Orthop Clin N Am 35 (2004) 473 – 483

Subtrochanteric femur fractures

Asheesh Bedi, MD, T. Toan Le, MD*
Department of Orthopaedic Surgery, University of Michigan Medical School, 1500 East Medical Center Drive,
TC2914, Ann Arbor, MI 48109, USA

Subtrochanteric femur fractures have demanded The subtrochanteric region is an area of high
special consideration in orthopaedic traumatology, stress concentration that is subject to multiple
given the high rate of complications associated with deforming forces, making anatomic reduction of a
their management. The intense concentration of de- fracture difficult. The greater trochanter is the site of
forming forces and decreased vascularity of the region insertion of the powerful hip abductors (gluteus
have challenged orthopaedists with problems of mal- medius and minimus) and short external rotators of
union, delayed union, nonunion, and implant failure. the hip. The lesser trochanter is a posteromedial bony
Only recently has a better understanding of fracture eminence at the inferior aspect of the intertrochanteric
biology, reduction techniques, and biomechanically ridge that provides attachment to the iliacus and psoas
improved implants allowed for subtrochanteric frac- hip flexors. These muscles act on the proximal
tures to be addressed with consistent success. fragment of a subtrochanteric femur fracture, result-
ing in a flexed, abducted, and externally rotated
position. The distal fragment is shortened and
adducted by the hamstrings and hip adductors,
Relevant anatomy resulting in an overall varus and anterior apex
deformity at the fracture site (Fig. 1) [1,3].
The subtrochanteric region of the femur is not
well defined. In an adult it is considered to be the area
extending 5 cm below the lesser trochanter to the
junction of the proximal and middle one third of the Epidemiology
femur. The fracture pattern of a subtrochanteric
fracture can be complex and propagate proximally Studies estimate that 7% – 34% of all femur
into the greater trochanter or piriformis fossa. The fractures occur in the subtrochanteric region [5 – 8].
subtrochanteric region consists of primarily cortical These are typically high-energy injuries with a sig-
bone, and the healing of this region is significantly nificant incidence of associated multisystem trauma.
slower than the well vascularized metaphyseal bone Studies have noted concomitant thoracoabdominal
of the intertrochanteric zone. In addition, the wide and head injuries in 10% – 30% of patients and mor-
canal and short proximal segment can make fixation tality rates as high as 21% [5 – 9]. There is a bimodal
with intramedullary devices difficult [1 – 4]. distribution to these injuries with approximately one
third of fractures occurring in patients younger than
age 50 years and two thirds of fractures occurring in
the older population [8]. Young patients tend to suffer
from high-energy mechanisms such as motor vehicle
* Corresponding author. collisions and tend to sustain comminuted, complex
E-mail address: [email protected] (T.T. Le). fracture patterns. Elderly patients more commonly are

0030-5898/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.ocl.2004.05.006
474 A. Bedi, T.T. Le / Orthop Clin N Am 35 (2004) 473 – 483

Fig. 1. Anatomy and deforming forces with subtrochanteric fracture. (A) Strong peritrochanteric hip musculature results in
abduction, external rotation, and flexion of the proximal fragment with varus deformity at the fracture site. (B) Clinically
correlated AP radiograph of characteristic deformity. (Adapted from Russell TA, Taylor JC. Subtrochanteric fractures of the
femur. In: Browner BD, Jupiter JB, Levine AM, Trafton PG, editors. Skeletal trauma. 2nd edition. Philadelphia, PA: WB
Saunders; 1992. p. 1836.)

subject to low-energy mechanisms such as simple are those that do not extend into the piriformis fossa,
falls, resulting in less comminuted, spiral fractures. preserving the portal for conventional antegrade
intramedullary nailing. Type II injuries extend proxi-
mally into the piriformis fossa. As a result, type II
Classification injuries may be secured more easily with extramedul-
lary compression hip screws, fixed angle devices, or
Over the years many different classification intramedullary devices using a trochanteric entry site.
schemes have been developed for subtrochanteric
injuries [1,2,10,11]. The most useful classification
system for subtrochanteric fractures, however, is that Patient evaluation and general principles
proposed by Russell and Taylor [1,4,12] (Fig. 2). In
addition to high interobserver reproducibility, this A careful history is important in determining the
scheme provides useful implications for treatment mechanism and energy of the injury. As with any
options and potential complications with different significant musculoskeletal injury, careful attention to
fracture patterns. The important variables are con- concomitant life-threatening injuries is of primary
tinuity of the lesser trochanter and fracture extension importance and the standard trauma life support
into the greater trochanter and piriformis fossa. The protocols should be applied. Care should be coordi-
subclassifications of A and B depict the amount of nated, with a multidisciplinary team approach in-
comminution in the lesser trochanteric region. The volving general surgeons and other subspecialties.
classification aids in guiding the selection of intra- Orthopaedic physical examination should identify
medullary (centromedullary or cephalomedullary) immediately any open injuries, a dysvascular extrem-
versus extramedullary implants [1]. Type I fractures ity, or associated neurologic injury. Closed subtro-
 A. Bedi, T.T. Le / Orthop Clin N Am 35 (2004) 473 – 483 475

Attention to patient positioning, reduction tech-

nique, and implant selection is critical before opera-
tive intervention to achieve accurate reduction of
length, rotation, and angular alignment. A Schanz pin
or pointed trocar may be required to manipulate and
overcome deforming forces and to reduce the
proximal fragment [3]. Furthermore, the importance
of balancing the quality of anatomic reduction with
excessive soft tissue stripping and devascularization
of the fracture zone must be recognized. Extensive
periosteal stripping to reduce the posteromedial
fragments devascularizes the region and contributes
to nonunion [9]. The degree of comminution, bone
density, type of implant, and appropriate implant
positioning are all important factors that affect
clinical outcome.

Biomechanics

Joint reaction forces at the hip and stress on the

proximal femur result from the compressive force of
body weight and forces generated by strong muscles
in this region. Biomechanic studies have demon-
strated that the subtrochanteric posteromedial femoral
cortex 1 – 3 inches below the lesser trochanter is the
most highly stressed region of the body, with forces
Fig. 2. Russell-Taylor classification system. Type I injuries exceeding 1200 lb/in2 in a 200-lb individual. Slightly
do not extend into the piriformis fossa, whereas type II less tensile forces of 900 lb/in2 occur at the proximal
fractures have fracture lines involving it. Subtype A injuries lateral femoral cortex [13,14]. These extreme loads
spare involvement of the lesser trochanter, whereas sub- justify the concern for implant failure and malunion
type B injuries have comminution extending into the lesser when the posteromedial buttress cannot be restored
trochanter and posteromedial femoral cortex. (Adapted from
secondary to comminution. If the posteromedial
Russell TA, Taylor JC. Subtrochanteric fractures of the
column can be restored with good cortical contact,
femur. In: Browner BD, Jupiter JB, Levine AM, Trafton PG,
editors. Skeletal trauma. 2nd edition. Philadelphia, PA: WB internal fixation devices can function as a tension
Saunders; 1992. p. 1883 – 925.) band along the lateral femoral cortex. Otherwise
implants are subject to high bending stresses that may
exceed the yield point and lead to loss of fixation or
chanteric femur fractures typically present with a hardware failure. In this situation intramedullary
swollen thigh and shortened limb. The distal aspect of devices have an advantage of reducing the moment
the proximal fragment is often prominent secondary arm over which the bending forces act compared with
to deforming forces that flex, abduct, and external a laterally placed plate [14 – 16]. It is important to
rotate the fragment [1,13,14]. note, however, that comminution of the medial femo-
An AP radiograph of the pelvis in addition to a full- ral cortex at the level of the lesser trochanter
length AP and lateral views of the affected femur are precludes the use of conventional interlocking intra-
required. Films must be reviewed carefully for fracture medullary nails, because their proximal locking
extension into the greater trochanter or piriformis screws are unable to gain the bicortical purchase
fossae and to evaluate diameter of the medullary canal. required for a stable biomechanic construct [10,17].
Occasionally contralateral images are needed to mea- Newer designed centromedullary and cephalo-
sure length, rotation, and neck-shaft angle to guide medullary reconstruction nails were able to provide
restoration of these parameters in the affected extrem- the necessary bending and torsional stability. This was
ity. Traction views of the affected proximal femur may achieved with a closed-section design and proximal
be necessary to assess fracture extension into the interlocking devices that incorporated biomechanical
piriformis fossae and trochanteric region. changes to reproduce more closely the stiffness of an
476 A. Bedi, T.T. Le / Orthop Clin N Am 35 (2004) 473 – 483

intact femur and simultaneously to provide capacity mortality associated with prolonged recumbency and
for rotational control by way of distal interlocking immobilization and high rates of nonunion, delayed
sites [1,12]. Follow-up studies by Pugh et al and union, and malunion [1,7,8]. In the case of a patient
Tencer et al demonstrated the Russell-Taylor design to with multiple injuries or hemodynamic instability that
restore 60% and 100% of torsional and bending delays operative intervention, skeletal traction by way
stiffness, respectively, and to improve the axial load to of a distal femoral or proximal tibial pin are required
failure to nearly 450% of body weight [16,18,19]. to maintain length and alignment until definitive
Though used primarily for intertrochanteric inju- fixation can be achieved.
ries, trochanteric portal intramedullary devices have
been adopted for subtrochanteric injuries. The origi- Intramedullary devices
nal short stem design with distal locking screw
portals at the level of the isthmus could generate Intramedullary fixation offers mechanical, techni-
significant stress risers and the potential for iatrogenic cal, and biologic advantages over other forms of
shaft fractures. In addition, the mismatched proximal fixation. Conventional statically locked intramedul-
angulation of the devices with the native femur lary nails are probably the most commonly used
increased the risk for intraoperative shaft fracture implant in the treatment of subtrochanteric fractures
[1,7,20]. Modifications in the design of intramedul- and have yielded consistently excellent results with
lary hip screws, including lengthening of the intra- type IA fractures. Multiple studies have shown
medullary stem and reduction of the proximal bow to intramedullary nails to confer stability to the fracture
match native anatomy, has led to significant improve- with low incidence of nonunion, hardware failure, or
ment of these devices and approval for use in internal loss of alignment [3,5,8,27 – 35].
fixation of subtrochanteric injuries [21 – 23]. In fact, Intramedullary devices allow for indirect fracture
the long Gamma nail (Howmedica-Osteonics, Allen- reduction, maintaining vascularity of the fracture
dale, NJ) was shown to allow the least fracture site zone. Reaming also may stimulate periosteal reaction
motion among other implants in an unstable, com- and generate debris that serves as autogenous graft
minuted subtrochanteric fracture model because of material at the fracture site [1]. The ability to place
its large proximal diameter, stainless steel composite, percutaneously the device may decrease surgical time,
and large interlocking lag screw [24]. and studies have documented significantly less intra-
Modern blade plates and hip compression screws operative blood loss with intramedullary devices
marketed in the United States have endurance compared with plate constructs [5]. Furthermore,
strengths and yield points that sufficiently exceed in intramedullary nails are load-sharing implants that
vivo cyclical bending loads and that are used may allow for earlier postoperative weightbearing and
routinely for subtrochanteric fracture fixation. Con- rehabilitation. Unlike plate devices, intramedullary
sistent success with use of these devices, however, devices span the entire femur without requiring ex-
depends more on use of indirect reduction techniques tensive soft tissue dissection, allowing simultaneous
and preservation of fracture blood supply than on treatment of more distal femoral shaft injuries [29].
mechanical failure of the implant [1,9]. Preservation Fractures extending into the lesser trochanter that
of soft tissue integrity and vascularity of the fracture compromise proximal interlocking screw placement
allows fracture healing and bridging callus formation with conventional nails are treated with cephalo-
to occur before implant failure with cyclic loading. medullary devices. These intramedullary nails use a
Furthermore, biomechanic studies have demonstrated piriformis or a trochanteric entry site but have
inferior stiffness and load-to-failure of extramedullary proximal interlocking fixation that gain purchase in
devices of fixed angle blade devices or hip compres- the femoral neck and head. They have been shown to
sion screw construct compared with that of second- provide superior biomechanic fixation of subtrochan-
generation reconstruction nails in a cadaveric model teric fractures with significant comminution at the
[16,18,19,25,26]. level of the lesser trochanter or in patients with severe
osteopenia [12,15,16,19,26,36]. Russell and Taylor
have reported a 100% union rate without complica-
Management tion in a series of more than 200 subtrochanteric
injuries managed with reconstruction nails, and other
Nonoperative treatment series have documented similar favorable results
(Fig. 3) [12,30].
Nonoperative treatment is no longer considered Use of a cephalomedullary device is more com-
acceptable, given the high rate of morbidity and plex when a subtrochanteric fracture has significant
 A. Bedi, T.T. Le / Orthop Clin N Am 35 (2004) 473 – 483 477

Fig. 3. Reconstruction nail fixation of subtrochanteric fracture. (A) A 50-year-old gentleman was crushed against a wall by
an automobile, sustaining multiple orthopaedic injuries, including bilateral subtrochanteric femur fractures and a pelvic ring
injury. Preoperative AP pelvis radiograph is shown. Postoperative AP and lateral radiographs of (B) right and (C) left hip
demonstrate anatomic reduction and fixation with bilateral reconstruction nails.
478 A. Bedi, T.T. Le / Orthop Clin N Am 35 (2004) 473 – 483

Fig. 4. Intramedullary fixation with type II injuries. (A) Withtype II fractures, special attention must be given to nail insertion in
the proximal and distal fragment. (B) Involvement of piriformis fossa predisposes to posterior displacement of the nail with
secondary malreduction and risk for blowout of intertrochanteric fragments with nail passage. (Adapted from Russell TA, Taylor
JC. Subtrochanteric fractures of the femur. In: Browner BD, Jupiter JB, Levine AM, Trafton PG, editors. Skeletal trauma. 2nd
edition. Philadelphia, PA: WB Saunders; 1992. p. 1868.)

trochanteric and piriformis fossa comminution. In extremity at the hip, reduction of the fracture can
these situations, insertion of the nail through these be facilitated readily and can allow for easier
regions may precipitate further displacement of the nail insertion.
intertrochanteric components of the fracture. When
there is fracture extension into the entry site, the nail Fixed angle devices
may displace posteriorly through the fracture site
(Fig. 4) [1,3,7]. Studies have demonstrated use of Historically, recommendations for open treatment
cephalomedullary devices in fractures involving the of subtrochanteric fractures with fixed angle devices
entry point with excellent clinical and radiographic included careful attention to anatomic reduction and
outcome. Barquet et al experienced no difficulty interfragmentary compression. Primary use of these
in placing a long Gamma nail in fractures with implants was limited to transverse, noncomminuted
comminution of the piriformis fossa [3,12,21,30] fracture patterns. Despite these restrictions, a 20%
(Fig. 5). rate of complications including delayed union and
Technical disadvantages of intramedullary devices hardware failure were reported in some series [5,11,
relate to the deforming forces acting on the proximal 29,37,38]. Iatrogenic devascularization of the postero-
fragment. Abduction of the proximal fragment makes medial cortex significantly contributed to high com-
finding a starting point difficult and often results in plication rate.
lateralized guide wires and reamers. In addition, A major advance for plating techniques of sub-
flexion of the proximal fragment by the iliopsoas can trochanteric injuries resulted from the work of Kinast
precipitate excessive reaming of the posterior cortex et al. They demonstrated that indirect reduction
of the proximal fragment [1,3,4,11]. Adjunct tech- without extensive dissection and appropriate tension-
niques to obtain and maintain reduction for passage ing of the AO blade plate device in combination with
of the intramedullary device may be necessary. These routine use of perioperative antibiotics resulted in a
include pointed trocars, fracture manipulation with 100% progression to union [9]. Maintaining the
Schanz pins, or opening of the fracture site with vascularity of the fracture zone with indirect reduc-
provisional fixation [1,3]. Residual apex anterior tion techniques has become truly a central tenet for
angulation with flexion of the proximal fragment still fracture care and has improved outcomes signifi-
may be seen after intramedullary fixation of sub- cantly with operative fixation of all injuries. As a
trochanteric fractures and represents a disadvantage result, plating with attention to preservation of soft
of these implant devices. Lateral positioning of the tissue integrity has led to successful use of fixed
patient with traction is recommended for nailing angle devices for management of type IIA and IIB
of subtrochanteric fractures. By flexing the affected subtrochanteric injuries in which portals for intra-
 A. Bedi, T.T. Le / Orthop Clin N Am 35 (2004) 473 – 483 479

Fig. 5. Long gamma nail fixation of subtrochanteric fracture. (A) An 87-year-old woman with a history of heart failure
and dementia sustained right subtrochanteric femur fracture after a fall down the stairs. AP radiograph of right hip is shown.
(B) Postoperative AP and (C) lateral radiographs demonstrate anatomic reduction and fixation with a long gamma nail device.

medullary devices have been compromised [1,3 – 5, sion band function of the fixed angle device can be
11,29,37,38](Fig. 6). compromised, resulting in a race between fracture
With the emphasis on preservation of vascularity healing and implant failure [1,9]. Current implants
of the fracture zone, little attempt is made at reduction have shown excellent ability to withstand cyclic
of posteromedial comminution. As a result, the ten- bending stresses while bridging callus is formed.
480 A. Bedi, T.T. Le / Orthop Clin N Am 35 (2004) 473 – 483

Fig. 6. Indirect reduction technique for fixed angle device. Use of an AO femoral distractor as described by Kinast et al
(Kinast C, Bolhofner BR, Mast JW, et al. Subtrochanteric fractures of the femur: results of treatment with the 95 degree condylar
blade plate. Clin Orthop 1989;238:122 – 30) can allow for indirect reduction and preservation of fracture zone vascularity.
Insertion of the plate can be technically difficult and anatomic alignment in three planes is required. Screws can be placed
proximal and distal to span the zone of comminution with sufficient stability. (Adapted from Russell TA, Taylor JC. Sub-
trochanteric fractures of the femur. In: Browner BD, Jupiter JB, Levine AM, Trafton PG, editors. Skeletal trauma. 2nd edition.
Philadelphia, PA: WB Saunders; 1992. p. 1851.)

With significant comminution medially, however, compression across the fracture site, placement of
consideration should be given to primary autogenous proximal screws by way of the plate into the proximal
bone grafting to accelerate fracture healing and fragment is avoided. Such a construct, however, is
minimize the risk for interim implant failure (Fig. 7). unable to prevent lateral migration of the head – neck
fragment in unstable fracture patterns, resulting in
Compression hip screw secondary malreduction and shortening. In addition,
with only the compression screw gaining purchase
Sliding hip screw devices have been used with through the barrel in the proximal fragment, sagittal
good success in the treatment of type IIA and IIB plane deformity may be difficult to control [3,4].
subtrochanteric fractures. Union rates of 95% and
average healing times of 2.5 months have been
reported with current implants [8,17,39,40]. Cutout Postoperative management
of the lag screw can be avoided with proper place-
ment of the compression screw in the center of the There are no universal guidelines for postopera-
femoral head as assessed by the tip-to-apex distance tive rehabilitation. The surgeon’s decisions often are
on AP and lateral views [1]. To allow dynamic influenced by fracture pattern and the implants used
 A. Bedi, T.T. Le / Orthop Clin N Am 35 (2004) 473 – 483 481

Fig. 7. A 95° blade plate fixation of subtrochanteric fracture. (A) A 45-year-old restrained driver involved in a motor vehicle
accident, sustaining multiple injuries including splenic laceration, pelvic ring injury, and a left subtrochanteric femur fracture.
Preoperative AP radiograph demonstrates type II fracture pattern with comminution extending proximally. (B) Postoperative AP
and (C) lateral radiographs demonstrate indirect reduction and fixation with 95° blade plate.

to address the injury. Early mobilization with bed-to- loading that can lead to implant failure and loss
chair transfers, range-of-motion exercises, and straight of reduction.
leg lifts can be initiated after fracture stabilization. In
situations of stable fracture pattern stabilized with an
intramedullary device, weightbearing as tolerated is
permitted with assistance of a walker or crutches. Complications
Complex fracture patterns with extensive comminu-
tion are allowed to partially weightbear initially and Delayed union or nonunion is the complication
are advanced with detection of progressive callus on encountered most frequently with subtrochanteric in-
radiographs to avoid the risk for excessive implant juries. The limited contact surface area, decreased vas-
482 A. Bedi, T.T. Le / Orthop Clin N Am 35 (2004) 473 – 483

cularity of bone compared with the intertrochanteric also has been reported with good success when
region, and high mechanical stresses particularly proximal femoral anatomy and alignment of the
increase the incidence of nonunion in this region. medullary canal has been preserved.
Continued pain at the proximal thigh with weight- Postoperative wound infection, hematoma, hetero-
bearing, loss of fixation, and inappropriate callus for- topic ossification, and nerve injury are other compli-
mation on radiographs are diagnostic of nonunion at cations of the surgical management of subtrochanteric
6 months [1,3]. fractures. A detailed discussion of these complica-
The first tenet of management of delayed union or tions and their management is beyond the scope of
nonunion involves patient counseling regarding the this article.
critical importance of smoking cessation. Persistent
noncompliance hampers any operative intervention
with high risk for failure. In the setting of a hy-
Summary
pertrophic nonunion, blade plate fixation has proven
to be a highly effective salvage technique. The lateral
Subtrochanteric femur fractures are often the
tension band mechanism effectively compresses the
result of complex, high-energy mechanisms and
nonunion site with cyclical axial loading. Autogenous
demand special surgical considerations. Careful pre-
bone grafting may provide additional osteoinductive
operative evaluation of the fracture pattern together
stimulus to promote fracture healing. If an intra-
with attention to implant selection, patient position-
medullary device has been used, exchange nailing
ing, and reduction techniques are critical. Emphasis
with over reaming and exchange to a larger implant
on preservation of blood supply and soft tissue
has been effective [1,5,28,30]. Closed manipulation
integrity in the fracture zone has decreased the
of the nonunion site has been recommended with this
complications and permitted earlier functional recov-
treatment to mechanically stimulate the fracture zone.
ery with intramedullary and extramedullary devices.
With either of these techniques, intraoperative cul-
Treatment based on the general principles and
tures should be obtained to identify occult infection
techniques described usually result in a satisfactory
that may be managed with concomitant antimicro-
outcome, but surgeon experience and comfort with
bial therapy.
different implant devices must be considered.
Malunion reflects inadequate restoration of align-
ment, rotation, or leg length at the time of fracture
reduction. With subtrochanteric fractures, the result-
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