HIP FRACTURE (SUBTROCHANTERIC)
Can you describe the radiographs?
These are AP and lateral radiographs of the left hip. The subtrochanteric region extends from the lesser trochanter to 5 cm distal to the lesser trochanter. Therefore, these show a subtrochanteric hip fracture. There is no obvious evidence that this is pathological.
In what position are the fragments lying and why?
The proximal fragment is flexed due to the unopposed action of iliopsoas, and abducted due to the glutei. It is also externally rotated due to the action of the short external rotators. If the lesser trochanter is attached to the distal fragment, the clas- sically flexed proximal fragment will not be present.
The distal fragment is shortened due to the action of the quadriceps and the ham- strings, as well as adducted due to the adductors inserting on the distal fragment.
Who gets subtrochanteric hip fractures and how would you classify them?
In the majority of cases, this is a fracture of the elderly. Most are caused by simple falls from a standing height, like all other hip fracture types. However, there is a higher incidence of pathological fractures in this region compared with other types of hip fracture. Patients on bisphosphates are susceptible to transverse fractures in this area, which may show a cortical thickening of the lateral cortex, absence of comminution and a medial spike. If this injury is sustained in a young patient, it is usually the result of a high-energy injury.
These are classified by the Russell–Taylor classification. Type I has no extension into the piriformis fossa, whereas type II does. This is further subdivided into A and B depending on the integrity of the medial buttress. This is a historical classification as type II fractures were treated with a fixed angle device rather than the cephalom- edullary nail used today.
Would you want any further investigations?
I would want full-length femur views and tailored imaging as indicated after a full history and examination in order to assess for a malignancy.
How would you treat this fracture operatively?
I would use a long cephalomedullary nail. In Parker and Handoll’s 2010 Cochrane review, they found that the use of intramedullary nails may have advantages over fixed angle plates for subtrochanteric and some unstable trochanteric fractures, but admitted that further studies are required to confirm this. More recent studies and meta-analyses have shown that fixation failure and revision surgery is reduced with the use of intramedullary implants for subtrochanteric fractures. The most recent National Institute for Health and Clinical Excellence (NICE) guidelines on hip frac- tures advise that subtrochanteric fractures are treated with intramedullary nails.