1. Multifragmentary intertrochanteric fracture (treated with a nail)
Case for small group discussion: Fractures of the femur
Ernest Kwek, SG
Discussion points (overview):
Imaging
Fracture classification
Deforming forces
Treatment options
Preoperative planning
Surgical approach
Entry point
Reduction
Tip-apex distance
Aftertreatment
Complications
Haidukewych GJ. Intertrochanteric fractures: ten tips to improve results. J Bone Joint Surg Am Mar 1;91(3):712–719.
Use the tip-to-apex distance
No lateral wall, NO HIP SCREW
Know the unstable patterns, and NAIL THEM
Beware the anterior femoral bow
Start slightly medial to tip of GT
Do not ream an unreduced fracture
Be cautious about nail trajectory
Avoid varus angulation
Lock nail distally if axially or rotationally unstable
Avoid distraction when nailing
AO Trauma Advanced Principles Course

2. Case description 76-year-old lady
Premorbid ADL-independent, ambulant using walking stick
Past medical history:
Diabetes mellitus
Hypertension
Hyperlipidemia
Hyperthyroidism, on carbomazole
Chronic renal disease, not requiring dialysis
Gout
Stumbled on a curb and fell onto left hip

3. Plain X-rays
Day 0

4. Classification
A2.1
A2.2
A2.3
Can you classify based on plain x-rays?
Is this stable or unstable?
Does this help you with choice of implant?
Can you classify this fracture based on plain X-rays?

5. CT
Is this fracture classifiable?
How does CT help you?

6. How would you treat this fracture?
Nonoperative treatment
DHS +/- TSP
Angled blade plate/ DCS
Proximal Femur Locking Plate
Intramedullary nail

7. Intraoperative views on traction table
Is reduction adequate? How can it be improved?
What to do about the trochanteric fragment?
Ideal nail entry point?

8. Postoperative X-rays Your comments on the postoperative result?
What is the ideal implant position?
Would you have used a long nail?

9. Full weight bearing as tolerated immediately
3 months

10. At 1 year: ambulates with walking stick

11. Is there an ideal trochanteric nail entry point?
There is no ideal lateral entry point
Variable depending on
Patient trochanteric profile
Patient neck-shaft angle
Implant geometry
Too lateral = varus malreduction

12. Influence of nail geometry
The tip of the trochanter, or even slightly medial, is recommended as the universal starting point for these nails.
Holland
10 degrees
TAN
5 degrees
Gamma 3
4 degrees
TFN
6 degrees
Ostrum RF, Marcantonio A, Marburger R. A critical analysis of the eccentric starting point for trochanteric intramedullary femoral nailing. J Orthop Trauma Nov-Dec;19(10):681–686.
Trochanteric entry point:
Trochanteric tip is only ideal in a minority of cases
70% of patients: ideal entry point was medial
23% lateral
Streubel PN, Wong AH, Ricci WM, et al. Is there a standard trochanteric entry site for nailing of subtrochanteric femur fractures? J Orthop Trauma Apr;25(4):202–207.
Ostrum RF et al (J Orthop Trauma. 2005;19:681–686)

13. Regardless of trochanteric or piriformis entry, the ideal portal is collinear with the long axis of the femur on the lateral

14. Summary and take-home message
Getting the entry point right is essential for IM nailing of an intertrochanteric fracture.
Respect the tip-to-apex distance.
IM nailing is ideal in elderly patients with unstable intertrochanteric fractures.
The priority in such patients is stable fixation for early mobilization.
Moderator should ask participants to summarize what else they have learned from this case.
Haidukewych GJ. Intertrochanteric fractures: ten tips to improve results. J Bone Joint Surg Am Mar 1;91(3):712–719.
Use the tip-to-apex distance
No lateral wall, NO HIP SCREW
Know the unstable patterns, and NAIL THEM
Beware the anterior femoral bow
Start slightly medial to tip of GT
Do not ream an unreduced fracture
Be cautious about nail trajectory
Avoid varus angulation
Lock nail distally if axially or rotationally unstable
Avoid distraction when nailing