak-ing analysis difficult.2,5,20,21 Also, STFs have always beenconsidered as a homogenous group irrespective of the causeor group of patients in which they were occurring.22,23

Conservative ManagementNo randomized controlled trial has compared the opera-tive versus conservative management of STFs, and mostresearchers have reported on the results of more than onemanagement option (Table 3).

Parker and colleagues9 prospectively studied a consecu-tive series of 103 patients with subtrochanteric fractures.Ten patients were treated non-operatively, while the other

93 underwent operative treatment. The overall fixation fail-ure rate was 12% with a re-operation rate of 6% at oneyear. There were six (8%) failures of fixation for the 74fractures treated with the sliding hip screw. No method offracture classification was demonstrated to be of value inpredicting either the choice of treatment or the risk of frac-ture healing complications.

TractionThe deforming forces across a STF are much greater thanacross an intertrochanteric fracture, and larger weights,applied using skeletal traction through a tibial pin, are rec-ommended. As flexion of the proximal fragment will oc-cur if the lesser trochanter remains attached to the proxi-mal fragment, Hamilton-Russel traction may aid reduction,as it enables some degree of flexion of the distal femur,thereby aiding alignment. Perkins traction has the advan-tage of maintaining knee movement thus preventing quad-riceps atrophy. Adjustment must be made under radio-graphic control until satisfactory reduction is obtained inboth anteroposterior and lateral views. One should aim forless than 5° of valgus or varus angulation, at least 25%opposition of the fracture fragments in both planes, andshortening of less than 1 cm. After 3 to 4 weeks, the leg isgradually extended, with abduction as necessary to preventvarus angulation. Weekly radiographs are used to monitorthe status of the fracture. Traction is continued until thefracture shows signs of clinical and radiographic union,generally 8 to 12 weeks from the injury. The patient is thenmobilized, initially non-weightbearing. A cast brace witha pelvic band can aid mobilization. The opposite limb maybe elevated with a 1.5 to 2 inch shoe lift in an effort to shiftthe centre of gravity over the fractured limb, thereby re-moving the varus stress present during weight bearing.

Velasco and Comfort6 found satisfactory results in only50% of 32 cases treated conservatively. Waddell13 reported10 satisfactory but 8 unsatisfactory results, and found 90°-90° traction superior to traction with a Thomas splint. Bajajand coworkers24 found Hamilton-Russell traction the mosteffective method of conservative management comparedto fixed and balanced traction.

Conservative management avoids the major problemsencountered with the failure of fixation (Table 4). The main

Table 3 Synopsis of Conservative Management

No. SatisfactoryStudy Patients (%) Non-union

Bajaj et al (1988) 23 83 0Delee et al (1981) 15 100 0Waddell (1979) 18 56 11Velasco & Comfort (1978) 22 50 0Seinsheimer (1978) 8 48 0Watson et al (1964) 8 50 -Overall 94 66 2


disadvantages are shortening and angulation at the fracturesite. However, conservative management necessitates bedrest and traction for 6 to 14 weeks. This has many associ-ated complications, especially in elderly patients. All pa-tients should be given thromboembolic prophylaxis.

Cast BracingExternal support by hip spica or cast brace with a pelvicextension has been described in only one report.25 FifteenSTFs were managed with 90°-90° traction followed by frac-ture bracing with a hinged knee single-hip spica cast. Allfractures united, and this option was recommended for openfractures and for patients unsuitable for operative repair.

Minimally Invasive ManagementPins in PlasterThe pins in plaster technique involved inserting two pinsabove and two pins below the fracture, and incorporatingthem into a thigh plaster.26 Full weightbearing was thenallowed. Seligson and Harman,27 in 6 patients, found prob-lems with pin tract infection, shortening, angulation, andmalrotation. Garland and associates28 used a few days in

traction before aligning the fracture under anesthesia. Withthe limb in adduction, two proximal and two distal pinswere inserted in the femur and incorporated in the plaster.They recommend initial reduction with slight over-distrac-tion of the fracture and reduction in slight varus with moul-ding of the plaster laterally to resist angulation. They ob-tained good results in 83% of patients, with no non-unions.

External FixationAnderson29 first described external fixation in trochantericfractures. However, even modern external fixators may notbe strong enough to permit full weightbearing. The use ofexternal fixation may be of value for open fractures or prob-lem fractures in children. Problems that can be encoun-tered are pin tract sepsis and non-union of the fracture.

Operative ManagementThe high incidence of fixation failure and nonunion ratesreported for STFs are due to the thin cortical bone at thefracture site. The implants used in STFs can be broadlydivided into intramedullary (IM) or extramedullary (EM)implants. Intramedullary implants have the theoretical ad-

Table 4 Synopsis of Extramedullary Implants

No. Satisfactory Non-union MechanicalStudy Patients (%) Rate (%) Failure

DHSLechner (1990) 23 - 0 4Whitelaw (1990) 47 87 0 9Britton (1990) 54 - - 5Ruff (1986) 45 - 4 7Wile (1983) 25 92 0 0Waddell (1979) 24 87 8 4Seinsheimer (1978) 2 - 0 0

Overall 220 89 2 5AO blade plate

Kinast (1989) 47 - 9 0Waddell (1979) 40 73 10 17Seinsheimer (1978) 8 - 12 37Asher (1976) 20 - 5 20

Overall 115 73 9 12

Figure 1 Antero-posterior and lateral views ofa subtrochanteric fracture in a 62-year-old malepatient involved in a road traffic accident.


vantage that the distance between the weightbearing axisand the implant is reduced, thereby reducing the lever ef-fect. Direct clinical comparisons of the intramedullary andextramedullary devices are scarce and the study designsoften of poor quality. Tencer and coworkers,19 in a cadav-eric study, found that the DHS produced a more rigid fixa-tion than IM devices, but interlocking nails could withstandhigher loads. In a report by Lechner and coworkers,30 45 of60 surgically treated patients received EM fixation. Thesepatients had slightly better results, especially forSeinsheimer grade V fractures. Less satisfactory resultswere obtained with EM fixation for Seinsheimer grade IIIfractures. The authors recommend that IM devices shouldbe used in more distally based STFs and in pathologicalfractures.

Extramedullary Fixation (Table 4)Jewett and McLauglin nail plates for the management ofSTFs show a failure rate of from 25% to 65%.17,24,31,32 Nailplate devices are significantly weaker than a DHS.13,30 Sand-ers and colleagues33 reported a nonunion rate of 23% withthe blade plate, and complications were higher with com-

minuted fractures. Waddell13 and Velasco and coworkers6

emphasized the importance of reconstituting the medialcortex. Kinast and associates34 suggested minimal soft tis-sue damage and avoidance of bone grafting to reduce thecomplication rate.

The DHS has been used extensively in STFs, and is atleast as effective as an angle blade plate.35 The few studieson the most suitable angle between the barrel and the platesuggested 150° plates to be superior to 130° plates.36,37

Mulholland and Gunn38 found a 150° plate difficult to in-sert through the strong cortical bone of the lateral femur,and recommended a 135° angle (Figs. 1 through 3).

The dynamic condylar screw is a hybrid of the bladeplate and the DHS, and has been used in STFs instead ofthe angled blade plate. Nungu and colleagues39 reported 3mechanical failures in 15 cases. Radford and coworkers40

reported 64% good results in 11 patients. Although it iscalled “dynamic,” in STFs it acts as a static implant.

Compression Hip Screw and Sliding Hip ScrewUsing a compression hip screw, Waddell13 reported a 90%success rate, with failure due to implant displacement

Figure 2 Same patient as in Figure 1. Antero-posterior view fol-lowing open reduction and internal fixation with a 130° DHS,cerclage wiring, and interfragmentary screw fixation.

Figure 3 Same patient as in Figure 1. Lateral view followingopen reduction and internal fixation with a 135° DHS, cerclagewiring, and interfragmentary screw fixation.


or nonunion. Mullaji and associates23 found a 91% unionrate with a sliding hip screw. Wile and coworkers37 andBerman and colleagues41 reported no implant failures intheir small series of 25 and 38 STFs, respectively.Berman and colleagues41 also added bone grafting in allfractures, and interfragmentary screw fixation when pos-sible. Ruff and Lubbers42 obtained a union rate of 95%in mostly comminuted STFs. They recommend valgusreduction, medial displacement of the shaft, and inser-tion of only the lag screw into the proximal fragment topromote impaction of the fracture. Parker and Pryor43

also recommend reduction in valgus, but did not advisemedialization of the femoral shaft. The collapse of thefracture and medialization of the shaft can be minimizedby using a trochanteric stabilizing plate.44

Medoff Axial Compression ScrewThe Medoff axial compression screw45 has been recentlyused for the management STFs.46 Medoff recommendsthe implant for transverse STFs with or without reverseobliquity. These principles have been applied in the man-agement of 32 consecutive patients, with a union rate of97% at one year.46 These investigators used eitheruniaxial or biaxial dynamization, but recommenduniaxial dynamization in pure STFs, with staged biaxialdynamization for combined intertrochanteric and STFs,or if early post-operative radiographs show completeplate sliding.

Intramedullary Implants (Table 5)Hey-Groves47 first reported IM nailing of a STF. In 1939,Kuntscher48 reported IM nailing of STFs, and Arnoff andassociates22 reported good results with IM nails, particu-

larly in STFs non-union.

Zickel NailThe first IM implant to give consistently good resultsand a high union rate (greater than 90%) was the Zickelnail.11,49,50 Technical difficulties associated with the nec-essary wide exposure can cause complications in up to10%.50 The Zickel51,52 IM nail has a tunnel through itsproximal portion, through which a tri-flanged nail is in-serted into the femoral head and neck, and locked in placewith a screw.

The Zickel nail can be used if other methods of inter-nal fixation have failed.11 Patients can be mobilized non-weightbearing immediately, occasionally adding a plas-ter hip spica for support. The most common problemencountered with the Zickel nail is difficulty in remov-ing the nail following fracture union13 and refracture isa recognized complication.53 Yelton and Low54 also re-port iatrogenic STFs as a complication of Zickel nailingand suggested that there is an inherent mechanical flawin the design of the Zickel nail. According to them, the10° anterior bow and valgus angulation 10 cm from theproximal end of the nail result in very high stresses tothe proximal end of the femur as the implant is with-drawn. They also suggest that the long-term conse-quences of stress shielding of bone with subsequent im-plant failure must be considered. Zickel recommendednail removal only if the patient is symptomatic. If re-moval of the nail is indicated, it should not be performedbefore 18 months after the operation. If the nail in theneck of the femur is not inserted deeply enough, stressfractures can occur at the tip of the nail, as this can actas a stress riser. Bergman and associates11 advocate ex-

Table 5 Synopsis of Intramedullary Fixation

No. Satisfactory Non-Union MechanicalStudy Patients (%) Rate (%) Failure

Zickel NailLechner (1990) 8 - 0 12Bergman (1987) 131 90 4 1Thomas (1986) 52 - - 0Templeton (1979) 26 - 4 0Zickel (1976) 94 - 1 1

Overall 301 90 3 1Ender Nail

Whitelaw (1990) 25 72 0 0Dobozi (1986) 79 - 0 10Pankovich (1980) 31 - 0 26

Overall 135 72 0 12Intramedullary Nail

Wu (1991) 31 - 10 3Papagiannopoulos (1989) 27 - 0 0Heiple (1979) 14 - 0 0Seinsheimer (1978) 4 - 0 25

Overall 76 - 4 3


change nailing at removal of the Zickel nail if the unionof the fracture is uncertain.

Ender NailOriginally, it was argued that Ender nailing is a faster andless traumatic procedure,55 but Levy and colleagues14 re-ported a high prevalence of postoperative knee pain, rota-tional deformity, and instability. Most investigators sug-gested its use in elderly patients with low energy fracturesand minimal comminution. Elderly patients have largemedullary canals, which accommodate four or five Endernails through both medial and lateral portals.

Open reduction of the fracture is frequently required,with supplementary fixation with cerclage wires, and post-operative traction may be necessary.56 Pankovich andTarabishy57 reported significant complications in patientswith significant osteoporosis (nails cutting out of the bone).Dobozi and coworkers58 reported good results with no fixa-tion failures or non-unions in 79 patients, but 8 patientsrequired revision surgery within the first week to correctproblems of fixation, and 4 fractures occurred at the site ofinsertion of the nail. In a study comparing the use of Endersnails with the DHS, Whitelaw and associates59 reportedsuperior results and a reduced reoperation rate (13% ver-sus 68%) with the DHS.

Gamma NailThe Gamma nail employs the same principle ofcephalomedullary fixation as the Zickel nail and was intro-duced in the late 1980s. It was designed to avoid the prob-lems associated with the Zickel implant. Several studieshave shown problems with this implant,44,60 as it causesthree-point loading on the trochanter and femoral corticesleading to intraoperative and postoperative fractures. Theshape of the nail and the insertion of distal locking screwscontribute to fractures of the femoral shaft, as does themediolateral curve of 10° in the stem. The rigid locking ofthe head screw can cause cutout if the neck collapses be-fore the fracture has united.

Interlocking Intramedullary NailsIntramedullary nailing has been used for the managementof STFs and it appears to be increasingly popular. A vari-ety of nails have been used, including the Kampala orHuckstep nail, the Kuntscher nail, the Russell-Taylor IMnail, the AO femoral nail, the Derby IM nail, the Gross andKempf nail, the fluted IM rod, the Variwall reconstructionnail,61 and the Russell Taylor reconstruction nail.44,62 Thereare several other intramedullary reconstruction devices onthe market (e.g., Osteonics, Ace). However only a few stud-ies have detailed their results. Mahaisavariya and cowork-ers63 reported a series of 24 STFs treated by the AO tibialnail. Of these, all the 18 non-pathological fractures healedwithout major complications. They recommend this as analternative for the fixation of a simple STF without tro-

chanteric extension in small-build patients.Proximal locking of the nail is essential for STFs. This

may be achieved either by screws passed across the fe-mur between the trochanters in the lateral to medial di-rection, or by screws into the femoral head and neck. Ifa screw is passed between the trochanters, the fracturemust be distal with no extension into the trochantericregion. Shortening and rotational deformity were over-come by the interlocking IM nails. First generation in-terlocking IM nails needed an intact piriformis fossa.The design of these nails has gradually improved, and,to date, the Russell-Taylor reconstruction nail is prob-ably the most useful IM implant that can be used forSTFs along with the Zimmer reconstruction nail, as theseprovide the strongest fixation.64-66 The Synthes nail isless stable to torsional stresses.64

The problems with the Gamma nail led to the develop-ment of the intramedullary hip screw (IMHS, Smith &Nephew Richards), which avoids the high refracture rate.

Special SituationsOpen FracturesOpen STFs are almost always associated either with pen-etrating trauma or high-energy trauma. Immediate sur-gical debridement, antibiotics, and tetanus prophylaxisare essential, followed promptly by the minimum fixa-tion necessary to adequately stabilize the fracture.3 Inthe past, this presented problems because most methodsinvolved further tissue dissection and contamination oftissue planes (Figs. 4 through 6). DeLee and associates25

recommended 90°-90° traction and cast bracing for openSTFs. Johnson67 recommended IM fixation after adequatedebridement, either acutely or 10 to 21 days later, afterdelayed primary closure. Grade I to IIIA68 STFs can befixed immediately. Grade IIIB or IIIC can be managedby external fixation.

Paget’s DiseasePaget’s disease presents technical problems during fixa-tion due to sclerotic bone, excessive bleeding, and theexcessive bowing of the proximal femur. In these in-stances, STFs show a high rate of non-union and fixa-tion failure.69 Dove70 reported a 35% rate of non-union,although Grundy71 had a 100% union rate in 17 patients,7 treated conservatively and 10 by surgery. Intramedul-lary nailing (standard or reconstruction) may be prefer-able to plate fixation.70,72

Bone GraftingAutogenous bone grafting in STFs has been widely pro-posed, especially in patients with medial wall comminu-tion73 and in revisions of failed internal fixation. Watsonand associates32 advocated acute autogenous iliac bonegrafting of traumatic STFs in young patients. Bone graft-ing is recommended if there is a gap medially after frac-


ture fixation.6,74 Bergman and coworkers11 recommend bonegrafting in fractures treated with a Zickel nail, as early in-corporation of bone graft would help to protect the fixationdevice from the varus forces present due to lack of themedial cortical bone support.13 Closed management obvi-ates the need for bone grafting because the fracture frag-ments are not devascularized as with open reduction.3

Non-union (Table 6)The rate of non-union varies with the fixation used. Non-union rates of 5%, 10%, and 11% have been reported.13,31,32

For a fixed nail plate, non-union rates of 6%,17 9%,34 and13%75 have been reported. The non-union rate for STFstreated with DHS has been reported as 4.4%.41 The lowestrates appear with the use of IM fixation, ranging between1%52 and 4%,11 although 10% failure has been reported.76

In 50% of all STFs, a DHS will be acting as a static fixa-tion device; this group of patients is more prone to non-union.

ConclusionsSubtrochanteric fractures pose a challenge to orthopaedictrauma surgeons. The inter-observer variation for classifi-cations of STFs is high. Two studies on the Evans classifi-cation for intertrochanteric fractures reported a high de-gree (25% to 30%) of inter-observer variation.77,78 Similarly,a study of the inter-observer variation of the Seinsheimerclassification found large variations between observers forall grades of fracture.79

Figure 4 Antero-posterior and lateral views of a subtrochantericfracture in a 45-year-old male patient who sustained a low en-ergy grade I open subtrochanteric fracture falling from a chair.The patient had ankylosing spondylitis.

Figure 5 Details of the same patient as in Figure 4.

Figure 6 Same patient as in Figure 4. Minimal internal fixationwith a 135° DHS and a plate with indirect reduction of the inter-calary fragment.


Conservative management provides satisfactory re-sults in approximately 56% of patients as opposed to70% to 80% with currently available operative methods.However, the studies on conservative management aredated and the outcome measures less stringent. Conser-vative management is, however, safe and does have alow frequency of non-unions. It is therefore indicatedwhere surgical facilities are suboptimal, in patients un-fit for surgery, and in children. If operative managementis chosen, experienced surgeons, using the method they

are most familiar with, should perform it. For the ma-jority of fractures, the DHS appears to give satisfactoryresults, especially if the fracture extends into the tro-chanteric region. The DHS has been reported to be themost effective of the extramedullary implants, and couldbe used for the majority of STFs. The Medoff plate ap-pears to be a safe option, with similar operative expo-sure and insertion technique as the DHS. This form offixation, however, relies on an intact medial cortex tobuttress the plate. If this is lost by comminution around

Table 6 Reported Incidence of Non-union or Other Causes of Mechanical Failure forSubtrochanteric Fractures (Percentage)

No. Percentage Mechanical AllYear Patients Non-union Failure % Failures %

AO blade plateAsher et al (1976) 11 1(9) 0 1(9)Seinsheimer (1978) 8 1(12) 3(37) 4(50)Waddell (1979) 40 4(10) 7(17) 11(28)Kinast et al (1989) 47 4(9) 0 4(9)Sanders and Regazzoni (1989) 22 3(14) 2(9) 5(23)

Overall 128 13(10) 12(9) 25(20)Dynamic condylar screw

Redford and Howell (1992) 11 0 2(18) 2(18)Nungu et al (1993) 15 3(20) 0 3(20)Warwick et al (1995) 43 4(9) 2(5) 6(14)Gibbons et al (1995) 42 0 5(12) 5(12)

Overall 111 7(6) 9(8) 16(14)Dynamic hip screw

Seinsheimer (1978) 3 0 0 0Waddell (1979) 24 2(8) 1(4) 3(13)Wile et al (1983) 25 0 0 0Ruff and Lubbers (1986) 45 2(4) 3(7) 5(11)Britton et al (1990) 54 - - 3(5)Whitelaw et al (1990) 47 0 5(11) 5(11)Lechner et al (1990) 23 - - 1(4)Mullaji and Thomas (1993) 42 1(2) 2(5) 3(7)

Overall 263 5(2) 11(4) 20(8)Zickel nail

Zickel (1976) 84 1(1) 0 1(1)Waddell (1979) 8 1(13) 1(13) 2(25)Templeton and Saunders (1979) 26 1(4) 0 0Thomas and Villar (1986) 52 0 0 0Bergman et al (1987) 131 5(4) 0 5(4)Lechner et al (1990) 8 - - 1(12)Reynders et al (1993) 41 0 1(2) 1(2)

Overall 350 8(2) 2(0.6) 10(3)Intramedullary nails(excluding Zickel or Enders nails)

Seinsheimer (1978) 4 0 1(25) 1(25)Heiple et al (1979) 14 0 0 0Papagiannopoulos (1989) 27 0 0 0Wu et al (1991) 31 3(10) 2(6) 5(16)Wiss and Brien (1992) 95 1(1) 0 1(1)Seif-Asaad et al (1995) 9 1(11) 1(11) 2(22)

Overall 180 5(3) 4(2) 9(5)


the lesser trochanter or below it, then the plate is likelyto fail.

IM fixation devices appear to give results comparableto the DHS. Of the available devices, the Zickel nail is themost tried and tested, but the present generation of inter-locking nails, such as the Russell-Taylor reconstructionnails, appears to be as strong as the Zickel nail. These nailsare technically easier to insert and complications, such asrefracture at implant removal, are much less frequent thanwith the Zickel nail. The more distal the extension of thefracture, the stronger the arguments for using an IM im-plant instead of a DHS.

These recommendations cannot be absolute and eachfracture must be considered individually looking at theconfiguration, the quality of the bone, the general condi-tion of the patient, and the experience of the surgeon.

The quality of the papers in the literature is disappoint-ing both in terms of the type of study and the outcomemeasures used. The more recently published papers try toaddress these problems but more work is needed in orderfor better recommendations to be given. Even the CochraneLibrary cannot give definite answers on the best form oftreatment based on the current literature.76,80-82

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