Optimal Treatment Approach for Proximal Femur Fractures Using Proximal Femur Nailing
For proximal femur fractures, cephalomedullary nailing is the treatment of choice for unstable intertrochanteric, reverse oblique, and subtrochanteric fractures due to superior biomechanical properties and improved patient outcomes. 1
Fracture Classification and Implant Selection
Extracapsular Fractures
Stable Intertrochanteric Fractures
- Sliding hip screw is preferred for stable patterns 1
- Consider proximal femur nailing for:
- Elderly patients requiring early mobilization
- Osteoporotic bone
- Patients with limited ability for protected weight-bearing
Unstable Intertrochanteric Fractures
- Antegrade cephalomedullary nail strongly recommended 1
- Benefits include:
- Better biomechanical stability
- Shorter lever arm
- Reduced surgical exposure
- Less blood loss
- Earlier weight-bearing potential
Subtrochanteric/Reverse Oblique Fractures
- Cephalomedullary devices are strongly indicated 1
- Provides superior control of the proximal fragment
- Prevents excessive medialization of the femoral shaft
Pathological Fractures
Technical Considerations for Proximal Femur Nailing
Preoperative Planning
- Complete imaging studies to assess fracture pattern
- Evaluate for other bone lesions in pathological fractures
- Measure canal diameter for appropriate nail selection
- Plan entry point based on fracture pattern and anatomy
Surgical Technique
Patient Positioning
- Fracture table with traction
- Careful positioning to avoid pressure damage to skin 2
- Avoid excessive flexion/internal rotation of contralateral hip
Reduction Technique
- Achieve anatomic reduction before nail insertion
- For difficult reductions:
- Use percutaneous reduction clamps
- Consider limited open reduction with cerclage wiring for comminuted fractures 4
- Avoid malreduction which can lead to implant failure
Entry Point
- Precise entry point is critical
- Typically at the tip or slightly medial to the tip of the greater trochanter
- Incorrect entry point can cause:
- Varus/valgus malalignment
- Iatrogenic fracture propagation
Nail Selection and Insertion
- Select appropriate nail length and diameter
- Ream the canal if necessary
- Insert nail with controlled force to avoid fracture propagation
- Consider expandable nails for enhanced fixation in osteoporotic bone 5
Proximal Locking
- Ensure proper position of lag screw in center-center position of femoral head
- Avoid screw cut-out by:
- Using appropriate screw length (avoid too short screws) 4
- Ensuring tip-apex distance <25mm
- Use anti-rotation screw/pin to prevent rotation of femoral head fragment
Distal Locking
- Static locking for unstable fractures
- Dynamic locking option for more stable patterns to allow controlled impaction
Bone Cement Implantation Syndrome Prevention
- Medullary lavage before cement insertion
- Good hemostasis
- Use cement gun for retrograde insertion
- Vent the femur
- Increase inspired oxygen concentration during cementation
- Maintain adequate intravascular volume 2
Perioperative Management
Anesthesia Considerations
- Regional anesthesia (spinal) should be considered unless contraindicated 2
- Lower doses of intrathecal bupivacaine (<10mg) to reduce hypotension
- Consider peripheral nerve blocks for multimodal analgesia
Blood Loss Management
- Tranexamic acid administration to reduce blood loss
- Monitor hemoglobin levels closely, especially with extracapsular fractures
- Be prepared for blood transfusion in symptomatic anemia 1
Thromboprophylaxis
- Administer LMWH between 18:00-20:00 to minimize bleeding risk with neuraxial anesthesia
- Use thromboembolism stockings or intermittent compression devices
- Continue pharmacological prophylaxis for 4 weeks postoperatively 2, 1
Temperature Management
- Active warming strategies during surgery
- Continue warming postoperatively to prevent hypothermia 2
Postoperative Care
Mobilization Protocol
- Immediate full weight-bearing to tolerance after surgery for most cases 1, 4
- Early mobilization improves respiratory function and reduces complications
- Physical therapy should begin day 1 post-surgery
Pain Management
- Multimodal analgesia with regular paracetamol
- Cautious use of opioids, especially in patients with renal dysfunction
- Avoid NSAIDs in elderly patients
- Avoid codeine (constipating, emetic, associated with cognitive dysfunction) 2
Monitoring and Follow-up
- Regular radiographic assessment at 2,6, and 12 weeks
- Monitor for complications:
- Cut-out of implant
- Non-union
- Malunion
- Avascular necrosis
- Hardware failure
Complications and Their Management
Intraoperative Complications
- Fracture propagation: Use cerclage wires
- Iatrogenic fracture: Consider longer nail or additional fixation
- Varus malalignment: Ensure proper entry point and reduction
Postoperative Complications
- Implant cut-out (2-8%): Revision surgery with arthroplasty
- Non-union (1-2%): Consider revision with bone grafting
- Infection (1-2%): Debridement, antibiotics, possible implant removal
- Avascular necrosis: May require conversion to arthroplasty
Special Considerations
Pathological Fractures
- Prophylactic nailing for impending fractures improves survival 3
- Consider adjuvant treatments (radiation, chemotherapy)
- Evaluate for other bone lesions
- May require more extensive fixation
Osteoporotic Bone
- Consider augmentation techniques (cement, expandable nails)
- Ensure proper implant position to reduce cut-out risk
- Consider longer nails to protect the entire femur
By following these technical principles and perioperative protocols, proximal femur nailing can provide excellent outcomes for proximal femur fractures, allowing early mobilization and reducing complications.