What is the recommended treatment for a subtrochanteric fracture in an elderly woman?

Treatment of Subtrochanteric Fracture in an Elderly Woman

Treat with surgical fixation using an antegrade cephalomedullary nail, performed within 48 hours of admission, followed by immediate full weight-bearing as tolerated. 1, 2

Surgical Approach

Cephalomedullary nail fixation is the definitive treatment for subtrochanteric fractures in elderly patients. 1, 2 The biomechanical superiority of intramedullary nails over extramedullary implants has been established, making them the gold standard for these fractures. 3

Implant Selection

• Use an antegrade cephalomedullary nail as the primary fixation device for subtrochanteric fractures. 1, 2
• Either short or long cephalomedullary nails are acceptable options based on fracture pattern and surgeon preference. 2
• The helical blade design provides strong fixation strength in osteoporotic bone. 4

Surgical Timing

• Perform surgery within 48 hours of admission, as delays beyond this timeframe significantly increase mortality risk. 2
• Provide thorough medical optimization without unnecessarily delaying surgery. 2
• Implement orthogeriatric comanagement from admission to improve outcomes and reduce mortality. 2

Perioperative Management

Anesthesia and Analgesia

• Either spinal or general anesthesia is appropriate for the procedure. 1, 5
• Administer multimodal analgesia with preoperative nerve block to optimize pain control and facilitate early mobilization. 1, 5

Blood Loss Prevention

• Give tranexamic acid perioperatively to reduce blood loss and transfusion requirements. 1, 5

Critical Pitfall to Avoid

• Do not use preoperative traction for hip fracture patients—this has strong evidence against its use. 5, 2

Surgical Technique Considerations

• Achieve anatomic reduction before nail passage to ensure optimal outcomes. 6
• Confirm adequate reduction with restoration of medial cortical continuity on post-operative radiographs. 1
• Verify implant position within the femoral head and appropriate neck-shaft angle restoration. 1

Postoperative Management

Weight-Bearing Protocol

• Allow immediate full weight-bearing as tolerated starting on postoperative day 2. 1, 2
• Recent evidence demonstrates that elderly patients with subtrochanteric fractures treated by intramedullary nailing can safely tolerate immediate full weight-bearing without increasing reoperation rates (2.7% implant failure rate overall). 7
• Early mobilization prevents recumbency complications including pneumonia, deep vein thrombosis, pressure ulcers, and reduces mortality. 1, 2

Thromboembolism Prevention

• Provide VTE prophylaxis for 4 weeks postoperatively. 2

Anemia Management

• Monitor for postoperative anemia and provide blood transfusion for symptomatic anemia. 2

Osteoporosis Evaluation and Secondary Prevention

All elderly patients with subtrochanteric fractures require systematic osteoporosis evaluation and treatment. 1, 5

During Hospitalization

• Order outpatient DEXA scan. 1, 5
• Measure vitamin D, calcium, and parathyroid hormone levels. 1, 5

Outpatient Follow-up

• Refer to an Orthopedics Bone Health Clinic or Fracture Liaison Service for comprehensive osteoporosis management. 1, 2
• Implement non-pharmacological measures including adequate calcium and vitamin D supplementation. 2

Rehabilitation Protocol

• Begin early physical training with muscle strengthening exercises. 2
• Implement long-term balance training to reduce subsequent fracture risk. 2
• Regular assessment of cognitive function, nutritional status, and pressure sore risk is essential. 2

Radiographic Monitoring

• Obtain serial radiographs to monitor fracture healing progression, maintenance of reduction, and hardware complications. 1
• Watch for excessive varus collapse or cutout complications (occurs in approximately 2-3% of cases). 1, 7
• Average bony union occurs within 19-22 weeks. 4