Академический Документы
Профессиональный Документы
Культура Документы
WITH CONTRIBUTIONS FROM MIGUEL E. (AIJANELA. M.D.. THOMAS A. RUSSELL. M.D.. MARC F. SWIONTKOWSKI. M.D..
ROBERT A. WINOtJIST. MI).. JOSEPH D. ZIJCKERMAN. M.D.. A. H. SCHMIDT. M.D.. AND K. J. KOVAL. M.D.
the proximal part of the femur is important not only for Most of the vascular supply to the femoral head
the continued health and vitality of the population but comes from the posterior medial and lateral femoral
also for the health of the economy. circumflex arteries that form an extracapsular ring
Fractures of the proximal part of the femur occur about the femoral neck (Fig. 1). Ascending cervical
predominantly as low-energy injuries in elderly patients branches arise from this network and enter the capsule
and as high-energy injuries in younger patients. The high at its insertion. Fractures of the femoral neck have been
prevalence of these fractures in the elderly is related to shown, both by injection techniques and by histological
numerous factors, including osteoporosis, malnutrition, study. to disrupt this vascular supply to the femoral
decreased physical activity, impaired vision, neurologi- head997. Experimental study has shown that. if both
cal impairment, poor balance, altered reflexes, and mus- the medial circumflex and the lateral epiphyseal vessels
cular weakness. Firooznia et al. showed. however. that have been disrupted, the collateral circulation maintains
elderly patients who sustained fractures of the proximal viability of the femoral head in less than 20 per cent of
part of the femur did not have a higher rate of osteopo- specimens99. However, Claffey showed that displaced
rosis than age-matched control subjects32. fractures of the femoral neck can occur without corn-
Fractures of the proximal part of the femur in el- plete disruption of the medial femoral circumflex or
lateral epiphyseal systems. These vessels may only be
*Printed with permission of The American Academy of Ortho- kinked; therefore, early anatomical reduction and inter-
paedic Surgeons. This article will appear in Instructional Course nal fixation of displaced fernoral-neck fractures is advo-
Lectures, Vo/utiie 44, The American Academy of Orthopaedic Sur- cated in order to restore blood flow.
geons. Rosemont. Illinois. 1995.
tDepartment of Orthopaedic Surgery. Hennepin County Medi- The osseous anatomy of the proximal end of the
cal Center, 701 Park Avenue South. Minneapolis. Minnesota 55415. femur dictates where the internal fixation device should
Anastomosis
between medial
and lateral
circumflex
arteries
Deep
femoral a. circumflex a.
Fto. I
Drawing showing the blood supply to the proximal end of the femur. The major sources are the lateral and medial circumflex arteries. which
traverse the capsule to become the lateral retinacular arteries supplying the femoral head. (Reprinted, with permission. from: Kyle. R. F.:
Fractures of the hip. In Fractures and Dislocations. edited by R. B. Gustilo. R. F. Kyle. and D. C. Templeman. Vol. 2. p. 789. St. Louis. Moshy-Year
Book. 1993.)
be placed for maximum purchase in the femoral head. rnal joint-reaction force can be as much as four to seven
Maximum bone density is found in the area where the times body weight. and in women, 2.5 to four times body
compression and tension trabeculae coalesce in the cen- weight737t. Stair-climbing causes peak hip forces of as
ter of the head (Fig. 2). Careful evaluation of the trabec- much as seven times body weight25. The mechanics of the
ular patterns allows the surgeon to estimate the degree hip are such that implants designed for the fixation of
of osteoporosis and to gauge the likelihood of success fractures or for prosthetic replacement must withstand
of internal fixation: however, the subjective nature of extremely high loads and bending moments. The activi-
the grading systems used for this purpose limits their ties of a bedridden patient can produce forces on the
reliability. implant equivalent to those that occur during walking
The ball-and-socket configuration of the hip joint is with the use of external supports73. Even when the struc-
inherently stable and allows an excellent range of mo- tural integrity of the hip has been restored, the major
tion in all directions. The two major forces acting on the muscle forces continue to test the stability of the frac-
hip joint are abductor muscle tension and body weight, ture fixation or of the prosthetic replacement. Using
as defined by the joint-reaction force. In men, the nor- instrumented nail-plate implants, Nordin and Frankel
Principal compressive
Secondary co
Fi;. 2
Drawing showing the internal trabecular pattern of the proximal third of the femur. The primary compressive and tension trabeculae
coalesce in the center of the head. W = Wards triangle. (Reprinted. with permission. from: Rockwood. C. A.. Jr.: Green. D. P.: and Bucholz.
R. W. leditorsl: Fractures in Adults. Ed. 3, vol. 2. p. 1488. Philadelphia. J. B. Lippincott. 1991.)
Fio. 5
Flowchart showing the various methods of treatment for fractures of the femoral neck. as determined by the amount of displacement of the
fracture. the age of the patient. and whether there is a history of hip disease. (Reprinted. with permission. from: Kyle. R. F.: Fractures of the
hip. In Fractures and Dislocations. edited by R. B. Gustilo. R. F. Kyle. and D. C. Templeman. Vol. 2, p. 8fX). St. Louis. Mosby-Year Book. 1993.)
Fio. 6-A
Figs. 6-A and 6-B: Lateral radiographs of a fracture of the femoral neck.
Fig. 6-A: The radiograph shows posterior comminution.
-.
. .
:k..
FIG. 6-B
Radiograph made after fixation. The screws have been placed along the posterior cortex to buttress the comminuted region.
troversial47. Several authors have reported lower the displacement of the fracture remains unchanged39.
rates of osteonecrosis and non-union in patients who Thus, these fractures are best treated with internal fix-
had reduction and rigid internal fixation of the fracture ation to prevent displacement and to decrease the at-
on an emergent basis7. In contrast, Barnes et al., in tendant risks of osteonecrosis and non-union45.
one of the largest over-all series of femoral neck frac- A patient who has a displaced femoral-neck frac-
tures, did not identify a significant increase in the rate ture is at high risk for both osteonecrosis and non-
of osteonecrosis or non-union when fixation had been union. Several authors, in studies of more than 100
delayed for as long as a week. Swiontkowski et al. patients, reported an average rate of non-union of 20
showed, in animal studies, that a minimum increase in per cent (range, 6 to 40 per cent) and an average rate
intracapsular pressure occludes the blood supply to the of osteonecrosis of 25 per cent (range, 10 to 43 per
femoral headix. We believe that there is a theoretical cent)59#{176}2#{176}23#{176}43997.
Arnold et al., in a study of 1000 non-
advantage, on the basis of the pathophysiology of the pathological fractures, including 670 displaced fractures,
fracture, to reduction and stabilization of the fracture as reported an over-all rate of non-union of 15 per cent5.
soon as the patient is medically stable. In the patients who had a displaced fracture, the rate of
The treatment of the fracture depends primarily on osteonecrosis was 12 per cent, and in those who had a
the age of the patient and the degree of displacement non-displaced fracture, it was 7 per cent. Barnes et al.,
(Fig. 5). A patient who has a non-displaced or a mini- in a study of 1503 subcapital fractures, reported that 289
mally displaced femoral-neck fracture is at low (0 to (19 per cent) were ununited and 183 (12 per cent) had
10 per cent) risk for osteonecrosis or non-union if late segmental collapse after three years of follow-up0.
C-ARM VIEWS
LATERAL ANTEROPOSTERIOR
FIG. 7
Diagrams showing the proper placement of the guide-pins. The cannulated screws are driven over one-eighth-inch (0.32-centimeter)
guide-pins to within five millimeters of the subchondral bone. Three screws, placed in a triangular pattern. provide optimum stability. The distal
screw lies against the medial cortex. to resist varus forces on the femoral head. The proximal screws are spread out and placed anterior and
posterior. to resist displacement and rotation. (Reprinted. with permission, from: Kyle. R. F.: Fractures of the hip. In Fractures and Dislocations.
edited by R. B. Gustilo. R. F. Kyle. and D. C. Templeman. Vol. 2. p. 807. St. Louis, Mosby-Year Book. 1993.)
Treatment of displaced femoral-neck fractures is based lar prosthesis with cement has been used. with excel-
on the age and the physical demands of the patient. In lent results. A modular hemiprosthesis, with a solid,
a younger. healthy, physically active patient, every effort exchangeable head on the femoral stem. is currently
should be made to preserve the femoral head. In an available; however, there have been no long-term corn-
elderly, physically debilitated patient, a second opera- parative studies of its clinical success. to our knowledge.
tion can be avoided by the use of primary prosthetic A total hip replacement is the treatment of choice for
replacement. There is. however, no documentation as to femoral neck fractures associated with severe osteo-
the exact age at which open reduction and internal fix- arthrosis. rheumatoid arthritis, or cancer.
ation to preserve the femoral head should be aban-
Treatment ofFractures of the
doned in favor of prosthetic replacement. In a patient
who is physiologically less than seventy to seventy-five Femoral Neck in Younger Adults
years old and is capable of withstanding a second oper- Protzman and Burkhalter reported disastrous re-
ation if the fixation fails, the treatment of choice is open sults, including very high rates of osteonecrosis and non-
reduction and internal fixation. A patient who is physi- union (nineteen patients [86 per cent] and thirteen
ologically more than seventy to seventy-five years old patients [59 per cent], respectively), in twenty-two pa-
should be considered a candidate for primary prosthetic tients who had a fernoral neck fracture and were less
replacement to avoid a second operation. A persons than fifty-five years old7. In more recent series, how-
physiological age is dependent on concurrent medical ever, the rates of osteonecrosis (20 to 30 per cent) and
problems that result in a change in activities of daily non-union (15 to 20 per cent) have been found to be the
living; it is not always the same as the chronological age. same as those in elderly patients. Swiontkowski et al., in
Prosthetic replacement may also be chosen for a patient a study of twenty-seven patients who were less than fifty
who has severe, pre-existing hip disease. such as os- years old, reported no non-unions; osteonecrosis devel-
teoarthrosis. compounded by a femoral neck fracture. oped in five patients (19 per cent)0. In a study by the
Various options for prosthetic replacement are Orthopaedic Trauma Hospital Association, the rates of
available. The choice of the prosthesis depends on the osteonecrosis and non-union in 1 12 patients who were
walking requirements of the patient and the degree of less than fifty-five years old were consistent with those
associated hip disease. In a patient who cannot walk or that have been reported in elderly patients.
transfer from bed to chair. a one-piece herniprosthe-
Evaluation ofReduction, and Acceptable Guidelines
Sis without cement may be used. This type of prosthesis
is best suited for sedentary patients because weight- A poor reduction of a femoral neck fracture pre-
bearing on the prosthesis is associated with a high prey- vents re-establishment of the blood supply to the femo-
alence of both pain in the thigh and later acetabular ral head and decreases the amount of apposition of
protrusion. In a patient who has moderate functional bone between the proximal and distal fragments, leav-
requirements. such as one who lives in a nursing home ing poor mechanical stability after fixation. Garden and
or who is restricted to walking about the house, a bipo- others have shown that reduction in more than 20 de-
..-- - -
- - 20
Schematic drawings showing the technique for a valgus osteotomy of the proximal end of the femur in the treatment of a non-union of a
femoral neck fracture. The osteotomy has changed the vertical orientation of the fracture line from 55 to 20 degrees. (Reprinted, with
permission. from: Wehe. B. G.. and Cech. 0.: Pseudoarthrosis. Bern, Hans Huber, 1976.)
grees of valgus is associated with a higher rate of os- screws at an angle of 130 to 135 degrees in relation to
teonecrosis50. Any varus deformity after reduction is the femoral shaft. If they are positioned at a higher (140
also associated with increased rates of osteonecrosis and to 145-degree) angle, the holes will be created in the
non-union. Anterior or posterior angulation of more lateral cortex, at or distal to the level of the lesser tro-
than 10 degrees should not be accepted. particularly in chanter. Holes at this location have been associated with
osteoporotic bone: such angulation increases the poten- a 20 per cent prevalence of subtrochanteric fracture5.
tial for redisplacement of the fracture because the bone
Operative Technique with the
is weak. The surgeon should pay particular attention
Use of Three Cannulated Screws
to the degree of posterior comminution seen on the
lateral radiograph. Both Garden and Banks have shown A one-eighth-inch (0.32-centimeter) guide-pin is
that fractures with marked posterior comminution have laid along the anterior aspect of the fernoral neck at an
a higher prevalence of non-union73. When treating
fractures with a large amount of posterior comminu-
tion, the surgeon should place the superior and poste-
nor screws along the calcar femorale to resist posterior
collapse (Figs. 6-A and 6-B). In some patients, bone-
grafting of the posterior aspect of the femoral neck may
be considered.
A displaced fracture that cannot be reduced in a
closed fashion in an elderly patient who has high func-
tional requirements and is able to walk about the corn-
munity (generally, a patient who is less than seventy-five
years old and has few medical problems) or in a younger
patient should be treated with open reduction and in-
ternal fixation. In a more fragile. elderly patient, the
surgeon should proceed with prosthetic replacement.
The use of multiple pins, such as Knowles pins, or of
screws is a simple and effective technique for fixation of
well reduced femoral-neck fractures. This technique can
be done percutaneously with use of a local anesthetic,
or it can be performed with an open technique with the
patient under general or spinal anesthesia. Stability at Fio. 9
the site of the fracture is maximized by the placement Multiple-screw of a fracture
fixation of the femoral neck and
of three pins in a triangular configuration. Mechanical plating of a fracture of the femoral shaft. (Reprinted, with permis-
sion, from: Kyle, R. F.: Fractures of the hip. In Fractures and Disloca-
studies have not proved the effectiveness of the use of tions, edited by R. B. Gustilo, R. F. Kyle. and D. C. Templeman. Vol.2,
more pins. Care must be taken to place the pins or p. 810. St. Louis, Mosby-Year Book, 1993.)
angle of 135 degrees. according to the technique of be tightened simultaneously. to apply uniform compres-
Tronzo. This guide-pin should appear. on image inten- sion across the fracture and to avoid tipping of the fem-
sification. to lie adjacent to the medial cortex of the oral head into varus angulation. The guide-pins are then
femoral neck. A 3.8-millimeter drill-hole is made in the removed, and image intensification is used to confirm
mid-part of the lateral cortex, parallel to the anterior the proper position of all three screws.
guide-pin. The position of the drill-bit is checked on the
anteroposterior and lateral radiographs. The drill is then Complications
removed, and the guide-pin is placed in the drill-hole. Non-union: Non-union of femoral neck fractures.
Under image intensification, the guide-pin is tapped which usually becomes apparent within one year. was
into place along the medial cortex of the fernoral neck reported in thirty-four (1 1 per cent) of 301 patients in
and into the head to within five millimeters of the sub- one series7, in thirty-nine (33 per cent) of 119 patients
chondral bone. The guide-pin should lie slightly inferior in another series2, and in none of five patients in a
in the femoral head on the anteroposterior radiograph third series. Arnold et al. reported a 15 per cent rate
and in the center of the head on the lateral radiograph. of non-union in 1000 patients who had a displaced
After this guide-pin has been placed. two more guide- fracture5. This range of occurrence may be explained
pins are inserted with use of image intensification. On by differences in the types of fractures and in the meth-
the anteroposterior radiograph, these pins lie slightly ods used for reduction and fixation. Non-union may
superior in the femoral head; on the lateral radiograph, or may not be accompanied by osteonecrosis. If non-
one lies slightly anterior and the other, slightly posterior, union occurs, a magnetic resonance image must be
forming a triangular pattern of guide-pins. Next, the made to evaluate the viability of the femoral head be-
length of the screws to be implanted is determined by fore the options for treatment are considered. In an
direct measurement of the guide-pins, each of which lies elderly patient who is able to walk about the commu-
within five millimeters of the subchondral bone of the nity, a non-union is treated with a total hip replace-
fernoral head (Fig. 7). Cannulated screws are then ment; in a younger patient, a Pauwels valgus osteotomy
driven over the guide-pins. The inferior screw is placed and repeat fixation are used. In a younger patient who
first. followed by the superior screws. The screws should has collapse of the fernoral head concurrent with a
Radiographs showing various problems with the older. solid fixation devices. The bone has impacted to a stable position. causing the implant
to break (Fig. 10-A). to penetrate the hip joint (Fig. 10-B). and to cut out of the femoral head (Fig. 10-C). (Reprinted. with permission. from:
Kyle. R. F.: Fractures ofthe hip. In Fractures and Dislocations. edited by R. B. Gustilo. R. F. Kyle. and D. C. Templeman. Vol. 2. p. 845. St. Louis.
Mosby-Year Book. 1993.)
wt433 M434
4 1
Osteotomy
OsteotomyL-
rn
wi4
WI. 434
Fio. 11-A
Figs. 1 I-A and 1 I-B: Drawings depicting two techniques of a stabilizing osteotomy for the treatment of an unstable intertrochanteric
fracture. (Reprinted. with
permission. from: Kyle. R. F.: Fractures of the hip. In Fractures and Dislocations, edited by R. B. Gustilo, R. F. Kyle.
and D. C. kmpleman. Vol. 2. p. 530. St. Louis. Mosby-Year Book. 1993.)
Fig. I 1-A: The medial displacement technique of Dimon and Hughston27. Wt. = weight.
non-union, a total hip replacement is indicated. Most tramedullary fixation. The femoral neck should be re-
non-unions have drifted into some varus angulation. duced. and it may be pinned temporarily with three one-
and a valgus intertrochanteric osteotomy allows corn- eighth-inch (0.32-centimeter) Kirschner wires, placed
pression loads to occur at the fracture site to promote anteriorly to avoid interference with the intrarnedullary
healing (Fig. 8). Another option for treatment is the nail. The intramedullary nail can then be introduced
use of a posterior muscie-pedicle graft. The success of through the piriformis fossa. The fernoral shaft should
this treatment is difficult to assess since the reported be overrearned by two millimeters to facilitate driving
series have been so smalI49. of the nail without excessive force, which could displace
Osteonecrosis: Over-all, the reported rate of osteo- the fernoral neck fracture. After the fracture of the fern-
necrosis in patients who have had a displaced femoral- oral shaft has been reduced and fixed with the nail, the
neck fracture has ranged from 4 to 40 per cent72 temporary fixation of the neck is removed, and three
Fielding et al. reported osteonecrosis in forty guide-wires are placed around the intramedullary nail
(16 per cent) of 256 patients3. The wide range in rates and into the femoral head under image intensification.
may. again. be explained. at least in part. by differences Cannulated screws are driven over the guide-wires,
in the types of fracture and in the respective authors with use of the technique described earlier. The intra-
chosen methods of reduction and fixation. Osteonecro- medullary nail must be locked to prevent rotation and
Sis is usually partial and does not involve the entire shortening at the site of the fracture of the shaft.
femoral head. In many patients. the head does not col- Alternatively, a second-generation locking nail (one
lapse. If a patient is asymptomatic. no additional treat- with two proximal locking screws, which are inserted
ment is indicated. If the osteonecrotic fragment has into the greater trochanter and angled into the femoral
collapsed and the patient is symptomatic but is able to head) may be used to stabilize the fernoral neck. but
walk about the community, total hip arthroplasty is proper placement of the locking screws in the femoral
indicated. head may be difficult, since the screws must be driven
through the nail. If there is a problem with placement
Operative Technique for Fractures of the Femoral Neck
of the screws through the second-generation nail, addi-
(111(1 the Ipsilateral Femoral Shaft
tional screws can be used outside of the nail. Swiont-
Special considerations may be necessary for a pa- kowski et al., as well as Sanders et al., described a
tient who has a fracture of the ipsilateral fernoral shaft. method in which a nail is inserted. after reaming, retro-
The injury of primary importance in this fracture com- grade from the medial fernoral condyle295. This tech-
plex is the femoral neck fracture. which must be reduced nique requires the use of a very flexible nail, and it may
and stabilized before fixation of the femoral shaft is result in valgus deformity at the site of the femoral shaft
attempted. fracture if it is not performed properly.
The fracture of the shaft may be treated with in- An acceptable, and recently more popular, alter-
Fracture is again
. Medial
cortices
apposed
Fl. Il-B
Il#{236}e
valgus osteotomy technique of Sarmiento and Williams03.
TABLE I
Tt tt RII..&F1oNsI 111 I3FF\VEEN 1111 Rxii o1 FAIE.LJRF OF FIxvrIoN 5NI) rilE PosirloN oi IHE NAIl. IN TvlI.I II FRsc1t RlS
2/2 34 46 11/12 (1 0
2/3 22 30 14/7 1 5
2/1 4 5 9/5 0
1/2 6 8 12/IS 2
1/3 4 14/11 1
3/3 4 5 15/16 1
Modified. with
permission. from: Kyle. R. F.: Fractures of the hip. In Fractures and Dislocations. edited b R. B. Gustilo. R. F. Kyle. and
I). C. Templeman. Vol. 2. p. 535. St. Louis. Moshy-Year Book. 1993.
lAP = anteroposterior.
)lhe center position (2) is associated with the lowest rate of failure. A = anterior and P = posterior.
have an intcrtrochanteric fracture with associated mild withstand. In 1935, Pauwels concluded that the forces
degenerative changes. internal fixation is the procedure acting on the hip in single-limb stance are equivalent to
of choice. If a patient is symptomatic after the fracture approximately three times the body weight, applied at
has healed. an arthroplasty can be performed more eas- an angle of 159 degrees to the vertical plane77. These
ily later than when the fracture was fresh. data were confirmed later by numerous authors47.
The value of prophylactic use of antibiotics has been These same forces act on any hip-fixation device that is
proved. The rates of infection have been reduced from placed across the fracture site.
5 per cent to less than 1 per cent with the use of broad- A sliding device with a screw-plate angle closest to
spectrum antibiotics. begun before the operation and the combined force vector allows optimum sliding and
given for at least one day postoperatively. impaction. The closer the nail-plate angle to the resul-
tant vector of the forces across the hip. the more force
Biomechanics Sliding
of Devices in
available to assist impaction (Fig. 17). A device that is
the Fixatioiz of Fractures of the Hip placed at a lower angle has less force working parallel
To use a sliding device correctly in a patient who has to the sliding axis and more force working perpendicu-
a fracture of the hip. it is essential to understand the lar to the sliding axis. This perpendicular force acts to
mechanics of the device and the forces that it must jam or bend the device, thereby preventing impaction.
Technically. however, the surgeon cannot place the slid- lowed. If the fixation is unstable, as when the bone is
ing device at a high angle in a small hip or in a hip with osteoporotic, only partial weight-bearing is permitted.
a varus deformity. Mechanically. it is desirable to place
Postoperative Care
the sliding device at as high an angle as clinically possi-
ble while still maintaining the placement of the device The patient is allowed to sit, if doing so is comfort-
in the center of the head. A device that is placed at a able, on the day after the operation. If solid fixation has
lower angle may he used effectively in a stable fracture been obtained, the patient is allowed to walk between
because controlled collapse is not important for impac- parallel bars, bearing weight on the injured extremity
tion of the fracture and early weight-bearing. However, as tolerated, on the second or third postoperative day.
an accurate assessment of the stability of the fracture is Weight-bearing is progressed as tolerated. If the bone is
sometimes difficult. In these questionable situations, osteoporotic or if only poor fixation has been obtained,
placement of the device at a higher angle will allow delayed weight-bearing with use of toe-touch only is
impaction. regardless of the degree of stability of the necessary until callus has formed. If there is a subtro-
fracture. chanteric component to the fracture, weight-bearing
The ideal position for the nail or screw in the femo- should be delayed until callus is seen on the radiograph.
ral head is apparent from a radiograph of the proximal Radiographs should be made at weekly intervals for
part of the femur. The point of coalescence of the ten- the first two weeks to ensure that proper impaction of
sion and compression trabeculae results in a dense pat- the fragments occurs. Additional radiographs should
tern of cancellous bone in the center of the fernoral be made at four and six weeks after the fracture. The
head. This is where the best purchase in the bone can be final radiographs should be made six months after the
obtained for a fixation device. When these trabeculae fracture.
are absent, the surgeon can expect a higher rate of fail- Low-dose heparin is not effective in the prevention
ure with use of the device. Placement in the center of of thromboembolic disease in patients who have a hip
the femoral head, within five millimeters of the sub- fracture2. Coumadin (warfarin) is the most effective
chondral bone, has resulted in the lowest rate of clinical drug in the prevention of thromboembolic disease, but
failure in patients who have an unstable intertrochan- formation of a hernatoma can complicate treatment
teric fracture3 (Table I). After anatomical reduction, a with anticoagulants if the prothrombin time is not kept
properly placed sliding device allows spontaneous irn- within the recommended range of fifteen to eighteen
paction and medial displacement of all intertrochan- seconds. Continuous passive motion and intermittent
teric fractures into a stable configuration (Figs. 18-A use of a positive-pressure splint may be of value in the
and 18-B) This allows early mobilization ofthe patient. prevention of thromboembolic complications, but both
If a patient has good fixation, full weight-bearing is al- require a specialized apparatus, which may interfere
FIG. 19-A
Figs. 19-A, 19-B. and I9-(: Radiographs showing a combined intertrochanteric-subtrochanteric fracture of the proximal part of the right
femur.
Fig. I 9-A: Radiograph showing involvement of the piriformis fossa.
with the mobilization of the patient. Stable fixation of reported to be 90 per cent, although Boyd and Lipinski
the fracture. which allows rapid mobilization of the pa- found that, of twenty-eight non-unions, twenty-two (79
tient, is the most effective method for the prevention of per cent) united after operative treatment3.
thromboembolic disease. The most common mode of failure of fixation is the
hip-screw cutting out of osteoporotic bone. allowing the
Complications
fracture to collapse into varus angulation. If little bone
The complications of fixation of intertrochanteric is left in the femoral head after this has occurred, a
fractures are minimum. compared with those associated blade-plate can be used to restore stability. The plate
with fixation of other fractures of the hip. if the surgeon provides more surface area to resist cutting out through
uses the appropriate device correctly and pays attention the femoral head. If the acetabulurn has been injured by
to accepted mechanical principles. The rate of failure the protruding nail. a total hip replacement is the treat-
with use of a collapsible hip-screw or nail of contempo- ment of choice.
rary materials and design is less than S per cent. With
prophylactic use of antibiotics, the rate of infection is Type-IV Fractures
less than 1 per cent. Osteonecrosis is extremely rare, A sliding hip-screw or a second-generation locking
occurring in less than 1 per cent of patients. nail may be used in the treatment of intertrochanteric-
The rate of non-union is less than 10 per cent. If subtrochanteric fractures that have a femoral shaft cx-
non-union does occur. the rate of success after simple tension. The second-generation locking nail is an
removal of the device, renailing in a more valgus posi- excellent form of fixation if the piriformis fossa is intact.
tion, and insertion of a cancellous bone graft has been When the piriformis fossa is not intact, treatment with
Fig. 19-B: Fixation is best accomplished with a sliding hip-screw, as it is very difficult to use an intramedullary nail when the piriformis fossa
is fractured.
Fig. 19-C: Six months postoperatively. the fracture has healed.
Figs. 20-A and 20-B: Schematic drawings of a reverse oblique fracture. These fractures are difficult to reduce and to fix because of the forces
that displace the distal fragment medially.
Fig. 20-A: In this fracture. a low-angle nail has been used. The barrel of the screw is placed through the lateral cortex of the proximal
fragment. thus preventing displacement.
Fig. 20-B: If the piriformis fossa is not involved, a second-generation nail (with two locking screws) may be used to prevent displacement of
the distal fragment.
a hip-screw with a long side-plate. combined with lim- Large fragments between the proximal and distal seg-
ited intcrfragmentary fixation and supplementary bone- ments are stabilized with interfragrnentary fixation and
grafting. is advisable (Figs. 19-A, 19-B, and 19-C). In placement of bone-screws through the side-plate, if the
subtrochanteric fractures that extend quite distally into fragments can be retrieved and fixed without additional
the shaft and that are combined with an intertrochan- periosteal stripping. Anatomical restoration of all corn-
teric fracture and involvement of the piriformis fossa, a minuted fragments is not necessary. Grafting of the me-
second-generation intramedullary nail may be the only dial defects with autogenous bone should be done to
option; however, the surgeon should anticipate difficulty promote early healing if medial comminution is present.
in its use because the starting point has been destroyed. A reverse oblique fracture3 needs special consider-
ation, because the major fracture line extends from
Operative Technique
proximal-medial to distal-lateral through the intertro-
For type-IV intertrochanteric-subtrochanteric frac- chanteric-subtrochanteric region (Figs. 20-A and 20-B).
tures, a one-eighth-inch (0.32-centimeter) guide-wire is While this type of fracture should be fixed in a manner
first placed into the proximal neck-and-head fragment, similar to that used for a type-IV fracture, it may be
as is done for routine type-I, II, and III fractures. The difficult to reduce, because the adductors and iliopsoas
distal aspect of the shaft is then exposed by dissection are intact and they pull the distal fragment medially
of the vastus lateralis from the lateral aspect of the shaft while the proximal fragment is abducted, flexed, and
with a periosteal elevator. The posterior sag is reduced pulled laterally. These fractures should be fixed with a
by traction and with pressure applied directly under the screw-plate placed at a lower angle so that the fixation
buttocks or femur at the site of the fracture. The frag- device does not have to be placed directly along the
ments are aligned by traction applied through the soft- fracture site. The fracture is reduced with manual trac-
tissue attachments with use of the principles of indirect tion and is held in place with a bone-clamp. Excessive
reduction as described by Kinast et al.2. The side-plate traction may cause additional displacement; often, the
is then applied to the distal aspect of the shaft and is traction must be released and the fragments must be
secured with a Verbrugge bone-clamp. The proximal rotated slightly and reduced manually to the side-plate.
fragment is well fixed by placement of the hip-screw in A longer side-plate is recommended for these fractures
the center of the head. The distal fragment is fixed by because of their distal extension. Some authors, such as
capture of at least eight cortices with four bone-screws. Kinast et al., have advocated the use of a right-angle
nail2. However, this device places high stresses on the internal fixation again became more popular, although
nail-plate junction. A second-generation locking nail complications remained frequent. Fielding and Magliato
may also be used for stabilization5. An advantage of the reported complications in association with sixteen (25
intramedullary position of this device is that it prevents per cent) of sixty-four subtrochanteric fractures that had
medial displacement of the distal fragments. been consecutively treated with a Jewett nail. The treat-
ment was a failure in ten (40 per cent) of the twenty-five
Postoperative Treatment fractures that were distal to the lesser trochanter.
A patient who has a type-IV fracture is allowed to KUntscher, in 1939, reported on the concept of in-
sit the day after the operation. Unlike the protocol for tramedullary fixation of subtrochanteric fractures with
a patient who has a type-I, II. or III fracture, weight- a Y nail. However, this double nail. the large trian-
bearing is delayed until callus has formed. The patient gular metal wedge of which was driven into the head
is then allowed to increase weight-bearing gradually as and neck fragment, proved difficult to use, and it did not
tolerated. gain general acceptance.
In summary, the treatment of unstable and complex
intertrochanteric and intertrochanteric-subtrochanteric
fractures has been simplified by the development of 5
Subtrochanteric Fractures
fragmentary fixation was used. There were also techni- teric fractures with an intramedullary nail and lock-
cal difficulties during insertion, and refracture of the ing screws was introduced. More recent advances in
femur occurred occasionally during extraction of the both technique and design have made possible the intra-
nai 74.I0) medullary fixation of subtrochanteric fractures that ex-
The AO angled blade-plate. introduced in the 1970s, tend into the shaft. Although it was believed that locking
was effective if the medial buttress could be restored nails might predispose a fracture to non-union because
and the plate could be used as a tension band. This they maintain distraction of the fracture fragments, din-
technique required accurate realignment and stable fix- ically this has not been the case. All known reported
ation of all medial fragments5. series of closed interlocking intramedullary nailing have
The sliding hip-screw or nail device, popularized by shown a high rate of union, a low rate of infection, and
Clawson3 and by Massie in the 1960s, was used in excellent maintenance of alignment25. The high
proximal subtrochanteric-intertrochanteric fractures, rate of mechanical failure noted with use of the Jewett
but the rate of failure was high in comminuted fractures nail has not been demonstrated with these newer devices.
with extension into the femoral shaft#{176}.The develop- The rapid rate of healing is attributed to the closed
ment of higher-strength metals, such as cold-worked operative technique, which gives excellent stabilization
stainless steel and titanium, markedly reduced the rate of the fracture and, through reaming, provides autoge-
of failure of these telescoping screw devices. The success nous bone graft to the area of the fracture. With reaming,
of these devices in the treatment of both subtrochan- larger (stronger) nails can be placed in the shaft of the
teric and comminuted intertrochanteric-subtrochanteric femur. The intramedullary position of the nail, as with the
fractures was improved further by the use of bone- Zickel device, greatly reduces the lever arm at the screw-
grafting about the highly stressed medial cortex. This nail junction, contributing to the decrease in the rate of
technique. which is used in conjunction with the method mechanical failure (Figs. 23-A and 23-B). The walls of
of indirect reduction advocated by Kinast et al.5, re- these nails are thicker than those of standard intra-
quires little or no periosteal stripping in the area of medullary nails, in order to reduce the stress-riser effect
comminution, and soft-tissue tension is used to realign of holes placed through them, and the increased thick-
the bone fragments. ness enhances their rigidity. For this reason, proper oper-
In the early 1980s, closed treatment of subtrochan- ative technique is critical to ensure that the wall of the
I2
FI;. 22-A
Radiographs showing a subtrochanteric fracture (Fig. 22-A) fixed with a Zickel nail (Fig. 22-B). (Reprinted, with permission, from: Kyle, R.
F.: Fractures of the hip. In Fractures and Dislocations. edited by R. B. Gustilo, R. F. Kyle. and D. C. Templeman. Vol. 2. p. 821. St. Louis,
Moshy-Year Book. 1993.)
tvhchamusm of Injury
The cause of subtrochanteric fractures is related to
the age of the patient. In most series, including those
that we reviewed at the Hennepin County Medical Cen-
ter, approximately one-half of the injuries were the re-
sult of a high-energy trauma, such as an automobile
accident or a fall from a height, usually in young peo-
plc. The other half were the result of a low-energy fall
in elderly patients7. A combination of a direct blow on
the lateral
along
aspect
the femur.
of the greater
and muscular
trochanter,
pull creates
axial force
various pat-
m = Fxd
terns of subtrochanteric fractures. These deforrning
muscle forces were reported by Froimson35, who clearly
described the proximal fragment being abducted by the FIG. 23-A
gluteal muscles, flexed by the iliopsoas, and externally
rotated by the short external rotators and the distal
fragment being displaced medially by the strong pull of
the adductors.
Classification
J;)
.#-,-. V
t;)
.5Ii1ii,t2 IIij .S(rea Sliding 1/i1; Siren cit/i I)isiai .5/taft 1.ciensio,s
IiieriuiI Iicatits t !iP5. .StcOI(I(;(fl(raIlO?z
(;r(iIi I.O(kW5 .\(IIl
FIG. 24
(lassification of subtrochanteric fractures (top). used at the Hennepin County Medical Center, and a flowchart (bottom) showing the
various methods of treatment. A type-I simple. high fracture involves the lesser trochanter and is treated with a sliding hip-screw or a
second-generation locking nail. In a type-I comminuted fracture that involves the piriformis fossa, the sliding hip-screw is preferred because
of the difficulty encountered with insertion of an intramedullary nail. In a type-Il simple or comminuted low fracture, a first-generation
locking nail (with a single locking screw) is used. (Modified, with permission. from: Kyle, R. F.: Fractures of the hip. In Fractures and
Dislocations. edited by R. B. Gustilo, R. F. Kyle. and D. C. Templeman. Vol. 2, p. 819. St. Louis, Mosby-Year Book. 1993.)
aware of accompanying injuries to the pelvis. axial spine, formed within forty-eight hours after the injury.
and other long bones. Associated pelvic and long-bone
Operative Techniquefor the Use of
fractures were found in 46 per cent of such patients who
Locking Intramedullary Nails
were evaluated at the Hennepin County Medical Cen-
ter7. The patient must also be evaluated for hernody- The surgeon may elect to perform the intramedullary
namic instability because of the loss of blood due to the nailing with the patient in either the supine or the lateral
high-energy fracture. position. The supine position is preferable, since it facil-
After being stabilized in the emergency room, the itates radiographic visualization of the hip in both the
patient is taken to the radiology suite for evaluation of anteroposterior and the lateral planes and makes posi-
the bone injuries.The fracture is splinted in Buck traction tioning of the patient easier. A patient who has sustained
or in a Thomas splint with a Pearson attachment during multiple trauma should always be placed in the supine
transfer. In a patient who has sustained multiple trauma, position to allow ease of access to the airway as well as
the fracture should be stabilized on an emergency basis. to facilitate treatment of the other injuries. The supine
If the patient has an isolated subtrochanteric fracture. position also facilitates reduction of the fracture and
stabilization may be delayed, but it should still be per- obtainment of an acceptable rotational alignment of the
PIRIFORMIS FOSSA
FIG. 25
Figs. 25-32: Drawings showing the operative technique for the use
of locking intramedullary nails.
Fig. 25: The patient is positioned on the fracture-table with the hip
in adduction and the torso away from the fracture, to aid in exposure
of the insertion site. (Reprinted. with permission, from: Kyle, R., and
Chadwick. R., Jr.: Operative technique for second-generation inter-
locking femoral nails. Op. Tech. Orthop.. 1(4): 288, 1991.)
to expose the tip of the trochanter. The skin incision should be in line with the femur and should
extend proximally from the greater trochanter. (Reprinted, with
A one-eighth-inch (0.32-centimeter) guide-wire is
permission, from: Kyle, R., and Chadwick, R., Jr.: Operative tech-
inserted into the piriformis fossa, and its correct posi- nique for second-generation interlocking femoral nails. Op. Tech.
tion is verified with image intensification (Fig. 28). The Orthop.. 1(4): 288. 1991.)
FIG. 30
The surgeon should not attempt to place the guide- Placement of the guide-wires for the proximal screws. The guide-
wires should lie adjacent to the calcar cortex and in the appropriate
wire with the closed technique for more than twenty to
amount of anteversion. (Reprinted. with permission. from: Kyle. R.,
thirty minutes. After such an interval, the fracture site and Chadwick, R., Jr.: Operative technique for second-generation
should be opened for placement of the guide-wire. interlocking femoral nails. Op. Tech. Orthop.. 1(4): 290. 1991.)
References
1. AlfYram, P.-A.: An epidemiologic study of cervical and trochanteric fractures of the femur in an urban population. Analysis of 1,664
cases with special reference to etiologic factors. Acta Orthop. Scandinavica, Supplementum 65, 1964.
2. AIho, A.; Stangeland, L.; Rottingen, J.; and Wiig, J. N.: Prophylaxis of venous thromboembolism by aspirin, warfarin and heparin in
patients with hip fracture. A prospective clinical study with cost-benefit analysis. Ann. Chir. Gynaecol., 73: 225-228, 1984.
3. Allis, 0. H.: Fractures in the upper third of the femur exclusive of the neck. Med. News., 59: 585-590, 1891.
4. Apel, D. M.; Patwardhan, A.; Pinzur, M. S.; and Dobozi, W. R.: Axial loading studies of unstable intertrochanteric fractures of the femur.
C/in. Orthop., 246: 156-164, 1989.
5. Aprin, H., and Kilfoyle, R. M.: Treatment oftrochanteric fractures with Ender rods.J. Trauma, 20: 32-42. 1980.
6. Arnold, W. D.; Lyden. J. P.; and Nlinkoff, J.: Treatment of intracapsular fractures of the femoral neck. With special reference to
percutaneous Knowles pinning. .1 Bone and Joint Surg.. 56-A: 254-262, March 1974.
7. Banks, H. H.: Factors influencing the result in fractures of the femoral neck. J. Bone amid Joint Surg., 44-A: 931-964. July 1962.
8. Banks, H. H.: Nonunion in fractures of the femoral neck. Orthop. Clin. North America, 5: 865-885. 1974.
9. Barnes, R.: The diagnosis of ischaemia of the capital fragment in femoral neck fractures [editorials and annotations]. .1. Bone and Joint
Surg., 44-B(4):760-761. 1962.
10. Barnes, R.; Brown, J. T.; Garden, R. S.; and Nicoll, E. A.: Subcapital fractures of the femur. A prospective review. J. Bone and Joint
Surg.. 58-B( 1 ): 2-24. 1976.
I I . Beckenbaugh, R. D.; Tressler, H. A.; and Johnson, E. W., Jr.: Results after hemiarthroplasty of the hip using a cemented femoral
prosthesis. A review of 109 cases with an average follow-up of 36 months. Mayo C/in. Proc., 52: 349-353, 1977.
12. Boyd, H. B., and Anderson, L. D.: Management of unstable trochanteric fractures. Surg., Gynec. and Obstet., 112: 633-638, 1961.
13. Boyd, H. B., and Lipinski, S. W.: Nonunion of trochanteric and subtrochanteric fractures. Surg.. Gynec. and Obstet., 104: 463-470. 1957.
14. Bridle, S. H.; Patel, A. D.; Bircher, M.; and Calvert, P. T.: Fixation of intertrochanteric fractures of the femur. A randomised prospective
comparison ofthe Gamma nail and the dynamic hip screw.J. BoneandiointSurg., 73-B(2):330-334, 1991.
15. Brown, J. T., and Abrami, G.: Transcervical femoral fracture. A review of 195 patients treated by sliding nail-plate fixation. J. Bone and
Joint Surg.. 46-B(4): 648-663. 1964.
16. Brumback, R. J.; Uwagie-Ero. S.; Lakatos, R. P.; Poka, A.; Bathon, C. H.; and Burgess, A. R.: Intramedullary nailing of femoral shaft
fractures. Part II: fracture-healing with static interlocking fixation.J. Bone andJoint Surg., 70-A: 1453-1462, Dec. 1988.
17. Burnett, J. W.; Gustilo, R. B.; Williams, D. N.; and Kind, A. C.: Prophylactic antibiotics in hip fractures. A double-blind, prospective
study. J. Bone amid Joint Surg., 62-A: 457-462, April 1980.
18. Catto, M.: A histological study of avascular necrosis of the femoral head after transcervical fracture. J. Bone and Joint Surg., 47-B(4):
749-776, 1965.
19. Chang, W. S.; Zuckerman, J. D.; Kummer, F. J.; and Frankel, V. H.: Biomechanical evaluation of anatomic reduction versus medial
displacement osteotomy in unstable intertrochanteric fractures. C/in. Orthop., 225: 141-146, 1987.
20. Chapman, M. W.; Stehr, J. H.; Eberle, C. F.; Bloom, M. H.; and Bovill, E. G., Jr.: Treatment of intracapsular hip fractures by the Deyerle
method. A comparative review of one hundred and nineteen cases. J. Bone and Joint Surg., 57-A: 735-744, Sept. 1975.
21. Christie, J.; Howie, C. R.; and Armour, P. C.: Fixation of displaced subcapital femoral fractures. Compression screw fixation versus
double divergent pins. J. Bone and Joint Surg.. 70-B(2): 199-201, 1988.
22. CIaffe T. J.: Avascular necrosis of the femoral head. An anatomical study. J. Bone and Joint Surg., 42-B(4): 802-809, 1960.
23. Clawson, D. K.: Trochanteric fractures treated by the sliding screw plate fixation method.J. Trawna, 4: 737-752. 1964.
24. Cobelli, N. J., and Sadler, A. H.: Ender rod versus compression screw fixation of hip fractures. C/in. Orthop., 201: 123-129, 1985.
25. Crowninshield, R. D.; Johnston, R. C.; Andrews, J. G.; and Brand, R. A.: A biomechanical investigation of the human hip. J. Biomech.,
11:75-85, 1978.
26. Davis, T. R. C.; Sher, J. L.; Horsman, A.; Simpson, M.; Porter, B. B.; and Checketts, R. G.: Intertrochanteric femoral fractures. Mechani-
cal failure after internal fixation.J. Bone andJoint Surg., 72-B(1): 26-31, 1990.
27. Dimon, J. H., III, and Hughston, J. C.: Unstable intertrochanteric fractures of the hip. J. Bone and Joint Surg., 49-A: 440-450, April 1967.
28. Evans, E. M.: The treatment of trochanteric fractures of the femur.J. Bone andioint Surg., 31-B(2): 190-203, 1949.
29. Evans, E. M.: Trochanteric fractures. A review of 110 cases treated by nail-plate fixation.J. Bone andJointSurg., 33-B(2): 192-204. 1951.
30. Fielding, J. W., and Magliato, H. J.: Subtrochanteric fractures. Surg., Gynec. and Obstet., 122: 555-560, 1966.
3 1 . Fielding. J. W.; Wilson, S. A.; and Ratzan, S.: A continuing end-result study of displaced intracapsular fractures of the neck of the femur
treated with the Pugh nail. J. Bone and Joint Surg.. 56-A: 1464-1472, Oct. 1974.
32. Firooznia, H.; Rafii, M.; Golimbu, C.; Schwartz, M. S.; and Ort, P.: Trabecular mineral content of the spine in women with hip fracture:
CF measurement. Radio/ogv, 159: 737-740. 1986.
33. Frandsen, P. A., and Kruse, T.: Hip fractures in the county of Funen, Denmark. Implications of demographic aging and changes in
incidence rates. Ada Orthop. Scandinavica, 54: 681-686, 1983.
34. Frankel, V. H.: The hmnora/ Neck: Function, Fracture Mechanism, lnterna/ Fixation; an Experimenta/ Study. Springfield, Charles C
Thomas. 1960.
35. Froimson, A. I.: Treatment of comminuted subtrochanteric fractures ofthe femur. Surg.. Gynec. and Obstet., 131: 465-472, 1970.
36. Garden, R. S.: Low-angle fixation in fractures of the femoral neck. .1. Bone and Joint Surg., 43-B(4): 647-663, 1961.
37. Garden, R. S.: Stability and union in subcapital fractures of the femur.J. Bone andJoint Surg., 46-B(4): 630-647, 1964.
38. Garden, R. S.: Malreduction and avascular necrosis in subcapital fractures of the femur.J. Bone andioint Surg.. 53-B(2): 183-197. 1971.
39. Garden, R. S.: Reduction and fixation of subcapital fractures of the femur. Orthop. C/in. North America, 5: 683-712. 1974.
40. Gerber, C.; Strehle, J.; and Ganz, R.: The treatment of fractures of the femoral neck. C/in. Orthop., 292: 77-86, 1993.
41. Graham, J.: Early or delayed weight-bearing after internal fixation of transcervical fracture of the femur. A clinical trial. J. Bone and
Joint Surg., 50-B(3): 562-569. 1968.
42. Greenspan. S. L.; Myers, E. R.; Maitland, L. A.; Resnick, N. M.; and Hayes, W. C.: Fall severity and bone mineral density as risk factors
for hip fracture in ambulatory elderly.J. Am. Med. Assn., 271: 128-133, 1994.
43. Hammer, A. .J.: Nonunion of subcapital femoral neck fractures. J. Orthop. Trauma, 6: 73-77, 1992.
44. Hibbs, R. A.: The management of the tendency of the upper fragment to tilt forward in fractures of the upper third of the femur. New
York Med.J., 75: 177-179, 1902.
45. Hinton, R. V., and Smith, G. S.: The association of age, race, and sex with the location of proximal femoral fractures in the elderly.
J. Bone andJoint Stag.. 75-A: 752-759. May 1993.
46. Holmberg, S.; Kal#{233}n,R.; and Thorngren, K.-G.: Treatment and outcome of femoral neck fractures. An analysis of 2418 patients admitted
from their own homes. Cliii. Orthop.. 218: 42-52, 1987.
47. Inman, V. T.: Functional aspects of the abductor muscles of the hip. J. Bone and Joint Surg.. 29: 607-619, July 1947.
48. Jewett, E. L.: One-piece angle nail for trochanteric fractures.J. Bone andJoint Surg., 23: 803-810, Oct. 1941.
49. Judet, R.: Traitement des fractures du col du femur par greffe pediculde. Acta Orthop. Scandinavica, 32: 421-427, 1962.
50. Karr, R. K., and Schwab,J. P.: Subtrochanteric fracture as a complication ofproximal femoral pinning. C/in. Orthop., 194: 214-217, 1985.
5 1 . Kenzora, J. E.; McCarthy, R. E.; Lowell, J. D.; and Sledge, C. B.: Hip fracture mortality. Relation to age, treatment, preoperative illness,
time of surgery. and complications. C/in. Orthop., 186: 45-56, 1984.
52. Kinast, C.; Bolhofner, B. R.; Mast, J. W.; and Ganz, R.: Subtrochanteric fractures of the femur. Results of treatment with the 95-degree
condylar blade-plate. C/in. Orthop., 238: 122-130, 1989.
53. Koch, J. C.: The laws of bone architecture. Ant. J. Anal., 21: 177-298, 1917.
54. K#{252}ntscher, G.: Dauerbruch und Umbauzone. Brims Beitr. k/in. Chir., 169: 557-572, 1939.
55. Kyle, R. F.: Operative techniques of fixation for femoral neck fractures in young adults. Tech. Orthop., 1: 33-38, 1986.
56. Kyle, R. F.: Intertrochanteric fractures. In Operative Orthopaedics. edited by M. W. Chapman. Vol. 1, pp. 353-359. Philadelphia. J. B.
Lippincott. 1988.
57. Kyle, R. F.: Subtrochanteric and intracapsular hip fracture update. Read at the Annual Meeting of The American Academy of Ortho-
paedic Surgeons. Anaheim, California. March 9. 1991.
58. Kyle, R. F.; Gustilo, R. B.; and Premer, R. F.: Analysis of six hundred and twenty-two intertrochanteric hip fractures. A retrospective and
prospective study.J. Bone andJoint Surg., 61-A: 216-221, March 1979.
59. Kyle, R. E; Wright, T. M.; and Burstein, A. H.: Biomechanical analysis of the sliding characteristics of compression hip screws. J. Bone
(111(1 Joint Surg., 62-A: 1308-1314, Dec. 1980.
60. Lambotte, A.: Lintervention operatoire darts les fractures r#{233}centes et anciennes; envisag#{233}e particu/i#{232}remetzt au point de vue de /ost#{233}o-
sy!lt/l#{234}se avec /a (/escri/)tion c/c p/usieurs techniques nouve/les. Brussels. Lamertain, 1907.
6!. Lane, J. M., and Vigorita, V. J.: Current concepts review. Osteoporosis. J. Bone and Joint Surg., 65-A: 274-278, Feb. 1983.
62. Larsson, S.; Elloy, M.; and Hansson, L. I.: Stability of osteosynthesis in trochanteric fractures. Comparison of three fixation devices in
cadavers. Acta Ort/iop. Scandinavica, 59: 386-390. 1988.
63. Larsson, S.; Friberg, S.; and Hansson, L. I.: Trochanteric fractures. Influence of reduction and implant position on impaction and
complications. C/i,z. Ort/top., 259: 130-139. 1990.
64. Lausten, G. S.; Vedel, P.; and Nielsen, P.-M.: Fractures of the femoral neck treated with a bipolar endoprosthesis. C/in. Orthop.. 218:
63-67. 1987.
65. Leung, K. S.; So, W. S.; Shen, W. Y.; and Hui, P. W.: Gamma nails and dynamic hip screws for peritrochanteric fractures. A randomised
prospective study in elderly patients. J. Bone amid Joitit Surg., 74-B(3): 345-351, 1992.
66. Manninger, J.; Kazar, G.; Fekete, G.; Fekete, K.; Frenyo, S.; Gyarfas, F.; Salacz, T.; and Varga, A.: Significance of urgent (within 6h)
internal fixation in the management of fractures of the neck of the femur. Injury, 20: 101-105, 1989.
67. Mariani, E. M., and Rand, J. A.: Nonunion of intertrochanteric fractures of the femur following open reduction and internal fixation.
Results of second attempts to gain union. C/in. Orthop., 218: 81-89, 1987.
68. Mmli, R. K.; Sch#{252}ller, H. M.; and Raaymakers, E. L. F. B.: Intertrochanteric osteotomy for non-union of the femoral neck. J. Bone and
JOiflt Surg.. 71-B(S): 782-787. 1989.
69. Massie, W. K.: Extracapsular fractures of the hip treated by impaction using a sliding nail-plate fixation. C/in. Orthop., 22: 180-202. 1962.
70. Massie, W. K.: Treatment of femoral neck fractures emphasizing long term follow-up observations on aseptic necrosis. C/in. Orthop., 92:
16-62. 1973.
7 1 . Meyers, NI. H.; Harvey, J. P., Jr.; and Moore, T. M.: Delayed treatment of subcapital and transcervical fractures of the neck of the femur
with internal fixation and a muscle pedicle bone graft. Orthop. C/in. North America, 5: 743-756, 1974.
72. Muller, M. E.; Allg#{246}wer, M.; Schneider, R.; and Willenegger, H.: Manua/oflnternal Fixation. Ed. 3, pp. 136-137. Berlin. Springer. 1991.
73. Nordin, M., and Frankel, V. H.: Biomechanics of the hip. In Basic Biomechanics ofthe Musculoske/eta/ System. Ed. 2, pp. 135-151. Phila-
delphia. Lea and Fehiger, 1989.
74. Ovadia, D. N., and Chess, J. L.: Intraoperative and postoperative subtrochanteric fracture of the femur associated with removal of the
Zickel nail.]. Bone andJoint Surg., 70-A: 239-243, Feb. 1988.
75. Parker, M. J.; Myles, J. W.; Anand, J. K.; and Drewett, R.: Cost-benefit analysis of hip fracture treatment. J. Bone and Joint Surg.,
74-B(2): 261-264. 1992.
76. Paul, J. P.: Forces at the human hip joint. Ph.D. thesis, University of Chicago. Chicago. Illinois. 1967.
77. Pauwels, F.: Der Sc/iemiken/io/shruck en, mnechanisches Prob/em. Grundlagen des Hei/ungsvorganges Prognose und kausa/e Therapie.
Stuttgart. Ferdinand Enke. 1935.
78. Praemer A.; Furner, S.; and Rice, D. P. [editorsj: Muscu/oske/eta/ Conditions in the United States. Park Ridge. Illinois. The American
Academy of Orthopaedic Surgeons. 1992.
79. Protzman, R. R., and Burkhalter, W. E.: Femoral-neck fractures in young adults. J. Bone and Joint Surg., 58-A: 689-695, July 1976.
80. Rizzo, P. F.; Braun, J. T.; Lyden, J. R.; Asnis, S. P.; Browne, M. G.; and Gould, E. S.: Classification of hip fractures based on MRI:
treatment and follow-up. Orthop. Trans., 17: 467, 1993.
81. Rydell. N.: Forces Actimig on the Feniora/ Head Prosthesis. Acta Orthop. Scandinavica, Supplementum 88. 1966.
82. Sanders, R.; Regazzoni, P.; and Routt, M., Jr.: The treatment of subtrochanteric fractures of the femur using the dynamic condylar screw.
Ort/zop. iramis.. I 2: 683. 1988.
83. Sarmiento, A.: Intertrochanteric fractures of the femur. 150-degree-angle nail-plate fixation and early rehabilitation: a preliminary
report of 1(8) cases. J. Bone amid Joint Surg.. 45-A: 706-722, June 1963.
84. Sarmiento, A., and Williams, E. M.: The unstable intertrochanteric fracture: treatment with a valgus osteotomy and I-beam nail-plate. A
preliminary report of one hundred cases.]. Bomie andJoint Surg., 52-A: 1309-1318, Oct. 1970.
85. Seinsheimer, F., III: Subtrochanteric fractures of the femur. J. Bone and Joint Surg., 60-A: 300-306. April 1978.
86. Senter, B.; Kendig, R.; and Savoie, F. H.: Operative stabilization of subtrochanteric fractures of the femur. J. Orthop. Trazinia, 4: 399-405. 1990.
87. Sevitt, S.: Avascular necrosis and revascularisation of the femoral head after intracapsular fractures. A combined arteriographic and
histological necropsy study. J. Bone and Joint Surg., 46-B(2): 270-296, 1964.
88. Sevitt, S., and Thompson. R. G.: The distribution and anastomoses of arteries supplying the head and neck of the femur. .1. Bone and
Joint Surg., 47-B(3): 560-573. 1965.
89. Sherk, H. H., and Foster, M. D.: Hip fractures: condylocephalic rod versus compression screw. C/in. Orthop., 192: 255-259, 1985.
90. Singh, M.; Riggs, B. L.; Beabout, J. W.; and Jowsey, J.: Femoral trabecular-pattern index for evaluation of spinal osteoporosis. Act,,.
Intern. Med., 77: 63-67, 1972.
91. Skinner, P. W., and Powles, D.: Compression screw fixation for displaced subcapital fracture of the femur. Success or failure? J. Bomie
and Joint Surg., 68-B( I ): 78-82, 1986.
92. Soto-Hall, R.; Johnson, L. H.; and Johnson, R. A.: Variations in the intra-articular pressure of the hip joint in injury and disease.
A probable factor in avascular necrosis. J. Bone and Joint Surg., 46-A: 509-516, April 1964.
93. Speed, K.: The unsolved fracture. Surg., Gynec. amid Obstet., 60: 341-352, 1935.
94. Steinberg, C. G.; Desai, S. S.; Kornwitz, N. A.; and Sullivan, T. J.: The intertrochanteric hip fracture. A retrospective analysis. Orthope-
dies, I 1: 265-273, 1988.
95. Strathy, G. M., and Johnson, E. W., Jr.: Enders pinning for fractures about the hip. Mayo C/in. Proc., 59: 411-414, 1984.
96. Swiontkowski, M. F.: Current concepts review. Intracapsular fractures of the hip. J. Bone amid Joint Siirg., 76-A: 129-138. Jan. 1994.
97. Swiontkowski, M. F., and Hansen, S. T., Jr.: The Deyerle device for fixation of femoral neck fractures. A review of one hundred
twenty-five consecutive cases. C/i,,. Orthop., 206: 248-252, 1986.
98. Swiontkowski, M. F.; Winquist, R. A.; and Hansen, S. T., Jr.: Fractures of the femoral neck in patients between the ages of twelve and
forty-nine years. J. Bone amid Joint Surg., 66-A: 837-846, July 1984.
99. Swiontkowski, M. F.; Harrington, R. M.; Keller, T. S.; and Van Patten, P. K.: Torsion and bending analysis of internal fixation techniques
for femoral neck fractures: the role of implant design and bone density. .1. Orthop. Res., 5: 433-444, 1987.
1(X). Swiontkowski, M. F.; Tepic, S.; Perren, S. M.; Moor, R.; Ganz, R.; and Rahn, B. A.: Laser Doppler flowmetry for bone blood flow
measurement: correlation with microsphere estimates and evaluation of the effect of intracapsular pressure on femoral head blood
flow.J. Orthop. Res., 4:362-371, 1986.
101. Tarr, R. R., and Wiss, D. A.: The mechanics and biology of intramedullary fracture fixation. C/imi. Ort/top.. 212: 10-17. 1986.
102. Thoresen, B. 0.; AIho, A.; Ekeland, A.; Stromsae, K.; Foller#{226}s, G.; and Haukebo, A.: Interlocking intramedullary nailing in femoral
shaft fractures. A report of forty-eight cases. .1 Bone and Joimit Surg., 67-A: 1313-1320, Dec. 1985.
103. Tronzo, R. G.: Surgery oft/ic Hip Joint. Philadelphia, Lea and Febiger, 1973.
104. Waddell,J. P.; Czitrom, A.; and Simmons, E. H.: Ender nailing in fractures of the proximal femur.J. Trauma, 27: 911-916, 1987.
105. Wile, P. B.; Panjabi, M. M.; and Southwick, W. 0.: Treatment of subtrochanteric fractures with a high-angle compression hip screw.
C/in. Ortliop., 175: 72-78, 1983.
106. Wiss, D. A.; Brien, W. W.; and Becker, V., Jr.: Interlocking nailing for the treatment of femoral fractures due to gunshot wounds. J. Bone
acid Joint Sirg.. 73-A: 598-606, April 1991.
107. Wiss, D. A.; Brien, W. W.; and Stetson, W. B.: Interlocked nailing for treatment of segmental fractures of the femur. J. Bone amid Joint
Surg., 72-A:724-728,June 1990.
108. Wiss, D. A.; Fleming, C. H.; Matta, J. M.; and Clark, D.: Comminuted and rotationally unstable fractures of the femur treated with an
interlocking nail. Climi. Orthop., 212: 35-47, 1986.
109. Yelton, C., and Low, W.: latrogenic subtrochanteric fracture: a complication of Zickel nails. J. Bone acid Joimit Surg., 68-A: 1237-1240,
Oct. 1986.
110. Zickel, R. E.: A new fixation device for subtrochanteric fractures of the femur. A preliminary report. C/ic,. Orthop., 54: 115-123, 1967.
1 1 1 . Zickel, R. E.: An intramedullary fixation device for the proximal part of the femur. Nine years experience. J. Bomie acid Joimit Surg.,
58-A: 866-872, Sept. 1976.
1 12. Zickel, R. E.: Subtrochanteric femoral fractures. Ortliop. C/in. North America, 11: 555-568, 1980.