Fractures of the Femur

Ovid: Manual of Orthopaedics

Editors: Swiontkowski, Marc F.; Stovitz, Steven D.
Title: Manual of Orthopaedics, 6th Edition
> Table of Contents > 23 – Fractures of the Femur

Fractures of the Femur
I. Fractures of The Femoral Neck
  • Mechanism of injury.
    Femoral neck fractures account for just over half of all proximal
    femoral fractures and are most common in patients older than the age of
    50 years; elderly patients account for approximately 95% of the total
    number of cases (1,2).
    These fractures become more common with increasing age because of the
    unhappy combination of osteoporosis and an increasing propensity for
    falls. Besides osteoporosis, other factors associated with an increased
    risk of femoral neck fracture are early menopause (or low estrogen
    state), alcoholism, smoking, low body weight, steroid therapy, history
    of stroke, phenytoin treatment, and lack of exercise. Excessive use of
    sedative drugs has also been implicated (3).
    Typical patients are female, fair, and thin. Eating a high fat diet is
    “poor dietary habit,” but does not put one at risk. Efforts at
    preventing falls in elderly persons seem to have the most potential for
    controlling this phenomenon. Trochanteric pads may lessen the risk of
    fracture with falls (4), but compliance is poor and their usefulness has been questioned (5). In the elderly, hip fractures result in an increased 1-year mortality rate of 12% to 18%.
    Femoral neck fractures in younger patients usually
    result from high-energy trauma. In addition to traumatic injuries,
    stress fractures of the femoral neck may occur in active patients.
    Stress fractures that occur along the superior aspect of the femoral
    neck are called tension fractures and have a high propensity to progress to complete fractures. The compression stress fracture, which occurs at the base of the femoral neck, is less likely to displace.
  • Classification of fractures. From the clinical standpoint, femoral neck fractures are of four basic types:
    displaced, nondisplaced, impacted, and the stress fracture. Radiographs
    can distinguish these, although some nondisplaced fractures may be
    radiographically occult and are only diagnosed after magnetic resonance
    imaging (MRI). Approximately two thirds of femoral neck fractures are
    displaced (2).
  • Symptoms and signs of injury. Patients with stress fractures, nondisplaced fractures, or impacted fractures may complain only of pain in the groin
    or sometimes pain in the ipsilateral knee. The patients with stress
    fractures have a history of a recent increase in activity and may
    believe themselves to have a muscle strain. In contrast, patients with
    nondisplaced or impacted fractures have some history of trauma. They
    generally have a higher intensity of pain, can associate the onset with
    a traumatic event, and are seen early for medical treatment. In all
    three groups of patients, there is no obvious deformity on physical
    examination, but there is generally pain with internal rotation. A high
    index of suspicion must be maintained to avoid delay in diagnosis.
    Patients with displaced femoral neck fractures complain of pain in the
    entire hip region and lie with the affected limb shortened and
    externally rotated. Anteroposterior and high-quality cross-table
    lateral (obtained by flexing the uninjured, not the injured, hip)
    radiographs of the hip are necessary and sufficient to diagnose
    displaced, nondisplaced, and impacted fractures and for planning
    treatment. MRI (with Short TI Inversion Recovery STIR images) has been
    shown to be the quickest, most cost-effective way of correctly
    identifying radiographically occult fractures. Pending treatment,
    patients should be non–weight bearing and allowed to rest with the
    limbs in the most comfortable position, which is generally in slight
    flexion on a pillow. Traction is not necessary and may increase pain.
  • P.318

  • Treatment
    • Stress fractures.
      These fractures commonly occur in young, vigorous individuals and
      require careful evaluation. A high index of suspicion for this injury
      should be kept for active patients presenting with groin pain (6). Patients with femoral neck stress fractures often have decreased bone density compared to age-matched controls (7).
      Femoral neck stress fractures often heal uneventfully but have the
      potential to displace, especially if on the superior/lateral side. Upon
      diagnosis, patients should be treated by restricted weight bearing. Use
      of crutches or a walker is mandatory, but patients should also be
      cautioned not to attempt straight-leg raising exercises and not to use
      the leg for leverage in rising or in changing positions, particularly
      getting up out of a chair. Partial weight bearing is safe within 6
      weeks, with full weight bearing in 12 weeks, as long as the fracture
      shows roentgenographic evidence of healing, which is evidenced by
      sclerosis at the superior femoral neck. Because of the potentially
      severe complications of displacement (nonunion, osteonecrosis, need for
      surgery), in-situ pinning should be considered in active or unreliable
      patients or any patient with a tension (superior) fracture. Compression
      types of fractures in elderly individuals generally do well with
      limiting activity as outlined above. Functional complaints may persist
      for years in patients with femoral neck stress fractures (8).
    • Impacted fractures
      • These can be treated either nonoperatively or operatively (1,9).
        With the nonoperative method, the patient usually is kept in bed for a
        few days with the leg protected from rotational stresses until the
        muscle spasms subside. A program of protected ambulation, as outlined
        for stress fractures, is then initiated. In a series of over 300
        patients with impacted femoral neck fractures treated nonoperatively,
        displacement only occurred in 5% of younger, healthy patients (9). When displacement occurred in these patients, operative treatment led to a successful outcome in all cases (9).
        Although the authors of this study suggest that surgery is only
        necessary in patients over age 70 with multiple medical problems,
        others would argue that even a 5% risk of late displacement is
      • Internal fixation
        of impacted fractures has many advantages over nonoperative methods,
        especially using percutaneous technique. Although the rate of avascular
        necrosis may not be different, a union rate of 100% in operative cases
        has been reported, compared to 88% with closed management. The authors
        recommend multiple screw fixation, either percutaneous or by open
        technique, because it allows immediate weight bearing and avoids the
        risk of late displacement (10) (see I.F).
    • Displaced fractures.
      The management of displaced femoral neck fractures continues to be an
      area of controversy. The treatment decision is best based on the
      activity level of the patient before the fracture because this is a
      direct measure of the functional demands of the patient that should be
      restored and because activity level correlates with bone density (1).
      Patient’s must be treated with understanding of their physical and
      mental abilities. Those that are most debilitated often need the
      surgery most. For example, the patient with poor cardiac function,
      while not an ideal surgical candidate, also needs to be as active as
      possible. The patient with dementia may need surgery as many do not
      understand recommendation for non–weight bearing. It is important to
      rapidly arrange family discussions and indepthly explain the risks and
      benefits of surgical intervention.
      • Currently, there is disagreement about
        how to best manage displaced fractures in active patients. Certainly,
        fractures in healthy patients less than age 60, with or without slight
        comminution, should be reduced, impacted, and internally fixed.
        Such surgery should be done as quickly as possible. When surgical
        repair was carried out within the first 12 hours, a 25% rate of
        avascular necrosis was reported, increasing to 30% with surgery between
        13 and 24 hours, 40% between 24 and 48 hours, and 100% after 1 week.


        tamponade from fracture hematoma has an unfavorable effect on femoral
        head blood flow, as does nonanatomic position, so there is a rationale
        for proceeding with some urgency (1,11,12,13,14,15,16).
        However, patients with dehydration or unstable cardiac conditions
        should be medically stabilized before surgery to minimize the risk of
        fatality (17). There is consensus that accurate reduction and impaction at the fracture site are essential to a good end result.

        • Authorities who stress an anatomic reduction with impaction
          believe that this allows the maximum opportunity for reestablishment of
          the vascular supply. Any stretch or kinking of the vessels of the
          ligamentum teres or retinaculum is avoided while stability of the
          fracture is optimized (13). Internal fixation with three pins or screws secures fracture stability; there is no value in using more than three implants (10).
          An exception to this generalization is the fracture comminuted with
          posterior comminution; in this instance the addition of a fourth screw
          may confer a little more stability (18).
        • Authorities who stress a valgus reduction
          believe that this position allows for maximum bone-on-bone stability
          and a reduced varus moment arm on the repaired fracture. In a valgus
          nailing, the nail or screw is near the center of the head, but the nail
          is rested along the calcar of the femoral neck to reduce the distance
          between the fulcrum of the nail or screw and the head. This positioning
          produces a shorter biomechanical moment and less stress on the device.
          Concern that the fixation cuts out superiorly or anteriorly can be
          eliminated by proper impaction of the fracture and the use of multiple
          pins or a sliding fixation apparatus (10,13).
          When valgus nailing is performed, it is more likely that screws will
          exit the femoral shaft at or distal to the lesser trochanter, which
          increases the risk of late subtrochanteric fracture.
      • The authors believe
        that an anatomic reduction is preferable to the valgus reduction, but
        when faced with a choice between slight valgus and any varus, then
        slight valgus is chosen
  • Reduction techniques
    • The authors favor a closed reduction
      on a fracture table that then allows for the insertion of internal
      fixation under two-plane image-intensifier control. Manipulative
      reduction should be gentle, and the authors have found the techniques
      of McElvenny and Deyerle to be the most satisfactory. Frequently,
      however, the fracture is reduced by the maneuver of applying traction
      on the limb with neutral adduction-abduction with internal rotation to
      bring the femoral neck parallel to the floor. Nonanatomic reduction
      should not be accepted; if acceptable reduction is not obtainable by
      closed means then open reduction should be considered.
      • In McElvenny’s technique,
        both extremities are placed in traction with the hips in extension. The
        affected leg is lined up with the long axis of the body and is then
        maximally internally rotated by rotating the knee rather than the foot
        to reduce stress on the knee ligaments. Traction then is released on
        the contralateral side. After viewing follow-up radiographs, if more
        valgus is required, the traction may be reapplied to the affected leg.
        Just before releasing the traction on the opposite leg, an abduction
        force at the knee is applied along with a simultaneous pushing inward
        over the trochanter.
      • The Deyerle technique
        achieves final alignment of the femoral neck and head in the lateral
        plane by a direct push posteriorly by two hands placed anteriorly over
        the greater trochanter while the pelvis on the contralateral side is
        supported to prevent ligament stress. This procedure is carried out
        after traction and internal rotation have reduced the fracture in the
        anteroposterior plane and before placement in slight valgus as
        described in a.
    • Open methods. Open reduction is performed through either a Smith-Petersen anterior approach or a Watson-Jones anterolateral approach


      when a satisfactory closed reduction cannot be obtained in a patient in whom prosthetic replacement is contraindicated (1).
      Although fracture site visualization may be best with the anterior
      approach, the screws have to be inserted through a separate lateral
      incision. The Watson-Jones interval is a more familiar approach for
      many surgeons, but fracture visualization may be a little more

  • Operative techniques
    • Multiple screws.
      The multiple screw method, using three implants, is the simplest method
      of obtaining internal fixation. This method can be a percutaneous
      procedure, thus reducing the risk of infection and the operative
      morbidity in elderly patients, extremely poor-risk patients, and
      bedridden patients. The alternative of prosthetic replacement in the
      low functional demand patient is chosen except when these criteria
      apply (19). When an adequate (anatomic) closed
      reduction is obtained, the screws can be placed through a small lateral
      incision, but a capsulotomy is recommended by extending the deep
      dissection anteriorly. When the reduction is nonanatomic, open
      reduction is advised (1,16).
    • Sliding hip screw fixation
      is an alternative to multiple screw fixation. With anatomic reduction,
      no mechanical advantage is obtained with the hip screw because fracture
      stability is most dependent on the quality of the reduction and the
      density of the bone in the femoral head. However, with a nonanatomic
      reduction, there is an advantage to the use of a hip screw because the
      fixation relies on the lateral cortex rather than opposition of the
      fracture surface (10,13).
      A sliding screw plate appears to have the advantage of firm fixation of
      the head, as well as allowing for impaction through sliding in a fitted
      barrel. An additional threaded pin or cancellous screw should be placed
      superiorly in the neck and head for improved torsional control (13).
      Regardless of the particular type of mechanism used, it is essential to
      obtain maximum holding capacity in the head, which necessitates the use
      of a 135-degree angle device in most individuals when anatomic
      reduction is obtained. When a valgus reduction is chosen, it is
      important to use a 150-degree nail plate device and to position the
      nail or screw in the deepest portion of the head.
    • Prosthetic replacement.
      Many studies have demonstrated improved functional outcomes and
      dramatically lower reoperation rates with hemiarthroplasty and total
      hip replacement when compared with internal fixation of displaced
      femoral neck fractures. However, arthroplasty procedures carry a higher
      risk of deep infection, dislocation, and potential need for revision (20). Use of an anterior or lateral approach significantly decreases the risk of dislocation (20).
      Hemiarthroplasty of the hip may be performed with unipolar or bipolar
      components. Traditionally, a unipolar prosthesis is used for patients
      with very low functional demand, while bipolar devices are used in
      patients with higher functional demands. However, recent studies have
      failed to demonstrate any significant difference in outcomes with
      either type of device (21), while bipolar components may contribute polyethylene wear particles with time (22).
      Total hip arthroplasty provides the best functional results but is
      considered to be associated with a higher risk (10%) of dislocation (23).
      Fortunately, the risk of recurrent dislocation and reoperation are not
      different than those after primary total hip arthroplasty (24).
      The use of larger femoral heads with cross-linked polyethylene and
      avoidance of posterior approaches should reduce the risk of
      dislocation, although this has not yet been demonstrated in the
      literature. Total hip replacement is the procedure of choice when
      femoral neck fractures occur in patients with rheumatoid arthritis.
      Such fractures are exceedingly rare in patients with degenerative
      arthritis of the hip, but total hip arthroplasty would also be
      appropriate in these cases.
    • The authors’ preference. Multiple screw fixation or a sliding hip screw with an additional pin or screw appears to offer optimum fixation (1,16).


      The techniques are not easily learned or applied and are only effective
      with anatomic reduction and maximum fracture impaction at the time of
      surgery. Given the difficulties inherent with either technique, the
      uncertain end-results if anatomic reduction is not obtained, and the minimum of a 12% avascular necrosis rate,
      the surgeon should consider femoral prosthetic replacement as an
      alternative in the older patient with low functional demands and poor
      bone quality or the very active older patient who will have the best
      function after total hip replacement (20).

  • Failed primary fixation.
    The most frequent complications following internal fixation of
    displaced femoral neck fracture are loss of reduction, protrusion of
    the screw or pins into the acetabulum, and collapse with symptomatic
    avascular necrosis. All of these complications are reliably salvaged by
    total hip arthroplasty.
  • Postoperative care and rehabilitation.
    The aim of treatment is to return the patient to preoperative status by
    the quickest, safest method. Therefore, rehabilitation planning should
    begin at the time of admission because most patients are elderly and do
    not tolerate prolonged periods away from familiar environments (17).
    Surgery is carried out as soon as possible, and the procedure should be
    one that allows immediate partial or full weight bearing, the first
    step in rehabilitation. Attempting to maintain a patient in
    non–weight-bearing status is frustrating for the surgeon, therapist,
    and family. The use of bedpans and the practice of straight-leg raising
    of the intact leg while in bed have been shown to produce considerable
    stress across the femoral neck. It is fallacious to attempt to protect
    the hip by non–weight-bearing with crutches, because approximately half
    the body weight is transmitted across the so-called non–weight-bearing
    hip. If the knee and hip are fully flexed, the forces at the hip
    approximate total body weight. The dependent position without the
    normal pumping action of muscles also predisposes to edema, venous
    stasis, and thrombophlebitis. The authors’ experience indicates that,
    as long as stable internal fixation is achieved, gains from early
    weight bearing far outweigh the risks. Patients are encouraged to
    ambulate and to apply as much weight as is comfortable. Initially, a
    walker is used, and then gradual progress is made to crutches, if
    practical, and eventually a cane. In the case of the patient with
    balance problems, the walker or cane may be used indefinitely to help
    prevent more falls.
  • Nonunion and avascular necrosis
    • In the past, nonunion
      has been an important complication, but with proper reduction,
      impaction, and internal fixation, its incidence should be reduced to
      less than 10% (1,20).
      Most fractures heal promptly and the union is well established within 4
      months. Occasionally, there is some resorption at the fracture site,
      probably a result of insufficient impaction at surgery and therefore
      some fracture instability. Further impaction and eventual healing
      usually occur, but the incidence of avascular necrosis is significantly
      higher than in patients who obtain primary union.
    • Avascular necrosis
      • The roentgenographic signs
        of avascular necrosis, with associated collapse, can occur at any time
        postoperatively. For practical purposes, however, changes with collapse
        are usually seen within 3 years. The incidence of avascular necrosis is
        variously reported to be within 12% to 35%, and it must be appreciated
        that for displaced femoral neck fractures, the head, or at least a
        major portion of it, is rendered avascular at the time of injury (1,20).
        The lower figure of 12% is identical to that reported by most authors
        for impacted valgus fractures and probably represents the lowest
        possible incidence. When avascular changes are identified, the patient
        should be managed according to symptoms. In many older patients, the
        condition may not be severe enough to warrant any further surgery, but
        in patients with complete collapse of the femoral head and increasing
        pain, early total hip replacement is the treatment of choice.
      • The role of bone grafting for either prevention or treatment of avascular necrosis remains uncertain. Currently, evidence for use of bone grafting for either of these conditions on a routine basis is lacking.
  • P.322

  • Prognosis.
    Anticipated complications and end results have been discussed for each
    fracture. Because of the advanced age of the typical patient,
    development of degenerative articular changes over a long period is
    difficult to assess, but it does not appear to be a frequent
    complication. The morbidity and mortality rates
    (12% for the 12 months following fracture) are high, but they can be
    notably decreased by treating this fracture with early reduction and
    early ambulation
    . The mortality rates return to those of age-matched control subjects after 1 year.
  • Fractures of the neck of the femur in children (25,26,27)
    • Treatment
      • Transepiphyseal fractures
        are uncommon, and there is no series of sufficient size to make any
        conclusions about the treatment of choice. The authors recommend
        reduction with capsulotomy and fixation with smooth pins (27).
      • Undisplaced and minimally displaced cervicotrochanteric fractures
        carry a risk of avascular necrosis. The pathophysiology may involve
        intracapsular tamponade of the vessels supplying the femoral head (27).
        The authors recommend capsulotomy, reduction if necessary, and fixation
        with lag screws short of the femoral head epiphysis. The screws are
        generally sufficient because of the density of the bone. In children 8
        years old and younger, postoperative spica cast immobilization is also
        used for 6 to 12 weeks. Displaced fractures are treated in the same
        way. These fractures must be treated emergently to minimize the
        complication of avascular necrosis.
    • Prognosis. These fractures have nearly a 100% rate of union with optimum management.
    • Complications
      • Coxa vara. Although this complication is commonly reported, it is generally associated with nonoperative management.
      • Avascular necrosis.
        This complication affects 0% to 17% of patients who undergo emergent
        treatment. The long-term consequence is generally degenerative
        arthritis, which requires total hip arthroplasty in patients in their
        40s to 60s.
      • Premature closure of the epiphysis occurred in 7% of the patients in Lam’s series (26). This complication is not a significant long-term problem except when it occurs in children younger than 8 years.
II. Intertrochanteric Fractures (28)
  • Surgical anatomy
    • The classic intertrochanteric fracture occurs in a line between the greater and lesser trochanters.
      Although in theory such a fracture is totally extracapsular, the
      distinction between an intertrochanteric fracture and a basilar femoral
      neck fracture is not always clear. In peritrochanteric fractures, the
      internal rotators of the hip remain with the distal fragment, whereas
      usually at least some of the short, external rotators are still
      attached to the proximal head and neck fragment. This factor becomes
      important in reducing the fracture because, in order to align the
      distal fragment to the proximal one, the leg must be in some degree of
      external rotation. This is in contrast to the internal rotation often
      needed to reduce transcervical femoral neck fractures and requires a
      distinctly different maneuver in the operating room with the patient on
      the fracture table to reduce the fracture.
    • When the forces producing the fracture
      are increased, the greater trochanter and lesser trochanter can be
      separately fractured and appear as separated fragments (three- and four-part fractures).
      Secondary comminution is not infrequent and usually involves one of the
      four major fragments. Anatomic restoration becomes a major undertaking
      but is not necessary to obtain a satisfactory result from a functional
      point of view. Occasionally, a subtrochanteric extension of the
      fracture is encountered.
  • Mechanism of injury.
    The intertrochanteric fracture almost invariably occurs as a result of
    a fall in which both direct and indirect forces are acting. Direct
    forces act


    the long axis of the femur or directly over the trochanter. Indirect
    forces include the pull of the iliopsoas muscle on the lesser
    trochanter and that of the abductors on the greater trochanter.

  • Classification. A number of classifications and subclassifications have been proposed (29,30).
    From the standpoint of treatment and prognosis, a simple classification
    into stable or unstable fractures is most satisfactory.
    • A stable intertrochanteric fracture
      is one in which it is possible for the medial cortex of the femur to
      butt against the medial cortex of the calcar of the femoral neck
      fragment. Not uncommonly, the lesser trochanter is fractured off as a
      small secondary fragment, but this does not interfere with the basic
      stability of the fracture.
    • The unstable intertrochanteric fracture
      is one in which there is comminution of the posteromedial-medial cortex
      (along the calcar femorale). In the most common unstable pattern, a
      large posteromedial fragment encompasses the lesser trochanter, with or
      without a fracture through the greater trochanter (four-part fracture).
      A fracture with high obliquity may be considered unstable because of
      the high shearing force at the fracture site despite anatomic reduction
      and internal fixation.
  • Physical examination.
    The fracture occurs primarily in the elderly, the average age reported
    being 66 to 76 years, which is slightly older than for femoral neck
    fractures. There is a predominance in women, with a ratio of occurrence
    in women to men of 2:1 to 8:1. The leg is shortened and lies in marked
    external rotation. Any movement of the extremity is painful and should
    not be attempted. If traction is applied with a Thomas splint for
    patient transport, it should be removed before radiographs are obtained
    because the ring interferes with proper assessment of the fracture.
    Both anteroposterior and lateral radiographs should be made to confirm
    the diagnosis and to delineate the fracture pattern. The lateral film
    is obtained as a cross-table view, which can be obtained by flexing the
    uninjured hip.
  • Treatment.
    Operative treatment is the procedure of choice if a skilled
    anesthesiologist and surgeon are available. The more debilitated the
    patient, the more urgent the indications. The goal of treatment must be
    to restore the patient to preoperative status as early as possible,
    which can be achieved best through reduction and internal fixation in a
    stable fashion so as to allow early ambulation. As with intracapsular
    fractures, if the patient is first seen with unstable medical
    conditions, these should be stabilized before surgery to minimize the
    risk of perioperative morbidity and mortality (17).
    If there are complicating injuries or illnesses that make it impossible
    to carry out operative reduction and fixation, well-leg traction is
    remarkably well suited to this situation. The leg must be held in some
    external rotation to maintain reduction of the fracture. This treatment
    allows movement from bed to chair and eliminates cumbersome traction
    apparatus for transport. Because treatment necessitates the use of
    crutches following the period of bed rest, weights should be used for
    strengthening the upper extremities. Great care must be taken to avoid
    secondary complications such as pressure areas over the sacrum and the
    heels, equinus contractures of the foot, and thromboembolic disease.
    Traction must be maintained until there is callus seen on radiographs
    usually approximately 8 weeks. Following this period, mobilization may
    begin using non–weight bearing and parallel bars, a walker, or
    crutches. The hip must be protected until there is mature callus and
    bridging bone an additional 4 to 6 weeks. The use of a cane in the
    opposite hand should be encouraged indefinitely to help prevent
    subsequent falls and injury.
    • Operative treatment of intertrochanteric fractures.
      Currently, the sliding hip screw is the “gold standard” for the
      fixation of stable and unstable trochanteric fractures of the femur (31). “Fixed angle” devices that do not allow collapse of the fracture produce inferior results (29).
      There has been renewed interest in the use of intramedullary devices
      whose use is perceived as less invasive and associated with less
      perioperative morbidity. However, structured literature reviews show no
      difference in outcomes between intramedullary devices and sliding hip
      screws, except for a greater incidence of


      both intraoperative and late femur fracture associated with intramedullary fixation (32,33).
      Most of the current available internal fixation devices for treatment
      of intertrochanteric fractures can be expected to yield satisfactory

      • When using a sliding hip screw,
        the fracture must be reduced to a stable position; that is, the medial
        cortices must abut each other anatomically. What is potentially a
        stable fracture can be converted into an unstable situation by
        inadequate reduction of the medial cortices. The reduction is
        accomplished on a fracture table by direct traction, slight abduction,
        and external rotation. If these maneuvers do not produce an anatomic
        reduction, the fracture site should be opened to ensure stability of
        the reduction. Not infrequently, there is some posterior displacement
        at the fracture site that requires the femur shaft to be lifted
        anteriorly to secure an anatomic reduction at the time of fixation.
        Regardless of the internal fixation used, in the elderly osteoporotic
        patient, the neck itself might be little more than a hollow tube; to
        gain purchase, it is essential to insert the nail or screw well into
        the head. The authors recommend insertion to within 0.5 inch of the
        subchondral bone. The position should be in the center of the femoral
        head on both views (34,35).
        Baumgaertner has popularized the “tip-apex distance” as a way to
        emphasize the center/center position within the femoral head. The plate
        should be securely fixed across both femoral cortices by four screws. The
        authors believe that a properly inserted sliding screw plate with the
        wide, threaded, blunt-nosed screw offers the best mechanical fixation
        for intertrochanteric fractures (Fig. 23-1)
        . With unstable fracture patterns, a trochanteric plate may be used to prevent excessive collapse (31).
      • When intramedullary devices
        such as the Gamma nail are used, one must be careful to ream adequately
        and always insert the nail by hand to avoid intraoperative fracture.
        Long devices should be used to prevent later fracture at the tip of the
        stem; however, long intramedullary implants risk perforation of the
        distal anterior femoral cortex (33,36,37).
      • In osteoporotic patients with highly comminuted fractures, hemiarthroplasty in total hip replacement may rarely be indicated (38). Comparative data are lacking to know whether outcomes are any different with arthroplasty compared to internal fixation.
      • A special fracture that deserves mention is the reverse obliquity fracture (Fig. 23-2).
        With this pattern, the primary fracture line is parallel to the axis of
        the femoral neck and the sliding vector of the hip screw. This results
        in tremendous instability and very high failure rates when sliding hip
        screws are used (39). Fractures with this pattern are better stabilized with intramedullary implants or fixed-angle 95-degree devices.
  • Postoperative treatment.
    There is little agreement in the literature as to what constitutes the
    best postoperative management of intertrochanteric fractures. Our
    recommendation for rehabilitation is that patients be moved to at least
    a sitting position on the first postoperative day. In 2 to 3 days, they
    should be taken to the physical therapy department where ambulation can
    be started using the parallel bars. Patients may be allowed to place as
    much weight on the fractured extremity as they wish. They are not
    forced to go beyond what is comfortable for them but are reassured that
    some weight bearing is desirable and not to be feared. As soon as they
    feel secure using the parallel bars, patients should be transferred to
    a walker or crutches, depending on their abilities based on their
    prefracture status. With this program, it is rare that individuals who
    were able to walk without support before fracture cannot be returned to
    a self-sufficient state within 10 to 14 days using either a walker or
    crutches. Patients may disregard the walker or crutches at any time
    they feel secure. The long-term use of a cane is encouraged as a
    preventive measure in elderly patients to avoid falls and injury.
  • Prognosis and complications. Because of the age of patients (many suffer from other debilitating conditions at the time of injury), mortality and morbidity rates


    will always be significant.
    With an aggressive treatment program, mortality rate should be 10% to
    15% for the first year after the fracture; subsequently, the mortality
    rate returns to that of age-matched controls. Mechanical failure and
    non-union can be reduced to 1% or less. Avascular necrosis is rare but
    has been reported (40). Infection is still a
    problem, with most series reporting an incidence of deep infections of
    1% to 5%. This rate can be significantly decreased by careful soft
    tissue technique (11,41) and the use of prophylactic antibiotics for 24 hours.


    With prompt internal fixation and an aggressive postoperative
    rehabilitation program stressing early weight bearing, complications
    from thromboembolic disease can be sharply reduced. The authors
    recommend the use of sequential compression devices and aspirin for all
    patients with the use of a low-dose warfarin of enoxaparin regimen. Even
    with optimum treatment, it is scarcely possible to return more than 40%
    of the patients to their true prefracture status, but one can obtain
    satisfactory results from treatment in approximately 80% of patients
    . Prophylactic antibiotics are recommended as discussed in Chap. 8, IV.E, and Chap. 10, I.B.2.

    Figure 23-1.
    A sliding screw plate. Note the proper positioning for maximum fixation
    with the screw centrally seated in the head within 1 cm of the
    subchondral bone. Four screws are used to insert the slide plate onto
    the femur.
    Figure 23-2. Reverse obliquity fracture.
III. Greater Trochanteric Fractures
  • Isolated avulsion or comminuted fractures of the greater trochanter occasionally are seen. Unless displacement of the fragment is greater than 1 cm,
    the fracture is treated as a soft-tissue injury with protected weight
    bearing until the patient is asymptomatic. Several days of bed rest are
    usually required, followed by walker


    or crutch ambulation for 3 to 4 weeks. In elderly patients, even with separation greater than 1 cm, operative treatment with internal fixation rarely is indicated.

  • In the younger patient, when displacement is greater than 1 cm,
    it is advisable to fix the fracture fragment internally with either two
    cancellous screws or a wire loop to secure fragments. This maneuver
    reconstitutes the functional integrity of the abductor mechanism.
    Postoperatively, the extremity is protected until soft-tissue healing
    is secured. Then the patient is allowed to ambulate without weight
    bearing for 3 to 4 weeks, followed by partial weight bearing for
    another 3 to 4 weeks until limp-free walking can be achieved.
IV. Isolated Avulsion Fractures of The Lesser Trochanter
  • These fractures are seen mainly in
    children and athletic young adults. If they occur in an older patient,
    one must consider the possibility of metastatic disease. Unless


    displacement is greater than 2 cm, operative fixation is not indicated and the end result is excellent.

  • With displacement greater than 2 cm,
    it is advisable to stabilize the avulsed fragment with a cancellous
    screw or a cortical screw, securing it to the opposite cortex. This
    procedure is most readily accomplished through a medial approach to the
    hip. Complications are minimal, and the end result is most satisfactory.
V. Subtrochanteric Fractures
  • Subtrochanteric fractures occur as extensions of intertrochanteric fractures or as independent entities (11).
    The mechanism is direct trauma, and significant forces usually are
    required. This type of fracture is ordinarily seen in younger
    individuals as compared with the intertrochanteric or femoral neck
    fracture. Subtrochanteric fractures, which are extensions of
    intertrochanteric fractures, are also seen in elderly patients. Thus,
    these fractures have a bimodal distribution.
  • P.329

  • Classification. Fielding (see Selected Historical Readings)
    classified subtrochanteric fractures as occurring in three zones: zone
    I, those at the level of the lesser trochanter; zone II, those 1 to 2
    in below the upper border of the lesser trochanter; zone III, those 2
    to 3 in below the upper border of the lesser trochanter. Seinsheimer’s
    classification and results have emphasized the importance of the
    posteromedial fragment. Internal fixation then acts as a tension band
    on the outer (distracting) cortex and allows for impaction and weight
    bearing directly through the medial cortex. If this internal fixation
    is not possible, the fracture pattern is unstable. The most practical
    classification of subtrochanteric fractures is the system of Russell (75)
    et al., which divides such injuries into high and low fractures and has
    direct implications for the most appropriate type of internal fixation (39).
    High fractures occur above the lesser trochanter and may or may not
    involve the greater trochanter and piriformis fossa of the proximal
    femur. Fractures that involve the piriformis fossa require plate
    fixation or trochanteric nailing. High fractures not involving the
    piriformis fossa may be treated by reconstruction nailing. Low
    fractures occur below the lesser trochanter, may or not be comminuted,
    and have varying degrees of extension down the femoral shaft. These
    fractures, regardless of pattern, are readily treated with standard
    intramedullary nails.
  • Physical examination.
    Because the forces required to produce the fracture are substantial,
    other injuries in the same extremity and elsewhere in the body often
    occur. Emergency splinting in a Thomas splint generally is required.
    Hemorrhage in the thigh may be significant, so the patient should be
    monitored for hypovolemic shock, and blood replacement may be
    necessary. Good anteroposterior and lateral radiographs are necessary
    to clearly assess the extent of the fracture.
  • Treatment.
    Operative stabilization to allow early rehabilitation is the treatment
    of choice. Traction may rarely be necessary for the severely comminuted
    fracture, but the healing time is longer than for an intertrochanteric
    fracture, and delayed unions and malunions frequently are encountered.
    Skeletal traction should be used and applied in such a way as to align
    the distal fragment to the proximal fragment. If the lesser
    trochanteric fragment with its attached iliopsoas muscle remains intact
    on the head and neck fragment, it is necessary to flex and externally
    rotate the distal fragment to obtain reduction. The strong adductors
    attached to the femoral shaft tend to cause varus angulation, and
    attempts to correct this by abduction of the hip often exert pull on
    the adductors and cause bowing at the fracture site or medial
    displacement of the shaft fragment. In this event, it is best for the
    patient to undergo treatment in a neutral position with reference to
    abduction-adduction and to increase the traction. When the fracture is
    comminuted and the lesser trochanter is off as a separate piece,
    treatment is the same as for intertrochanteric fractures. If traction
    treatment is used, it should be maintained until there is
    roentgenographic evidence of union. The patient is then placed in a
    single spica cast or hip abduction brace for protected weight bearing
    until the callus matures.
  • Operative treatment
    • Fractures involving the lesser trochanter
      (Fielding zone I). Fractures in this region not involving the
      piriformis fossa may be treated with intramedullary nailing using a
      second-generation (reconstruction) nail with fixation into the femoral
      neck and head. When there is comminution involving the piriformis,
      there are two potential options. The first is to proceed with
      intramedullary nailing using a trochanteric nail, again with proximal
      fixation in the femoral neck and head. This may be difficult because
      the nail may still need to be inserted directly through the fracture
      site. In the author’s opinion, use of a 95-degree fixed-angle device
      such as a blade plate or dynamic condylar screw is the ideal method for
      these fractures. With either method, the procedure is facilitated by
      use of a fracture table and with the patient in the lateral position. Indirect reduction techniques
      should be used to restore length, rotation, and alignment; it is not
      necessary to expose, manipulate, or bone-graft the comminuted region of
      the lesser trochanter.
    • Fractures below the lesser trochanter (Fielding zones II and III). These fractures represent proximal femoral shaft fractures and are usually amenable to


      the same techniques of fixation (i.e., intramedullary nailing) (42).
      Compression plating is equally satisfactory in the hands of persons
      familiar with its application, but it is not used routinely because of
      the large surgical dissection required.

  • Postoperative management.
    Stable subtrochanteric fractures or those that can be rendered stable
    by operative treatment can be managed much as intertrochanteric
    fractures. The unstable subtrochanteric fracture must be supported and
    protected from weight bearing until the union is secure.
  • Complications.
    In the event of a frank nonunion or a delay in union of an
    intertrochanteric or subtrochanteric fracture, a careful assessment of
    the cause of this failure should be made. Too often it is caused by
    less-than-strict adherence to the treatment principles outlined. If the
    fixation is secure and the reduction adequate, bone grafting may
    suffice. As soon as problems with union are recognized, optimal
    position of the fracture should be obtained and standard internal
    fixation combined with fresh autogenous cancellous grafting carried
    out. Osteotomy may be required, especially if there is varus
    malposition of the proximal femur. Once this process is completed, the
    management is the same as for a fresh fracture, except that it may be
    necessary to delay patient activity until discomfort from the graft
    donor site has subsided.
VI. Intertrochanteric and Subtrochanteric Fractures in Children
These fractures may be treated in balanced skeletal traction,
aligning the distal fragment to the proximal one. Often, this requires
that traction be applied with the hip and knee flexed (90-90 traction).
Traction is maintained until the fracture is stable (4–6 weeks), at
which time the extremity is placed in a single spica cast for
immobilization until union is solid (approximately 12 weeks).
Increasingly, percutaneous pin or screw fixation with supplemental
spica casting is used. The authors favor reduction and percutaneous
Steinmann pin fixation followed by supplemental spica casting.
VII. Femoral Diaphyseal Fractures in Adults (43, 44, 45)
  • Diaphyseal fractures of the femur are the result of significant trauma and usually are associated with considerable soft-tissue damage.
    Blood loss of 2 to 3 units is common. In addition, these fractures have
    a high incidence of associated injury in the same extremity (46,47), including fractures of the femoral neck (48), posterior fracture-dislocations of the hip, tears of the collateral ligaments of the knee (47), and osteochondral fractures involving the distal femur or patella and fractures of the tibia (46).
  • Examination.
    Diagnosis usually does not present any clinical problem if care is
    taken to rule out the other associated injuries by physical examination
    and radiographs.
  • Radiographs. Films are obtained primarily to confirm the diagnosis and for preoperative planning. It is essential
    to view the joint above and the joint below the fracture. Films of the
    uninjured femur are helpful for selecting the appropriate internal
    fixation device. An anteroposterior and lateral roentgenogram of the
    injured femur should be supplemented by the anteroposterior pelvis to
    obtain optimum views of the femoral neck (49).
    Unpublished data indicate that routine computed tomographic (CT)
    imaging of the femoral neck reduces the rate of missed ipsilateral
    femoral neck fracture.
  • Treatment
    • Emergency treatment consists of the
      immediate application of a Thomas or Hare splint before radiographs are
      obtained. Unless there is gross comminution or the patient is not a
      surgical candidate, fractures of the shaft of the femur from the lesser
      trochanter to approximately 10 cm above the knee joint should be
      treated by closed antegrade interlocking nailing (see Fig. 25-3), with reaming of the canal using flexible reamers and prebent nails (44,45).
      Current areas of controversy include the role of retrograde nailing and
      the timing of surgery. In general, once associated body cavity and
      other extremity injuries are ruled out, the patient should receive
      urgent operative stabilization. The more severely injured the patient,
      the more critical stable fixation of the femur fracture becomes. Early
      fixation has been shown to be


      with decreased narcotic use, reduced pulmonary complications (e.g.,
      adult respiratory distress syndrome), and decreased mortality rate (43).
      Even patients with isolated femoral shaft fractures, including elderly
      patients, benefit from urgent (within 24 hours of admission)
      stabilization of the femur with an interlocking nail (43,50,51).
      These procedures are carried out on a fracture table in the operating
      room under fluoroscopic control, although some authors report good
      results with nailing on a standard radiolucent table (52).
      Although many authors recommend routine supine positioning because of
      the ease of placement of locking bolts, we favor the lateral position
      on the fracture table when the patient does not have chest, abdominal,
      or pelvic injuries. This allows greater ease of access to the greater
      trochanter and use of smaller incisions in large patients. When the
      patient is severely traumatized, especially those with traumatic brain
      injuries at risk for secondary brain insults, fracture stability can be
      achieved with external fixation or plates much more rapidly on a
      standard table. The fixator is generally exchanged for an interlocking
      nail within the first 5 to 7 days when the patient’s condition has
      stabilized. Primary interlocking nailing immediately following
      debridement is the procedure of choice for most open femoral shaft
      fractures (53). Some advocate the use of small
      diameter locked nails without reaming, especially in patients with
      severe cardiopulmonary trauma; this has been associated with longer
      healing time and implant failure (54,55,56).

    • Recently, implants for retrograde locked nailing have been developed (57,58).
      Indications for retrograde nailing include severe obesity, pregnancy,
      bilateral fractures, and ipsilateral tibia, patella, or acetabular
      fractures (that require repair via a posterior hip approach) (59).
    • Balanced suspension skeletal traction may
      be used until a cast-brace can be applied only when the equipment or
      expertise necessary for locked nailing is unavailable and when the
      patient cannot be transported (60).
  • Complications
    • Associated vascular and nerve damage,
      especially a transient peroneal or pudendal nerve palsy, is not
      uncommon. These problems are generally associated with excessive or
      prolonged traction.
    • Shortening and malrotation of the extremity frequently occur (61),
      even with intramedullary nailing. Slight shortening is associated with
      earlier fracture union, and shortening up to 0.5 inch should be
      accepted without hesitation.
    • Skin breakdown over bony prominences and pin track infections are complications of traction.
    • Infection is extremely rare with the closed nailing technique (62).
    • Nonunion
      occurs in approximately 1% of fractures treated with nailing. This
      problem is easily managed with nail removal, reaming, and repeat
      nailing. Healing complications are more common when small-diameter
      nails are used.
    • Rotational malunion occurs in 10% to 20% of patients; the deformity is generally external rotation (63).
    • Weakness of the abductor muscles and hip pain can occur in one third of patients (64,65).
    • Knee injuries are common after femoral shaft fractures (66).
VIII. Diaphyseal Femur Fractures in Children
  • For children younger than 6 to 8 years
    with an uncomplicated, isolated femoral shaft fracture, a spica cast
    can be used for primary treatment. The technique is as follows (67):
    • When the patient’s general condition has
      stabilized, usually after at least 24 hours of observation in 2 to 3 lb
      of Buck’s traction, the patient is placed under general anesthesia on a
      fracture table. The feet are placed in stirrups, and traction is
      applied. If necessary, a sling attached to an overhead bar may support
      the fractured thigh to restore the normal anterior bow of the femur.
      For a


      younger than 2 years, it may be desirable to flex the hip and knee to
      90 degrees. For the older child, the hip is flexed approximately 20 to
      30 degrees, abducted 20 degrees, and externally rotated to best align
      the distal fragment to the proximal fragment. The knees are kept
      extended. Radiographs are made to verify the reduction. The object of
      manipulation is to provide approximately 1 cm of overriding of the
      fragments (bayonet apposition in good alignment in both planes). When
      this position has been achieved, the skin between the knees and ankles
      is then sprayed with medical adhesive. A single layer of bias-cut
      stockinet is wrapped over the entire area as described for extremity
      casting (see Chap. 7).
      Quarter-inch felt, sponge rubber, or several additional turns of Webril
      may be used over bony prominences except between the knee and ankle. A double hip spica cast
      is then applied, molded carefully around the pelvis, and extended to
      embrace the rib margin. When the cast has hardened, the foot pieces of
      the fracture table are removed, and if radiographs confirm the proper
      position, the cast is extended to include both feet and ankles, which
      are well padded, in a neutral position. A crossbar is added to the cast.

    • Postcasting treatment.
      Follow-up radiographs are made at 1, 2, and 3 weeks to be certain of
      the maintenance of position. The cast is worn for 6 to 12 weeks,
      depending on the age of the patient and the type of fracture. The
      family must be instructed in cast care and told to alert the physician
      if there is any evidence of pain, fever, or loss of extension of the
      great toe.
  • Children older than 8 years
    are not ideally managed with spica casts and usually receive some sort
    of operative fixation. Antegrade interlocking nails, as used in adults,
    are not appropriate in skeletally immature patients because of the risk
    of osteonecrosis of the hip. For transverse, length stable fractures,
    retrograde flexible nailing has gained increased acceptance (68).
    Trochanteric nails may be considered for the teenage child with
    fractures of the diaphysis of the femur. The starting point for the
    nail should be moved slightly lateral to decrease the risk of avascular
    necrosis. Compression plating remains a very good option (69); percutaneous submuscular plating is another recent option.
  • Children with head injuries
    or multiple trauma should be managed with operative stabilization. In
    patients younger than 12 years, this should involve plates, retrograde
    flexible nails, or external fixators. Children older than 12 years may
    undergo treatment with intramedullary nails.
IX. Unicondylar, Supracondylar, and Intracondylar Fractures (62)
  • Mechanism of injury.
    In older individuals, these fractures are sustained with minimal
    trauma. In young people, these fractures generally are caused by
    massive trauma and often are associated with vascular and other
    soft-tissue injuries. This fracture has a bimodal age distribution as
  • Examination.
    A careful assessment of nerve and vascular status distal to the
    fracture is critical here as with any fracture. Care must be taken to
    ascertain any injuries to the soft tissues about the knee and whether
    the fracture extends into the joint.
  • Radiographs. Anteroposterior, lateral, and, occasionally, oblique views are necessary.
  • Treatment
    • Displaced unicondylar fractures
      should be treated by open reduction and internal fixation. Although
      good results can be anticipated with use of traditional devices such as
      the dynamic condylar screw or blade plate (35),
      newer periarticular plates may be an advantage. Retrograde nailing is
      advocated by many; its advantages include a less invasive approach and
      better stabilization in severely osteoporotic patients.
    • Undisplaced supracondylar fractures
      or fractures displaced less than 1 mm involving the joint surface may
      be treated by percutaneous screw fixation, generally with cannulated
      screw systems. Alternatively, a hinged knee brace or cast-brace may be
      used, but frequent radiographs must be obtained. In either case, early
      motion must be initiated to optimize results.


      Inferior results with nonoperative management for these fractures has been documented (70).

    • Extra-articular distal femur fractures or those occurring above total knee replacements can be nicely managed with retrograde supracondylar nails (71,72) or standard antegrade nails (73).
    • Displaced intra-articular or supracondylar fractures are managed by internal fixation (41,58,74,75).
      The fracture requires open reduction of the joint surface via a lateral
      or anterolateral approach to ensure that it is anatomically reduced.
      Minimal stripping of the soft-tissue attachments to the extra-articular
      fragments must be completed. This speeds union and decreases the need
      for bone grafting while minimizing infection (76).
      A 95-degree condylar blade plate or dynamic condylar screw is the
      optimum device for fixing these fractures, but they require 1.5 to 2.0
      cm of intact bone proximal to the compression screw or blade (75).
      With extremely comminuted fractures, a condylar buttress plate is
      required, which allows for more screws into the distal fragment.
      Fixed-angle locking plates have revolutionized the care of these
      fractures (74). Medial or varus collapse is
      prevented, and fixation in osteoporotic bone is improved. Minor
      malunion is common with the use of fixed angle devices (77).
      If the expertise or equipment to perform these procedures does not
      exist and the patient cannot be transported to a facility where they
      are available, skeletal traction can be used. A tibial pin is inserted
      with the knee flexed 20 degrees, and balanced suspension is used. Early
      active quadriceps exercises are necessary to prevent joint fibrosis.
      Because of the pull of the gastrocnemius, which extends the fracture,
      the flexed position should be maintained for the first several weeks.
      The distal fragment must be aligned to the proximal fragment, which is
      usually in external rotation.
  • Postoperative care.
    Continuous passive motion is used while the patient is in the hospital
    and may be extended to the early posthospitalization period (first 3
    weeks) in most cases in which stable internal fixation has been
    achieved. A hinged-knee brace is generally used for 6 weeks. The goal
    of full extension and 120 degrees of flexion by 6 weeks postoperatively
    is standard. Full weight bearing is delayed for 10 to 12 weeks.
    Strengthening exercises can then be initiated. Patients in traction
    require aggressive physical therapy to regain full extension and 90
    degrees of flexion. Active and gentle passive motion protocols are
    initiated once the fracture is clinically and radiographically healed
    at about 8 weeks after injury. Some permanent loss of motion is
    expected for fractures treated this way as well as for severe
    intra-articular fractures managed operatively (74).



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73. Leung
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74. Kregor
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75. Russell TA, Taylor JC. Subtrochanteric fractures of the femur. In: Browner BD, Jupiter JB, Levine AM, et al. eds. Skeletal Trauma, 2nd ed. Philadelphia, PA: Saunders, 1992.
76. Ostrum RF, Geel C. Indirect reduction and internal fixation of supracondylar femur fractures without bone graft. J Orthop Trauma 1995;9:278–284.
77. Zehntner
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Selected Historical Readings
Clawson DK. Trochanteric fractures treated by the sliding screw plate fixation method. J Trauma 1964;4:737–752.
Clawson DK, Smith RF, Hansen ST Jr. Closed intramedullary nailing of the femur. J Bone Joint Surg (Am) 1971;53:681–692.
Dimon JH, Hughston JC. Unstable intertrochanteric fractures of the hip. J Bone Joint Surg (Am) 1967;49:440–450.
Fielding JW. Subtrochanteric fractures. Clin Orthop 1973;92:86–99.
Garden RS. Malreduction and avascular necrosis in subcapital fractures of the femur. J Bone Joint Surg (Br) 1971;53:183–197.
Kempf I, Grosse A, Beck G. Closed locked intramedullary nailing: its application to comminuted fractures of the femur. J Bone Joint Surg (Am) 1985;67:709–720.
Kyle RF, Gustilo RB, Premer RF. Analysis of 622 intertrochanteric hip fractures. J Bone Joint Surg (Am) 1979;61:216–221.
Lesin BE, Mooney V, Ashby ME. Cast-bracing for fractures of the femur. J Bone Joint Surg (Am) 1977;59:917–923.
McElvenny RT. The importance of the lateral x-ray film in treating intracapsular fractures of the neck of the femur. Am J Orthop 1962;4:212.
Neer CS, Grantham SA, Shelton ML. Supracondylar fractures of the adult femur. J Bone Joint Surg (Am) 1967;49:591–613.
Olerud S. Operative treatment of supracondylar-condylar fractures of the femur. J Bone Joint Surg (Am) 1972;54:1015–1032.
Seinsheimer F. Subtrochanteric fractures of the femur. J Bone Joint Surg (Am) 1978;60: 300–306.
Singh M, Nagrath AR, Main PS. Changes in trabecular patterns of the upper end of the femur as an index of osteoporosis. J Bone Joint Surg (Am) 1970;52:457–467.
Zickel RE. A new fixation device for subtrochanteric fractures of the femur. A preliminary report. Clin Orthop 1967;54:115–123.

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