What is the step-by-step procedure for treating a subtrochanteric fracture using intramedullary (IM) nailing?

Step-by-Step Procedure for Subtrochanteric Fracture Treatment Using Intramedullary Nailing

For subtrochanteric femoral fractures, intramedullary nailing with cephalomedullary devices is the preferred treatment approach, allowing immediate full weight-bearing and optimal functional recovery. 1

Preoperative Assessment and Planning

• Evaluate the entire femur through imaging (radiographs, CT, or MRI) to detect any additional lesions that may affect treatment planning
• Assess fracture pattern and stability (comminution, involvement of lesser trochanter)
• Review patient's:
  • Life expectancy (especially important for pathological fractures)
  • Mental status
  • Pre-injury mobility status
  • Pain level
  • Metabolic and nutritional status
  • Skin condition

Patient Positioning

• Supine position on a fracture table is traditional
• Prone position can be considered as it offers:
  • Easier fracture reduction by adjusting only the leg plate on injured side
  • Better intraoperative fluoroscopic imaging in both AP and lateral views
  • Easier establishment of appropriate entry point, especially in obese patients 2

Surgical Procedure

1. Anesthesia and Preparation

   • General or regional anesthesia
   • Position patient appropriately
   • Prepare and drape the affected limb

2. Entry Point Establishment

   • Make a small incision at the tip of the greater trochanter
   • Use an awl to create the entry portal at the tip of the greater trochanter
   • Confirm proper entry point position with fluoroscopy in both AP and lateral views

3. Fracture Reduction

   • For complex subtrochanteric fractures with long oblique or spiral components, consider percutaneous cerclage wiring for temporary reduction of main fragments 3
   • Apply traction to achieve length and alignment
   • Use fluoroscopy to confirm reduction

4. Guide Wire Insertion

   • Insert guide wire through the entry point down the femoral canal
   • Confirm proper position with fluoroscopy
   • Pass the guide wire across the fracture site into the distal fragment

5. Reaming

   • Progressive reaming of the medullary canal
   • Ream 1-1.5mm larger than the selected nail diameter

6. Nail Insertion

   • Select appropriate nail length and diameter
   • Mount nail on insertion jig
   • Insert nail over guide wire
   • Advance nail across fracture site to appropriate depth
   • Confirm position with fluoroscopy

7. Proximal Locking

   • For standard subtrochanteric fractures, insert proximal locking screw(s)
   • For pathological fractures, consider cephalomedullary device with screws into femoral head 1
   • When treating atypical femoral shaft fractures, use only a proximal locking screw toward the femoral head to prevent secondary subtrochanteric fracture 4

8. Distal Locking

   • Insert distal locking screws using the targeting device or freehand technique
   • Confirm position with fluoroscopy

9. Final Assessment

   • Check final reduction and hardware position with fluoroscopy
   • Ensure rotational alignment is correct
   • Irrigate wound thoroughly

10. Closure

    • Close wound in layers
    • Apply sterile dressing

Postoperative Management

• Immediate full weight-bearing to tolerance is recommended for most patients 1, 5
• Administer appropriate pain management
• Initiate early mobilization to improve respiratory function
• Provide venous thromboembolism prophylaxis
• Schedule follow-up radiographs at 2,6, and 12 weeks to assess healing progression 5

Special Considerations

• For periarticular subtrochanteric fractures extending into the nail entry area, prosthetic replacement may be more appropriate 1
• For pathological fractures, intramedullary nailing with locking screws introduced by minimally-invasive technique and augmented by bone cement is recommended for patients with short life expectancy 1
• For unstable fractures with comminution of the medial cortex or involvement of the lesser trochanter, consider additional fixation techniques such as cerclage wiring 3

Potential Complications

• Implant failure
• Malunion or nonunion
• Infection
• Femoral shaft fracture during nail insertion
• Secondary subtrochanteric fracture (especially in patients with atypical femoral fractures) 4
• Varus malalignment

By following this structured approach, successful outcomes with anatomical reduction, stable fixation, and early mobilization can be achieved for patients with subtrochanteric fractures.