Subtrochanteric Fractures

Ovid: Rockwood And Green’s Fractures In Adults

Editors: Bucholz, Robert W.; Heckman, James D.; Court-Brown, Charles M.; Tornetta, Paul
Title: Rockwood And Green’s Fractures In Adults, 7th Edition
> Table of Contents > Section Four – Lower Extremity > 49 – Subtrochanteric Fractures

Subtrochanteric Fractures
George J. Haidukewych
Joshua Langford
Subtrochanteric fractures typically occur in the
proximal femur between the inferior aspect of the lesser trochanter and
a distance of about 5 cm distally. These fractures generally occur in
two patient age distributions: the young, high-energy, often
polytraumatized population, and the elderly osteopenic population,
typically resulting from a low-energy fall from a standing height.2,9
Fractures in the subtrochanteric region present challenges to achieving
stable fixation and appropriate reduction regardless of age. The
subtrochanteric region of the femur is one of the highest stressed
zones in the human skeleton where tensile or compressive stresses can
exceed several multiples of body weight. Additional challenges include
short proximal fragments which are deformed by the hip flexors and
abductors which may make accurate reduction and fixation challenging.
There are several internal fixation options for managing these
fractures that generally fall into two categories: some form of
intramedullary fixation or some form of plating. There are many
specific technical hurdles that must be overcome to ensure stable
proximal fragment fixation performed in a biologically friendly manner
and with accurate alignment and implant position.
Mechanisms of Injury
Subtrochanteric fractures in the younger patient population typically occur as a result of high-energy trauma.2,9,19
Prioritization of other life-threatening injuries should occur first,
and the subtrochanteric fracture should be stabilized as early as
possible after appropriate resuscitation of the patient in order to
allow early mobilization and avoid the complications of prolonged
recumbency. In the elderly population, medical optimization is
recommended; however, associated injuries are relatively uncommon as
these typically result from a fall from a standing height.
Subtrochanteric fractures are relatively rare compared to
intertrochanteric fractures in the elderly. A relatively unique


pattern has been associated with bisphosphonate therapy. It is
typically transverse; at the metadiaphyseal junction, there are signs
of lateral cortical thickening and a medial cortical spike. Prodromal
symptoms were often present.15

History and Physical Examination
Attention should first be focused on prioritization of
life-threatening injuries utilizing standard advance trauma life
support protocols. The fractured limb is then examined with careful
circumferential examination of the skin to rule out an open fracture.
The neurovascular status of the limb should be documented, and any
areas of abrasion or other skin compromise should be evaluated as this
may change one’s surgical incision. Elderly patients should be
evaluated for ipsilateral upper extremity fractures and any head injury
or loss of consciousness, since subdural hematomas can occur with
surprisingly little impact.
Imaging and Other Diagnostic Studies
High-quality biplanar plain radiographs will usually
provide enough information to guide the treatment of the vast majority
of subtrochanteric fractures. The length of the proximal fragment and
the diameter of the diaphysis distally should be evaluated. A traction
view may be helpful in defining fracture geometry and location. Careful
attention to any proximal fracture extent into the piriformis fossa,
greater trochanter, or involvement of the lesser trochanter can
influence the surgeon’s choice of implant. If there is any concern
about fracture extension into the piriformis fossa or the greater
trochanter, a computed tomographic scan can be obtained, or if one was
obtained during the trauma workup, it can be reviewed for any proximal
fracture lines.
Russell-Taylor classification of subtrochanteric fractures. Note the
emphasis on lesser trochanteric integrity and piriformis fossa
Diagnosis and Classification
Several classifications exists for subtrochanteric
fractures. The authors find three to be generally useful in guiding
treatment. The Russell-Taylor classification38 (Fig. 49-1)
essentially guides the surgeon in determining the integrity of the
proximal fragment which historically has facilitated decision-making
regarding nail or plating choices. The classification is divided based
on whether the piriformis fossa is involved and whether the lesser
trochanter is involved. Previously, this information would guide
decision-making regarding standard locking of an intramedullary nail
from greater to lesser trochanter or the need for so-called
“reconstruction” nailing with cephalomedullary type fixation (Figs. 49-2 and 49-3).
Historically, with piriformis fossa extension proximally, plating
techniques were considered for fear of losing capture of the proximal
fragment with a piriformis fossa starting point nailing. Essentially,
the nail could “fall out the back” of the proximal fragment.2,13
With more contemporary nailing techniques that enter the tip of the
greater trochanter, these issues have become less problematic (see “Current Treatment Options”). The Seinsheimer classification40 (Fig. 49-4)
is more detailed but can also be useful as it grades fracture obliquity
and the extent of comminution in the subtrochanteric region. The
Orthopaedic Trauma Association classification11 (Fig. 49-5)
is also useful. The commonality to all classification schemes is that
they try to categorize fractures based on the integrity of the proximal
fragment, comminution, and fracture geometry to help the surgeon with
appropriate implant selection. With modern nailing techniques, however,
these classifications no longer influence a “nail versus plate”
decision, but may influence the locking configuration.

A segmental subtrochanteric fracture with an extremely short proximal
fragment. Note the flexion, abduction, and external rotation of the
proximal fragment.
Postoperative radiograph demonstrating good reduction of both
fractures. Due to the short proximal fragment a cephalomedullary device
was chosen.
Seinsheimer classification of subtrochanteric fractures. Note the
emphasis on fracture obliquity, comminution, and proximal extension.

Orthopedic Trauma Association classification of subtrochanteric
fractures. (Redrawn from Marsh JL, Slongo TF, Agel J, et al. Fracture
and dislocation classification compendium—2007: Orthopaedic Trauma
Association classification, database, and outcomes committee. J Orthop
Trauma 2007;21(10 Suppl):S32-36, with permission.)
Surgical and Applied Anatomy
The subtrochanteric region of the femur experiences the
highest tensile and compressive stresses of any bone in the human
skeleton. Several multiples of body weight will challenge any fixation
construct (Fig. 49-6). Comminution in this area
often involves the medial cortex; therefore, the implant chosen must
withstand enormous compressive and tensile loads. Compressive forces in
the medial cortex can exceed 1200 lbs per square inch (in a 200-lb
person).22 The fixation constructs chosen, therefore, should be load-sharing and be able to withstand such multiples of body weight (Fig. 49-7).
Additionally, the deforming muscular forces of short proximal fragments
can be problematic, especially when one is attempting either an
indirect reduction for a plating technique or a closed intramedullary
nailing technique. The proximal fragment is abducted by the abductor
mechanism, externally rotated and flexed by a combination of the short
external rotators and the iliopsoas tendon (Fig. 49-8).
Additionally, the femoral shaft distally is adducted and shortened by
the pull of the adductors and quadriceps mechanism. This essentially
moves the tip of the trochanter and the piriformis fossa away from the
surgeon and flexes the proximal fragment. These deformities must be
overcome and controlled in order to allow accurate reduction and avoid
varus. Varus alignment can increase the stresses in compression on any
internal fixation construct by changing the trajectory of
weight-bearing forces across the femoral neck. For example,
theoretically, a proximal fragment aligned with a neck shaft angle of
100 degrees will likely experience more compressive stresses on its
medial cortex than a proximal fragment aligned in 135 degrees. The
relationship between the tip of the greater trochanter and the center
of the femoral head should be evaluated during reduction and internal
fixation. If this relationship is coplanar, then in general the
neck-shaft angle will be in its normal anatomic location for that
particular patient, and varus can be


An anteroposterior view of the pelvis will allow assessment of the
contralateral neck shaft relationship, which may assist evaluation of
appropriate alignment.

FIGURE 49-6 Koch’s diagram showing the magnitude of the compressive stresses medially and the tensile stresses laterally.
Common Surgical Approaches
Since most nailing is done in a percutaneous fashion, no
formal surgical dissection is necessary. The technique is discussed in
the section below on intramedullary stabilization. With regard to
plating techniques, or if open reduction is necessary during
intramedullary nailing, the most common surgical approach is a direct
lateral approach to the proximal femur. A direct lateral incision is
made over the flare of the trochanter and deepened in through the
subcutaneous tissue and the fascia lata. The vastus lateralis is
elevated from its attachment on the lateral femur, and the
intermuscular septum and perforators are coagulated with
electrocautery. It is important to note that medial dissection over the
femoral shaft should be avoided as this is the main location of the
blood supply to the subtrochanteric region and devitalizing this area
by excessive dissection may contribute to delayed union or nonunion.
A highly comminuted subtrochanteric fracture with a very short proximal
fragment. Any implant chosen to stabilize this fracture must withstand
substantial forces.
The typical deforming muscular forces cause the proximal fragment to be
flexed by the iliopsoas, externally rotated by the short rotators, and
abducted by the abductors. The femoral shaft is shortened and adducted
by the adductors and quadriceps.
Nonoperative treatment in adult patients is only
indicated for the most infirm, moribund patients where surgical
intervention is impossible. For example, a nonambulatory demented
patient with fixed contractures and prohibitive medical comorbidity.
Again, the vast majority of cases should be treated with some form of
internal fixation to avoid the morbidity of prolonged recumbency.
General internal fixation categories appropriate for subtrochanteric fractures include some form of nailing or some form


of plating. Given an understanding of the substantial forces across any
fixation construct used to stabilize the subtrochanteric region of the
femur, it is clear that an intramedullary implant with a shorter lever
arm on the proximal fixation and load-sharing characteristics would be
the preferred implant in the vast majority of subtrochanteric
fractures. Plating techniques, however, can be useful for extremely
short proximal fragments and in certain situations such as delayed and
nonunion. Our discussion, therefore, will focus on these two general
categories of stabilization methods.

External fixation may be useful for rapid, provisional
stabilization of polytraumatized patients, but it is generally not
recommended for definitive treatment.14
Arthroplasty may have a role in pathologic fractures due to neoplasm
with extensive proximal fragment involvement or for multiply operated
nonunions, but, in general, has no role in acute, nonpathologic
Operative Treatment—Nailing
The mechanical and biologic advantages of intramedullary
techniques for the stabilization of subtrochanteric fractures have
already been discussed. A nailing technique should be chosen for the
overwhelming majority of subtrochanteric fractures for those reasons.
In general, the surgeon needs to make three major decisions when
nailing subtrochanteric fractures. The first decision is whether the
starting point should be in the piriformis fossa or in the tip of the
greater trochanter. Good results have been described with both
treatment techniques,35,42
and the quality of reduction is probably more important than whether a
trochanteric or piriformis starting point is chosen. It is far easier
to locate the starting point on the tip of the greater trochanter since
it is more lateral and the entry trajectory is more lateral as well.
Additionally, piriformis fossa involvement is not a contraindication
for greater trochanteric nailing. The starting point decision is based
on surgeon preference and accuracy of starting point placement;
regardless of philosophy it is critical to obtaining and maintaining
fixation and alignment of the proximal fragment.
The second decision is whether to perform the proximal
locking in a standard “greater to lesser” trochanteric fashion with a
single locking screw or whether to place locking screws into the
femoral head and neck, the so-called “reconstruction” or
“cephalomedullary” nailing. The decision to use a single greater to
lesser locking screw or a cephalomedullary locking configuration should
be made based on the integrity of the proximal fragment (i.e.,
involvement of the lesser trochanter or extension of a fracture line
proximally) and bone quality. If the proximal fragment is intact and
the fracture is completely below the lesser trochanter, then a standard
antegrade nail with a greater to lesser trochanter single locking screw
will likely be adequate (in the authors’ experience, this situation is
quite rare). If comminution exists, if there is any concern about the
integrity of the proximal fragment (lesser trochanteric or proximal
involvement), or in elderly patients with osteopenic bone, the authors
recommend cephalomedullary fixation (Fig. 49-9).
If cephalomedullary nailing is chosen, the third decision involves
whether a single large central lag screw (such as in a Gamma-type
nail), or two smaller diameter screws (such as in the standard
reconstruction type nail) should be selected. Most reconstructionnails
have a 13-mm proximal diameter, while Gamma-type devices are 16 to 17
mm in diameter. In general, for young patients with excellent bone
quality, the authors prefer two reconstruction type screws into the
femoral head since these nails have smaller proximal diameters and
probably cause less abductor damage.8
For older patients, one large central lag screw may provide better
purchase due to the larger surface area a large lag screw provides.
Also, this effectively “protects” the femoral neck as insufficiency
fractures after nailing have ben reported.21 A biomechanical study by Roberts et al.36
demonstrated that if comminution existed, then a single large lag screw
device was stiffer than a reconstruction type nail with two smaller
screws; however, the clinical performance of one versus two
cephalomedullary screws have not been studied in equivalent populations
(Figs. 49-10 and 49-11).10
FIGURE 49-9 Intramedullary fixation of a subtrochanteric fracture with a so-called cephalomedullary or “reconstruction” nail.
FIGURE 49-10 A comminuted reverse obliquity subtrochanteric fracture.

FIGURE 49-11
Fixation with a cephalomedullary device. Note the slight varus
malalignment. This is common when the medial cortex below the lesser
trochanter is comminuted since there is no surface to deflect and
contain the nail.
Operative Treatment—Plates
Plating techniques can be useful for subtrochanteric
fractures, especially those with very short proximal fragments that can
be extremely difficult to nail due to limited nail containment and
difficulty with reduction. Several categories of plates can be useful
ranging from a traditional sliding hip screw or dynamic condylar screw
or 95-degree condylar blade plate. The obliquity of the fracture should
be evaluated carefully if a plating strategy is chosen. For so-called
reverse obliquity and transverse patterns, sliding hip screws should
not be used as proximal fragment lateralization is uncontrolled and
fixation failure has been reported. A 95-degree angled blade plate or a
locking plate are better choices as they resist these proximal
lateralizing forces. More recently, anatomically precontoured proximal
femoral locking plates have been developed to facilitate fixation of
such short fractures; however, limited data is available documenting
their efficacy to date. The common features of any plating technique
include the need for a relatively large dissection and the fact that
plating must be done in a biologically friendly manner (discussed
below) to allow relatively rapid healing.2,5,18,20,24,25,29,32,39
Plates are inherently biomechanically inferior to nails because of
their more lateral position (longer lever arm on the proximal fixation)
and their nonload-sharing characteristics, therefore it is critical
that a biologically friendly (indirect reduction) technique be chosen
for their implantation.
The incidence of malunion is probably higher than
reported. Malunion can result in a varus alignment to the proximal
femur which decreases abductor efficiency due to a more proximal
position of the greater trochanter (Fig. 49-29). This can also affect limb length and clinical rotation.16
The amount of deformity that is problematic remains undefined, so the
surgeon will have to individualize treatment decisions based on patient
complaints and physical examination. There are no large published


on the management of proximal subtrochanteric malunion; however,
corrective osteotomy may be indicated if the deformity is severe.
Implant choice for corrective osteotomy will depend on the previously
placed implants, available bone quality, and defects in the femoral
head. The author prefers to use a 95-degree angled blade plate in this
situation since the plate can be placed in the proximal fragment, a
corrective osteotomy performed at the apex of the deformity, and when
the plate is reduced to the femoral shaft, correct alignment is usually
obtained, similar to the technique used for indirect reduction of acute
fractures. The blade can typically be placed in the inferior femoral
head, an area unlikely to be violated by previous internal fixation

FIGURE 49-29
Subtrochanteric malunion. Note the lateral starting point, the varus
malalignment, and the very visible lesser trochanter which implies
external rotational malreduction of the proximal fragment.
Nonunion is a rare but problematic complication of subtrochanteric fractures (see Fig. 49-26).
The treatment of nonunion will vary; however, the surgeon must
determine whether the fracture is aligned in a suitable fashion and can
be treated with an exchange nailing or whether there is concomitant
malalignment that will require realignment via a full nonunion takedown
(the more common situation) (Fig. 49-30). In
general, if the nonunion is well aligned and was previously nailed,
then the authors prefer to perform an exchange nailing, with a larger
diameter nail, in a closed fashion. A nail with a different locking
screw configuration into the proximal fragment may provide better
fixation if bony defects from prior fixation are present (Fig. 49-31).
If there has been hardware failure, the proximal fragment is short or
there is problematic malalignment, then the author prefers an open
plating technique with a 95-degree blade plate. Usually a full nonunion
take-down—removing all fibrous tissue from the nonunion site—will be
required and compression must be achieved. Several studies have
demonstrated that successful union can be obtained as long as stable
proximal fragment fixation can be obtained.1,7,17
The authors prefer to use bone graft or a bone graft substitute for
atrophic nonunions or those with bony deficiency. Arthroplasty may have
a role in the multiply operated nonunion in the elderly patient,
especially if the proximal fragment has massive bone defects from prior
fixation attempts or articular damage from screw cut-out.
FIGURE 49-30
Subtrochanteric nonunion with varus, shortening, and external
rotational malreduction of the proximal fragment. Such a situation will
require open nonunion takedown and realignment probably with a blade
FIGURE 49-31
A subtrochanteric nonunion after cephalomedullary nailing was treated
with antegrade exchange nailing. A different proximal locking
configuration was chosen to optimize fixation of the proximal fragment.
Infection remains one of the most difficult
complications to manage and is often associated with nonunion. Early
postoperative infection is managed with débridement, retention of
stable hardware, and a period of intravenous organism specific
antibiotics. For chronic infections or those with loose or broken
hardware, the authors prefer to remove all hardware, thoroughly
irrigate and débride the area (typically reaming the femoral canal),
and place the patient on a period of intravenous organism-specific
antibiotics. Intramedullary antibiotic spacers can be useful as well to
provisionally stabilize the subtrochanteric region. The authors use a
metal ball-tipped guide rod as an endoskeleton and surround the wire
with antibiotic loaded bone cement. The definitive fixation with or
without bone grafting is then performed after eradication of infection.
For extremely unstable fractures temporary external fixation can be
useful until definitive fixation can occur.
The published data regarding intramedullary fixation of
subtrochanteric fractures has generally been good with a high rate of
clinical union and a low rate of reoperation. Malalignments are common,
and these surgeries can be difficult with long operative times and
significant blood loss. Multiple studies support the superiority of
nailing techniques over plating techniques.2,3,4,6,12,23,26,27,28,31,33,34,37,41,43,44,45,46,47 Plating techniques can also be effective;


however, the best outcomes have been reported with fixed angle devices
implanted with technically demanding indirect reduction techniques.
Published data on management of nonunions have generally demonstrated
good outcomes if stable proximal fragment fixation can be obtained.

Further research is needed into the role of
percutaneously applied locking plates, analogous to techniques utilized
for fractures of the distal femur. Nail developments will likely focus
on percutaneous reduction instruments and various proximal locking
options to optimize proximal fragment fixation. Computer-navigated
reduction of the proximal fragment may someday assist the surgeon in
avoiding varus and rotational malunions. It is likely that data will
emerge that routine “mini-open” nailing of the short, deformed,
so-called “high” subtrochanteric fracture will improve reduction
quality with no deleterious effects on union rates. Although
historically discouraged, it is likely that the judicious use of
cerclage in certain spiral and long oblique fracture patterns will play
an increasing role in minimizing malreduction and nonunion.
1. Barquet
A. The treatment of subtrochanteric nonunions with the long gamma nail:
26 patients with a minimum 2-year follow-up. J Orthop Trauma
2. Bedi A, Toanle T. Subtrochanteric femur fractures. Orthop Clin N Am 2004;35(4): 473-483, review.
3. Brien
WW, Wiss DA, Becker V Jr, et al. Subtrochanteric femur fractures: a
comparison of the Zickel nail, 95 degrees blade plate, and interlocking
nail. J Orthop Trauma 1991; 5(4):458-464.
4. Broos
PL, Reynders P. The use of the unreamed AO femoral intramedullary nail
with spiral blade in nonpathologic fractures of the femur: experiences
with 80 consecutive cases. J Orthop Trauma 2002;16(3):150-154.
5. Celebi
L, Cam M, Muratli HH, et al. Indirect reduction and biological internal
fixation of comminuted subtrochanteric fractures of the femur. Injury
6. Chevalley
F, Gamba D. Gamma nailing of pertrochanteric and subtrochanteric
fractures: clinical results of a series of 63 consecutive cases. J
Orthop Trauma 1997;11(6):412-415.
7. deVries JS, Kloen P, Boren SO, et al. Treatment of subtrochanteric nonunions. Injury 2006;37(2):203-211.
8. Dora
C, Leunig M, Beck M, et al. Entry point soft tissue damage in antegrade
femoral nailing: a cadaver study. J Orthop Trauma 2001;15(7):488-493.
9. Fielding JW, Magliato HJ. Subtrochanteric fractures. Surg Gynecol Obstet 1966;122: 555-569.
10. Fissel
B, Moed BR, Bledsoe JG. Biomechanical comparison of a 2 and 3 proximal
screw configured antegrade piriformis intramedullary nail with a
trochanteric reconstruction nail in an unstable subtrochanteric
fracture model. J Orthop Trauma 2008;22(5):337-341.
11. Fracture
and Dislocation Compendium. Orthopaedic Trauma Association Committee
for Coding and Classification. J Orthop Trauma 1996;10(Suppl 1):v-ix,
12. French
BG, Tornetta P. Use of an interlocked cephalomedullary nail for
subtrochanteric fracture stabilization. Clin Orthop 1998;348:95-100.
13. Garnavos
C, Peterman A, Howard PW. The treatment of difficult proximal femoral
fractures with the Russell-Taylor reconstruction nail. Injury
14. Giannoudis
PV. Aspects of current management: Surgical priorities in damage
control in polytrauma. J Bone Joint Surg (Br) 2003;85B:478-483.
15. Goh
SK, Yang KY, Koh JS, et al. Subtrochanteric insufficiency fractures in
patients on alendronate therapy: a caution. J Bone Joint Surg
16. Guggenheim
JJ, Probe RA, Brinker MR. The effects of femoral shaft malrotation on
lower extremity anatomy. J Orthop Trauma 2004;18(10):658-664.
17. Haidukewych GJ, Berry DJ. Non-union of fractures of the subtrochanteric region of the femur. Clin Orthop 2004;419:185-188.
18. Hasenboehler
EA, Agudelo JF, Morgan SJ, et al. Treatment of complex proximal femoral
fractures with the proximal femur locking compression plate.
Orthopedics 2007;30(8): 618-623.
19. Hildebrand F, Giannoudis P, Krettek C, et al. Damage control: extremities. Injury 2004; 35:678-689.
20. Kinast
C, Bolhofner BR, Mast JW, et al. Subtrochanteric fractures of the
femur: results of treatment with the 95 condylar blade-plate. Clin
Orthop 1989;28:122-130.
21. Kitajima
I, Tachibana S, Mikama Y, et al. Insufficiency fracture of femoral neck
after intramedullary nailing. J Orthop Sci 1999;4:304-306.
22. Koch JC. The laws of bone architecture. Am J Anat 1917;21:177-198.
23. Kraemer
WJ, Hearn TC, Powell JN, et al. Fixation of segmental subtrochanteric
fractures: a biomechanical study. Clin Orthop 1996;332:71-79.
24. Krettek
C, Muller M, Miclau T. Evolution of minimally invasive plate
osteosynthesis (MIPO) in the femur. Injury 2001;32(Suppl 3):SC14-23.
25. Krettek
C, Schandelmaier P, Miclau T, et al. Minimally invasive percutaneous
plate osteosynthesis (MIPPO) using the DCS in proximal and distal
femoral fractures. Injury 1997;28(Suppl 1):A20-30.
26. Kummer
FJ, Olsson O, Pearlman CA, et al. Intramedullary versus extramedullary
fixation of subtrochanteric fractures. A biomechanical study. Acta
Orthop Scand 1998;69(6): 580-584.
27. Lee
PC, Hsieh PH, Yu SW, et al. Biologic plating versus intramedullary
nailing for comminuted subtrochanteric fractures in young adults: a
prospective, randomized study of 66 cases. J Trauma
28. Mahonmed MN, Harrington IJ, Hearn TC. Biomechanical analysis of the Medoff sliding plate. J Trauma 2000;48:93-100.
29. Neher
C, Ostrum RF. Treatment of subtrochanteric femur fractures using a
submuscular fixed low-angle plate. Am J Orthop 2003;32(9 Suppl):29-33.
30. Ostrum
RF, Marcantonio A, Margurger R. A critical analysis of the eccentric
starting point for trochanteric intramedullary femoral nailing. J
Orthop Trauma 2005;19(10): 681-686.
31. Pai
C-H. Dynamic condylar screw for subtrochanteric femur fractures with
greater trochanteric extension. J Orthop Trauma 1996;10(5):317-322.
32. Perren
SM. Evolution of the internal fixation of long bone fractures. The
scientific basis of biological internal fixation: choosing a new
balance between stability and biology. J Bone Joint Surg Br
33. Pugh
KJ, Morgan RA, Gorczyca JT, et al. A mechanical comparison of
subtrochanteric femur fracture fixation. J Orthop Trauma
34. Rantanen
J, Aro HT. Intramedullary fixation of high subtrochanteric femoral
fractures: a study comparing two implant designs, the Gamma nail, and
the intramedullary hip screw. J Orthop Trauma 1998;12(4):249-252.
35. Ricci
WM, Schwappach J, Tucker M, et al. Trochanteric versus piriformis entry
portal for the treatment of femoral shaft fractures. J Orthop Trauma
36. Roberts
CS, Nawab A, Wang M, et al Second-generation intramedullary nailing of
subtrochanteric femur fractures: a biomechanical study of fracture site
motion. J Orthop Trauma 2002;16(4):231-238.
37. Robinson
CM, Houslian S, Khan LA. Trochanteric entry long cephalomedullary
nailing of subtrochanteric fractures caused by low-energy trauma. J
Bone Joint Surg Am 2005; 87(10):2217-2226.
38. Russell-Taylor classification of subtrochanteric fractures. Skeletal Trauma 1998;2: 1891-1897.
39. Sanders
R, Regazzoni P. Treatment of subtrochanteric femur fractures using the
dynamic condylar screw. J Orthop Trauma 1989;3(3):206-213.
40. Seinsheimer F III. Subtrochanteric fractures of the femur. J Bone Joint Surg 1978;60A: 300-306.
41. Shukla
S, Johnston P, Ahmad MA, et al. Outcome of traumatic subtrochanteric
femoral fractures fixed using cephalo-medullary nails. Injury
42. Starr
AJ, Hay MT, Reinert CM, et al. Cephalomedullary nails in the treatment
of high-energy proximal femur fractures in young patients: a
prospective, randomized comparison of trochanteric versus piriformis
fossa entry portal. J Orthop Trauma 2006;20(4): 240-246.
43. Trafton PG. Subtrochanteric-intertrochanteric femoral fractures. Orthop Clin North Am 1987;18:59-71
44. Van
Doorn R, Stapert JW. The long gamma nail in the treatment of 329
subtrochanteric fractures with major extension into the femoral shaft.
Eur J Surg 2000;166(3):240-246.
45. Waddell JP. Subtrochanteric fractures of the femur: a review of 130 patients. J Trauma 1979;19:585-592.
46. Wiss
DA, Brien WW. Subtrochanteric fractures of the femur: results of
treatment by interlocking nailing. Clin Orthop 1992;283:231-236.
47. Wu CC, Shin CH, Lee ZL. Subtrochanteric fractures treated with interlocking nailing. J Trauma 1991;31(3):326-333.
48. Afsari
A, Liporace F, Lindrall E, et al. Clamp assisted reduction of high
subtrochanteric fractures of the femure. J Bone Joint Surg Am

This website uses cookies to improve your experience. We'll assume you're ok with this, but you can opt-out if you wish. Accept Read More