From the Guidelines
For challenging proximal femur fractures, a temporary stabilization with an external fixator or osseous traction is often necessary, followed by a safe definitive osteosynthesis as early as possible, to reduce morbidity and mortality, as recommended by the most recent guidelines 1.
Key Considerations
- The timing and modalities for performing fracture fixation are crucial in reducing local and systemic complications, particularly in patients with severe limb trauma 1.
- In the absence of severe visceral injury, circulatory shock, or respiratory failure, early definitive osteosynthesis within the first 24 hours is recommended for diaphyseal fractures, including femoral and tibial shaft fractures 1.
- However, in the presence of severe visceral injuries, circulatory shock, or respiratory failure, a delayed definitive osteosynthesis is probably recommended within the first 24 hours to reduce the incidence of systemic complications 1.
Surgical Approach
- A sequential surgical approach, also known as damage control orthopaedic surgery (DCO), may be necessary in patients with unstable fractures, involving a simplified temporary stabilization at the initial phase, followed by a delayed osteosynthesis surgery 1.
- The entry point for nail insertion is critical, and for antegrade nailing, it should be slightly medial to the tip of the greater trochanter.
- Maintain appropriate neck-shaft angle (130-135 degrees) and ensure adequate tip-apex distance (<25mm) to prevent cut-out.
Postoperative Care
- Early mobilization with weight-bearing as tolerated is beneficial for most patients, though this may need modification based on fracture stability and bone quality.
- The use of high-quality imaging, including AP and lateral radiographs, and CT scans for complex patterns, can help guide the surgical approach and ensure proper reduction and fixation of the fracture.
- Consideration of cement augmentation or additional fixation techniques, such as cerclage wiring, may be necessary for comminuted fragments or osteoporotic bone.
From the Research
Tips for Fixation of Challenging Proximal Femur Fractures
- Careful insertion of cephalomedullary nails is required to avoid complications, as highlighted in studies 2, 3
- Single-stage cephalomedullary fixation can be an effective treatment option for ipsilateral proximal femur and shaft fractures, with a mean operative time of around 78 minutes 3
- The use of lag-screw fixation preceded by closed, unreamed nailing can provide consistently good results, despite the stability or location of the fracture 4
- Techniques to avoid malalignment in proximal femoral fractures managed with cephalomedullary nails include addressing rotational mismatch, central placement of lag screw, and limb rotation restoration 5
- Strategic patient positioning is key to the reduction and fixation of proximal femur fractures without complications, with various positioning options available, including the use of fracture tables and radiolucent tables 6
Key Considerations
- High degree of accuracy and technical expertise is required for cephalomedullary nailing 2
- Surgery for proximal femur fractures can be technically demanding with a definite learning curve 3
- Careful consideration of patient positioning and fracture reduction is necessary to avoid complications and achieve favorable outcomes 6
- The use of intramedullary devices and fracture tables can increase the risk of malrotation, highlighting the need for careful technique and attention to detail 6