What is the treatment approach for proximal femur fracture using proximal femur nailing?

Proximal Femur Nailing: Comprehensive Management Approach

Proximal femur nailing (PFN) is the preferred surgical treatment for intertrochanteric and subtrochanteric femur fractures, providing superior stability that allows for early mobilization and improved functional outcomes compared to other fixation methods. 1, 2

Indications for Proximal Femur Nailing

• Intertrochanteric femur fractures (AO/OTA classification 31.A.1, A.2, and A.3)
• Subtrochanteric femur fractures
• Pathologic fractures of the proximal femur
• Prophylactic fixation for high-risk metastatic lesions 1

Types of Proximal Femoral Nails

1. Conventional PFN: Uses two proximal screws (lag screw and anti-rotation screw)
2. PFNA/PFNA2: Uses a helical blade instead of screws for better bone compaction, particularly beneficial in osteoporotic bone 3
3. Gamma nail: Combines advantages of sliding screw with intramedullary nail 4
4. Expandable PFN systems: Newer technology that expands within the femur for enhanced stability 5

Pre-operative Management

• Analgesia:

  • Peripheral nerve block (femoral or fascia iliaca) with ultrasound guidance in the Emergency Department 6
  • Regular paracetamol 1g every 6 hours 6

• Fluid Management:

  • Pre-operative fluid therapy should be prescribed routinely 6
  • Consider cardiac output-guided fluid administration to reduce hospital stay 6

• Thromboprophylaxis:

  • Low-molecular-weight heparin should be started on admission 6
  • Consider mechanical prophylaxis as an adjunct 6

Surgical Technique

1. Patient Positioning: Supine on fracture table with the affected limb in slight adduction

2. Entry Point: Greater trochanter tip or slightly medial to it

3. Nail Selection:

   • Diameter: Typically 10mm (most common) 3
   • Length: Short nails (240-250mm) for stable fractures; Long nails (380mm+) for subtrochanteric extension 3
   • PFNA2 is preferred for elderly patients with osteoporotic bone due to shorter operative time 3

4. Reduction Technique:

   • Closed reduction under fluoroscopy is attempted first
   • Limited open reduction if closed reduction fails

5. Proximal Locking:

   • For PFN: Insert lag screw followed by anti-rotation screw
   • For PFNA: Insert helical blade with controlled impaction

6. Distal Locking:

   • Dynamic locking is preferred for better fracture compression during weight-bearing 3
   • Static locking for unstable fractures

7. Augmentation Techniques:

   • Cement augmentation can be considered for severely osteoporotic bone
   • Improves stability and allows for immediate full weight-bearing 7

Anesthetic Considerations

• Either spinal anesthesia or general anesthesia is appropriate 1

• Spinal anesthesia recommendations:

  • Lower doses of intrathecal bupivacaine (<10 mg) to reduce hypotension 1
  • Consider adding intrathecal fentanyl for postoperative analgesia 1

• General anesthesia recommendations:

  • Reduced doses of induction agents for elderly patients 1
  • Higher inspired oxygen concentrations may be required 1

• Peripheral nerve blockade should always be considered as an adjunct to either technique 1

Post-operative Management

1. Analgesia:

   • Continue regular paracetamol
   • Peripheral nerve blocks can be repeated if needed 6
   • Minimize opioid use to prevent confusion in elderly patients 1

2. Oxygen Therapy:

   • Supplemental oxygen for at least 24 hours postoperatively 1, 6

3. Fluid Management:

   • Early oral fluid intake should be encouraged 1, 6
   • Remove urinary catheters as soon as possible to reduce UTI risk 1, 6

4. Mobilization:

   • Early mobilization is crucial for recovery 1
   • Physical therapy consultation for day 1 post-op 6
   • Weight-bearing status:
     • Full weight-bearing is generally allowed with stable fixation 2
     • Cement-augmented PFN allows immediate full weight-bearing even in osteoporotic bone 7

5. Nutrition:

   • Nutritional assessment and supplementation as needed (60% of hip fracture patients are malnourished) 1, 6

Complications and Management

1. Mechanical Complications:

   • Z-effect/reverse Z-effect (migration of screws)
   • Screw cut-out (especially in osteoporotic bone)
   • Implant failure
   • Periprosthetic fracture

2. Medical Complications:

   • Deep vein thrombosis (continue thromboprophylaxis) 2
   • Infection (requires debridement and antibiotics) 2
   • Postoperative cognitive dysfunction (common in 25% of patients) 1, 6

Outcomes and Prognosis

• Healing time: Average of 8-10 weeks with 99% union rate 2, 4
• Mortality: Approximately 8-10% at 30 days; higher in patients with ASA scores 3-4 1, 2
• Functional recovery: Most patients can regain pre-injury mobility level with proper rehabilitation 7, 2

Special Considerations

• Osteoporotic Bone: Consider PFNA2 with helical blade or cement augmentation 3, 7
• Pathologic Fractures: Long nails are preferred; consider adjuvant radiotherapy 2-4 weeks postoperatively 1
• Young Patients: Higher energy injuries may require more robust fixation and longer rehabilitation

Proximal femur nailing has revolutionized the treatment of hip fractures, allowing for early mobilization and improved outcomes compared to traditional methods. The choice between different nail designs should be based on fracture pattern, bone quality, and surgeon experience.