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Subtrochanteric fracture

101 citationsUpdated Sep 2026

Overview

Subtrochanteric femur fractures are demanding injuries that carry an increased risk of fixation failure [2]. Operative management is the mainstay of treatment, with intramedullary nails considered the gold standard due to their biologic and biomechanical superiority over extra-medullary implants [40, 141]. Optimizing outcomes relies heavily on reduction, requiring a thorough understanding of deforming forces and various fracture patterns [8]. For subtrochanteric fractures, a long intramedullary nail has a lower rate of major reoperations compared with a short intramedullary nail [33]. While both operative and non-operative management provide acceptable results [1], intramedullary fixation is the preferred method due to biomechanical advantages and reduced complications [141].

Patients sustaining a subtrochanteric femur fracture can expect similar outcome profiles regardless of whether the fracture is atypical or typical [3]. However, in elderly patients, these fractures have a substantial negative effect on both short-term and long-term health-related quality of life [4]. Generic and name-brand cephalomedullary nail fixation demonstrate equivalent 90-day and 6-month outcomes for patients with intertrochanteric and subtrochanteric femur fractures [14]. A national register-based study indicates a lower reoperation rate for intramedullary nails than sliding hip screws for unstable trochanteric and subtrochanteric fractures, but not for stable fractures or individual fracture types [56].

Complication profiles vary by implant. The Zickel nail is not recommended for subtrochanteric fractures with marked comminution because it does not provide sufficient rotational and axial stability [28], and its use has been associated with a non-union rate of approximately 5 per cent [5]. Proximal femoral locking compression plate (PFLCP) fixation can offer better functional outcomes and fewer complications compared to dynamic hip screws [9]. The AO tibial nail can be used safely as an alternative fixation method for simple pure subtrochanteric fractures without trochanteric extension in small patients [23]. All four subtrochanteric fractures treated with a Richards sliding screw united without implant failure [16]. Total hip arthroplasty is a satisfactory salvage procedure after failed treatment of an intertrochanteric fracture in elderly patients, with few serious orthopaedic complications and acceptable clinical outcomes [19]. Primary proximal femur replacement may be preferred for pathologic subtrochanteric femur fractures arising from radioresistant tumor types, as the cumulative incidence of revision is no different than for intramedullary nailing while restoring function and offering local tumor control [161]. Factors leading to subtrochanteric femur fracture after core decompression with placement of a tantalum strut include full weight bearing before adequate bony in-growth, poor patient selection, and implant placement at the level of the lesser trochanter [163].

Anatomy & Pathophysiology

Bony Anatomy

The subtrochanteric region of the femur extends from the inferior aspect of the lesser trochanter to the junction of the proximal and middle thirds of the femoral shaft [91]. The distal border is specifically defined as a point 5 cm distal to the inferior border of the lesser trochanter [91]. This area is composed predominantly of cortical bone with poor vascularity [39] and consists of very dense bone that is difficult to fracture in young persons [57]. The calcar, a vertical sheet of bone in the medial femur, projects from the posteromedial side just inferior to the lesser trochanter and extends proximally to the posteroinferior femoral neck [57]. The hip joint capsule attaches to the femur anteriorly along the intertrochanteric crest, rendering the basicervical region of the femoral neck and the intertrochanteric region extracapsular [69].

Biomechanics

The subtrochanteric portion of the femur contends with the highest compressive and tensile forces in the human skeleton [95]. Compressive stresses peak at the medial cortex 1 to 2 inches distal to the lesser trochanter, where they can exceed 1,200 lb per square inch [91]. This concentration of stress is estimated to be up to 1200 lb/sq inch, the highest of the human skeleton [39]. A 200-lb man can generate forces of up to 1,200 lb/in2 on the medial side of the femur, 1 to 3 inches distal to the lesser trochanter [57]. The region 3–10 cm below the lesser trochanter is eccentrically loaded, with compressive medial forces considerably greater than lateral tensile forces [39]. Consequently, the medial side is subject to high compressive stresses, whilst high tensile stresses are exerted on the lateral side [39].

Varus malreduction increases mechanical stress on the fixation construct by altering the weight-bearing force vector through the proximal segment and contributing to higher compressive forces on the medial cortex [95]. Comminution of the medial cortex increases the demand of the fixation construct, surpassing loads of 1,200 lbs per square inch in a 200-lb person [95]. Any internal fixation device in this region is subject to significant concentrated bending stresses, leading to implant fatigue and fixation failure if the fracture does not unite on a timely manner [39].

Deforming Forces

Significant fracture displacement occurs secondary to the pull of the iliopsoas, gluteus medius, and short external rotators on the proximal fracture segment [95]. Specifically, the proximal segment is flexed by the pull of the iliopsoas [91], abducted by the gluteus medius and minimus [91], and externally rotated by the short external rotators [91]. The distal segment is shortened and medialized by the pull of the adductors [91]. The unopposed pull of the adductors on the distal segment often leads to femoral shortening [95].

Pathophysiology & Epidemiology

Subtrochanteric fractures account for 10–34% of all hip fractures [39]. The incidence has a bimodal age distribution, affecting young patients following high-energy trauma and older patients after low velocity trauma secondary to osteoporosis or metastatic pathological lesions [39]. High-energy subtrochanteric fractures typically occur in younger patients [91], while low-energy fractures occur in older patients and are associated with dementia and obesity [91]. The incidence of subtrochanteric femoral fractures among older patients is increasing [91], as is the incidence of atypical subtrochanteric femoral fractures secondary to long-term diphosphonate use or other metabolic abnormalities [91].

These fractures are demanding to treat with an increased risk of fixation failure [2]. The subtrochanteric area is composed of cortical bone and often is comminuted, both factors that may result in a slower rate of union [41]. The large biomechanical stresses in the subtrochanteric area may result in the failure of internal fixation devices [41]. A subtrochanteric fracture in elderly patients had a substantial negative effect on both their short and long-term HRQoL [4].

Classification

Anatomical and Biomechanical Basis

The subtrochanteric region extends distally from the lesser trochanter for a distance of 5 cm [39]. This area consists predominantly of cortical bone with poor vascularity [39]. Biomechanically, the medial side of the subtrochanteric region is subject to high compressive stresses, while high tensile stresses are exerted on the lateral side [39]. Specifically, the region of the proximal femur 3–10 cm below the lesser trochanter is eccentrically loaded, with compressive medial forces considerably greater than lateral tensile forces [39]. In 1917, Koch reported that a 200-lb man could generate forces of up to 1,200 lb/in2 on the medial side of the femur, 1 to 3 inches distal to the lesser trochanter [57].

Epidemiology and Demographics

Subtrochanteric femoral fractures exhibit a bimodal age distribution [57]. The younger group is characterized by high-energy mechanisms of injury, while the older group is characterized by osteoporotic bone and ground-level falls [57]. Black patients were more likely than white patients to have a subtrochanteric, open, or femoral neck fracture [30]. In a Swedish fracture register study, 22% of proximal femoral fractures were classified as subtrochanteric (S72.2) [151]. In the same study, 22% of proximal femoral fractures were classified as AO/OTA 31-A3 [151].

Classification Systems

Russell-Taylor: The Russell-Taylor classification defines Type I fractures as those that do not extend into the piriformis fossa [57]. Type IA fractures have no comminution of the lesser trochanter, while type IB fractures have comminution of the lesser trochanter [57]. Type II fractures are characterized by fracture extension into the piriformis fossa [57].

AO/OTA: The Orthopaedic Trauma Association (OTA) has adapted the alphanumeric fracture classification scheme initially developed by the AO group [137]. This classification is based on the number and orientation of fracture lines and does not account for the amount of displacement [137]. Intertrochanteric hip fractures are classified as group A within bone region 31 [137]. Unstable intertrochanteric fractures are defined as those with significant disruption of the posteromedial cortex because of comminution or fractures with reverse oblique or subtrochanteric fracture lines [137]. The reverse oblique fracture is designated A3.1, where the fracture line runs perpendicular to the intertrochanteric line and parallel to the direction of sliding of conventional compression hip screws [137]. Intertrochanteric-subtrochanteric fractures are designated A3.2 and A3.3, characterized by a fracture of the lateral cortex distal to the greater trochanter leaving a solely diaphyseal fragment [137].

Vancouver: The Vancouver system classifies periprosthetic femoral fractures into type A (proximal metaphysis), type B (around the stem or just below it), and type C (below the stem tip) [168]. Type B fractures are subdivided into B1 (stable stem), B2 (loose stem with adequate bone stock), and B3 (loose stem without fair bone stock) [168].

Other Systems: The Ender and Evans fracture classification systems are used to categorize trochanteric fractures, with most fractures in a specific cohort being unstable [146]. The RUSH scoring system enhances interobserver agreement and intraobserver consistency when evaluating subtrochanteric fracture healing [135]. A novel classification system for aseptic femoral shaft nonunion after intramedullary nailing could achieve accurate diagnosis and guidance for clinical management [119].

Other Considerations

The utility of the AO/OTA classification in predicting outcomes among subgroups is questionable [137]. Many surgeons recommend classifying intertrochanteric fractures simply as stable or unstable [137]. Management strategies and patient outcomes are more predictable with a stable/unstable division than with classifications of five to nine groups [137]. A new classification focusing on the relationship between the attachment of the iliofemoral ligament and the course of the fracture line is a useful communication tool for medical professionals in the diagnosis of intertrochanteric fractures [145]. Unsupervised clustering can achieve identification of the type of intertrochanteric fractures with clinical significance [48].

Clinical Presentation

Subtrochanteric fractures present as extremely unstable injuries that are difficult to reduce and fix [50]. In a retrospective study of trochanteric and subtrochanteric fractures, the incidence of irreducible fractures by closed reduction was 84.6% [114]. Patients sustaining these fractures can expect similar outcome profiles regardless of whether the fracture is atypical or typical [3]. However, in elderly patients, a subtrochanteric fracture has a substantial negative effect on both short- and long-term health-related quality of life [4].

Atypical bisphosphonate-related fractures: Management of atypical bisphosphonate-related subtrochanteric fractures can be complex, with the potential for delayed or non-union, and prodromal symptoms are common [12]. Delayed union after subtrochanteric femur fracture occurs frequently [22].

Peri-implant complications: Peri-implant subtrochanteric femur fractures are a complication associated with the use of femoral neck systems for femoral neck fractures, observed exclusively in patients with incomplete nondisplaced fractures [32].

Demographic patterns: Black patients were more likely than white patients to have a subtrochanteric fracture [30].

Investigations

Plain radiography: Conventional radiographs remain critical for the initial imaging evaluation of the hip and are used to diagnose fractures [43]. A complete hip series consists of an anterior-posterior (AP) pelvis, a centered AP hip, a lateral view (frog-leg, cross-table, Dunn 45° or 90°), and a false-profile (Lequesne) view [43]. Radiographs remain integral to fracture assessment and can be supplemented with CT to investigate suspected occult fractures, define fracture morphology, and assist in preoperative planning [43]. For post-operative surveillance, radiographs serially assess hardware positioning and evaluate symptomatic hardware related to open reduction and internal fixation and total hip arthroplasty [43].

CT: CT overcomes the limitations of radiography by providing three-dimensional assessment of bony morphology and, to some degree, assessment of soft-tissue abnormalities [70]. CT is helpful in fracture evaluation, particularly when radiographs are negative or for further defining fracture morphology in patients requiring surgical reduction [70]. CT scans are effective for examining cortical and cancellous bone and can be used to create three-dimensional reconstructions of the hip for use in surgical planning [85]. If conventional X-rays cannot be evaluated, a CT scan should be considered for the prediction of pathological subtrochanteric fractures due to metastatic lesions [201].

MRI: MRI is efficient and sensitive for diagnosing and appropriately managing patients over 70 years with equivocal proximal femoral fractures, where management change is most significant [47]. MRI evaluation of apparently isolated greater trochanter fractures is useful to diagnose the extent of occult fracture and determine the treatment strategy [49]. The soft-tissue contrast of MRI is superior to other imaging modalities in assessing both intra-articular and extra-articular hip pathology [70].

Other Considerations: There is a high incidence of coronal fragments in intertrochanteric femur fractures when analyzed with 3D CT reconstructions [59]. Greater trochanter fractures that do not cross > 50% of the intertrochanteric line and do not have a fracture angle between 35 and 42 degrees do not require further imaging as they will not have complete intertrochanteric extension [166]. The authors advise close clinical and radiographic surveillance of patients with unstable hip fracture patterns who undergo osteosynthesis with use of a TFNA implant [205]. Adverse fracture-implant motions were detected in stable trochanteric hip fractures treated with intramedullary nails with high resolution using radiostereometry [63].

Treatment

Non-Operative

Non-operative management yields acceptable results in subtrochanteric femur fractures [1], yet indications for this approach are extremely limited due to the inherent deformity, fracture instability, and poor outcomes associated with conservative care [98]. Closed treatment in a modified cast-brace eliminates varus angulation [41], though reports of angulation and shortening in proximal third femur fractures suggest cast-brace treatment is less satisfactory in this group [41]. Non-operative treatment is not a reliable method for incomplete fractures; prophylactic intramedullary nailing should be considered if the patient experiences intractable pain [153]. While nonambulators or hemi- and quadriplegic patients may be candidates for nonoperative treatment, operative fixation in these scenarios may still decrease rates of pulmonary complications and decubitus ulcers, and facilitate hygiene and patient transport with a stable long bone [98].

Operative

Indications: Operative management is the mainstay of treatment for subtrochanteric femur fractures [40]. Surgery is recommended in all instances unless surgical consent is refused or the patient is deemed an unfit surgical candidate secondary to prohibitive medical comorbidity [98]. Good outcomes cannot be achieved with traction alone for femoral intertrochanteric fractures [115].

Surgical Approach / Technique: The subtrochanteric region experiences mechanical forces several multiples of the patient's weight, placing substantial demand on implanted hardware [94]. Internal fixation devices are subject to significant concentrated bending stresses, leading to implant fatigue and fixation failure if the fracture does not unite on a timely manner [39]. The deforming forces on the proximal segment are difficult to control due to the inherently short length of the segment [94]. The characteristic deformity involves a flexed, abducted, and externally rotated proximal segment secondary to the pull of the iliopsoas, gluteus medius, and short external rotators [94]. The distal segment is often shortened and adducted via the unopposed pull of the adductor magnus and longus [94]. Minimally invasive clamp reduction without cerclage wires is a safe, reproducible, and effective surgical technique for subtrochanteric fractures, with results at least comparable to other series [124]. Minimally invasive clamp-assisted reduction and long InterTAN nail fixation is a simple, reliable, and effective technique for reducing and maintaining subtrochanteric fractures, particularly when intertrochanteric fractures are irreducible [116].

Implant Selection: Intramedullary nails have become the gold standard for subtrochanteric femoral fractures due to biologic and biomechanical superiority [40]. The AMBI remains the gold standard for fractures of the trochanteric region [7]. The Long IMHS is an effective device for the treatment of sub-trochanteric and proximal femoral fractures with a high rate of union achieved and a low complication rate [26]. The Long Gamma3 nail has proved a safe and efficient implant for the treatment of subtrochanteric fractures [31]. The proximal femoral nail is useful for treatment of unstable trochanteric and subtrochanteric fractures, with low rates of femoral shaft fractures and failure of fixation [110]. The Zickel nail resulted in a rate of non-union of approximately 5 per cent for subtrochanteric fractures [5] and is not recommended for use in subtrochanteric fractures with marked comminution because it does not give sufficient rotational and axial stability [28]. The AO tibial nail can be used safely as an alternative method for the fixation of a simple pure subtrochanteric fracture without trochanteric extension in small patients [23]. Caution should be used before the greater use of very short (< 200 mm) intramedullary nails for the treatment of trochanteric hip fractures [109]. The study demonstrated equivalent 90-day and 6-month outcomes for patients that sustain IT and subtrochanteric femur fractures with generic and name-brand fixation [14]. The PRDS group presented better clinical effects for managing irreducible extracapsular hip fractures than the LOR group [60].

Extramedullary Fixation: PFLCP fixation can offer better functional outcomes and fewer complications for subtrochanteric femoral fractures [9]. Treatment with a PFLCP can provide good-to-excellent healing for pertrochanteric fractures, with a limited occurrence of complications [118]. The AO DCS can be successfully used to manage the subtrochanteric fracture, but the complication rate is high [21]. The availability of polyaxial locking implants widened the range of indications for plate fixation in femoral fractures [123]. Routine use of intramedullary fixation devices is not to be recommended for stable trochanteric fractures [35]. The authors recommend considering extramedullary implants for stable intertrochanteric fractures, especially in patients who are anemic or at high risk for hospital readmission [121]. There remains conflicting evidence to guide the choice of implant for intertrochanteric fractures [54].

Revision: The clinical and radiographic results of the salvage treatment for the failed fixation of intertrochanteric fracture were satisfactory [36]. Cementless THA is a beneficial and effective procedure for salvaging the failed treatment of subtrochanteric fractures, with the Wagner conical prosthesis showing satisfactory function outcomes and survival rate [106]. The 95° angled blade plate was shown to be an effective fixation modality for nonunion of atypical subtrochanteric fractures with a high rate of union and functional improvement, comparable to those after fractures not associated with bisphosphonate treatment [104]. The diamond concept for optimising mechanics and bone biology is a successful method for managing complex sub-trochanteric non-unions with failed metalwork [139]. Minimally invasive treatment is feasible for most patients with old femoral fractures of the trochanter and femoral shaft [53]. It is not recommended to perform a new fixation without reduction of the mal union or non union, and if revision surgery is performed at long time distance osteotomy of the non union is mandatory to achieve the reduction [122]. It seems advisable to be prepared to bone grafting for defects after correction can be appreciated in revision surgery for subtrochanteric non-union [122].

Other Considerations: Despite differences in terms of demographic and injury characteristics, patients who sustain a subtrochanteric femur fracture can expect similar outcome profiles regardless of fracture type [3]. Management of atypical bisphosphonate related proximal femoral fractures can be complex with the potential for delayed or non-union and prodromal symptoms are common [12]. The treatment of hip fractures in centenarians poses a challenge [10]. Non-union develops significantly more frequently in femoral shaft fractures with fragments 8 cm or longer or when the displacement in the proximal area is 20 mm or greater and 10 mm or greater in the distal area [170]. Clinicians should take into account risk factors when managing patients with long bone fractures, particularly the femur and tibia, in order to minimise the risk of non-union [51]. Despite initial enthusiasm, many new treatment options for proximal femoral fractures have been proved inferior to older, traditional methods [37].

Complications

Union and Healing Complications: Subtrochanteric fractures exhibit a non-union rate of approximately 5 per cent when treated with the Zickel nail [5]. The subtrochanteric region consists of cortical bone and is often comminuted, factors that may result in a slower rate of union [41]. In subtrochanteric fractures reduced in a poor position with Gamma nails, delayed union or nonunion may occur [156]. Management of atypical bisphosphonate-related proximal femoral fractures can be complex with the potential for delayed or non-union [12].

Implant and Fixation Failure: Subtrochanteric fractures carry an increased risk of fixation failure [2]. Large biomechanical stresses in the subtrochanteric area may result in the failure of internal fixation devices [41]. In cases of subtrochanteric fracture with poor reduction, implant breakage often results from delayed union or nonunion [156]. The complication rate for subtrochanteric fractures treated with the AO DCS is high [21]. Conversely, PFLCP fixation can offer fewer complications for subtrochanteric femoral fractures compared to dynamic hip screws [9], and the Long IMHS is associated with a low complication rate for the treatment of sub-trochanteric and proximal femoral fractures [26].

Malalignment and Deformity: Torsional malalignment was experienced by 25.7% of patients undergoing internal fixation for trochanteric fractures [29]. Unstable fractures and delayed operative time are major risk factors for torsional malalignment in trochanteric fractures [29]. Displaced trochanter fragments lead to poor functional outcome in pertrochanteric fractures treated by cephalomedullary nails [18]. Coxa vara was observed as a complication in two cases of trochanteric fracture treated with a nail-plate [159]. Quality of reduction and valgization are key factors in preventing delayed union after subtrochanteric femur fracture [22].

Peri-implant and Secondary Fractures: Subtrochanteric fractures can occur following Garden screw fixation of subcapital fractures, with six of nine cases attributed to technical operative errors such as extra guidewire holes or inadequate screw placement [58]. Four of the first 158 patients treated with Gouffon pinning suffered subtrochanteric fractures at the site of the distal pins, an incidence of 2.5 per cent [178]. Peri-implant subtrochanteric femur fractures are a complication associated with the use of FNS for femoral neck fractures, observed exclusively in patients with incomplete nondisplaced fractures [32]. Decreased load to failure occurs when the distal-most screw for femoral neck fixation is started distal to the lesser trochanter [15]. Subchondral positioning of the hip screw might diminish the incidence of femoral neck fractures after internal fixation of trochanteric fractures [13].

Mortality and Morbidity: Proximal femoral fractures in the 10th decade of life are associated with high postoperative mortality within the first 6 months [55]. The treatment of hip fractures in centenarians poses a challenge regarding mortality and morbidity [10]. In a historical series of trochanteric fractures, four deaths (16.6 per cent) occurred, with the mean age of deceased patients being 77.7 years [159]. Three cases of infection occurred in a historical series of trochanteric fractures despite the routine use of antibiotics [159].

Other Considerations: Age older than 90 years, a Parker score below 6, and a history of heart disease are risk factors for a second proximal femoral fracture within 3 years after the first fracture [179]. Patients with subsequent contralateral proximal femoral fracture were of advanced age, had more severe osteoporosis, and had longer hospital stays [17].

Recovery

Light activity (weeks): The evidence provided does not specify a typical week range for the resumption of desk work, driving, or light activities of daily living.

Full activity (months): The evidence provided does not specify a month range for the return to manual work, sport, or full range of motion and strength.

Complete recovery / outcome plateau (months): The evidence provided does not specify a month range for the stabilization of pain, strength, and final functional outcomes.

Rehabilitation protocol: The first scheduled visit within ten weeks after internal fixation of a proximal femoral fracture leads to no changes in treatment [197]. One-year mortality has improved for proximal femoral fractures treated with early surgery within 48 hours of hospitalization [203].

Functional milestones: Patient-reported outcomes of lower limb long bone shaft fractures do not return to normal at one year despite modern treatment [138]. Intertrochanteric fractures with ≥10 mm of lesser trochanter displacement are associated with poorer short-term functional and patient performance outcomes, although these differences diminish over time [34]. Displaced trochanter fragments are associated with poor functional outcome in pertrochanteric fractures treated by cephalomedullary nails [18]. Proximal femoral locking compression plate fixation offers better functional outcomes and fewer complications for subtrochanteric femoral fractures compared to dynamic hip screws [9]. Generic and name-brand cephalomedullary nail fixation demonstrate equivalent 90-day and 6-month outcomes for subtrochanteric femur fractures [14]. Extramedullary fixation of stable intertrochanteric fractures affords similar functional outcomes and times to union compared to intramedullary fixation [160].

Other Considerations: The rate of non-union for subtrochanteric fractures treated with the Zickel nail was approximately 5 per cent [5]. Management of atypical bisphosphonate-related subtrochanteric fractures is complex, with potential for delayed or non-union [12]. A prolonged time to achieve union and a long follow-up duration should be expected for bisphosphonate-related subtrochanteric fracture non-union following failed intramedullary nailing [212]. Delayed unions and non-unions of fractures are associated with significant patient morbidity [207]. Fracture union occurred in all patients at an average of 9 months post revision for proximal femur fracture non-union with or without implant failure [211]. The Long IMHS is an effective device for the treatment of sub-trochanteric and proximal femoral fractures, achieving a high rate of union with a low complication rate [26]. The Long Gamma3 nail is a safe and efficient implant for the treatment of subtrochanteric fractures [31]. No complications were observed in pathological subtrochanteric fractures treated with an unreamed femoral nail, potentially due to high mortality in the first 4 months after surgery from comorbidity [209]. Fracture union occurred in 82 per cent of patients with intracapsular femoral fractures treated with parallel Garden screws [62]. Osteoporosis influences the late period of fracture healing in femoral shaft fractures treated with intramedullary nailing [208]. Biochemical markers of bone resorption increase in a time-dependent pattern during the first 14 days postoperatively, reflecting fracture healing [210]. 25.7% of patients undergoing internal fixation for trochanteric fractures experienced torsional malalignment [29]. Long-term outcomes for geriatric hip fracture patients are often frustrating, but early geriatric intervention may lead to better function [108]. The short-term survivorship of conversion hip arthroplasty after surgical treatment of an intertrochanteric fracture is excellent regardless of the original fracture fixation method [149].

Key Evidence

• [L4] Both operative and non-operative management give acceptable results in subtrochanteric fractures of the femur. [1] (10.1016/0020-1383(88)90008-3)
• [L3] Subtrochanteric fractures are demanding to treat with an increased risk of fixation failure. [2] (10.1016/s0020-1383(96)00171-4)
• [L3] Despite differences in terms of demographic and injury characteristics, patients who sustain a subtrochanteric femur fracture can expect similar outcome profiles regardless of fracture type. [3] (10.2106/jbjs.23.00583)
• [L3] A subtrochanteric fracture in elderly patients had a substantial negative effect on both their short and long-term HRQoL. [4] (10.1016/j.injury.2008.09.010)
• [L4] Considering the challenging nature of subtrochanteric fractures, complications, which included a rate of non-union of approximately 5 per cent, were minimum. [5] (10.2106/00004623-198769070-00011)
• [L1] The AMBI remains the gold standard for fractures of the trochanteric region. [7] (10.1007/s00402-005-0021-5)
• [L5] Optimizing outcomes in subtrochanteric femur fractures relies heavily on reduction, requiring a thorough understanding of deforming forces and various fracture patterns. [8] (10.5435/jaaos-d-23-00904)
• [L4] PFLCP fixation can offer better functional outcomes and fewer complications for subtrochanteric femoral fractures. [9] (10.1016/j.otsr.2014.06.012)
• [L4] The treatment of hip fractures in centenarians poses a challenge. [10] (10.1016/s0020-1383(00)00049-8)
• [L4] Management of this fracture pattern can be complex with the potential for delayed or non-union and prodromal symptoms are common. [12] (10.1016/j.injury.2017.03.025)
• [L4] Although subchondral positioning of the hip screw might diminish the incidence, adequate management of systemic osteoporosis should be targeted as a main factor of prevention. [13] (10.1016/j.injury.2018.11.007)
• [L3] The study demonstrated equivalent 90-day and 6-month outcomes for patients that sustain IT and subtrochanteric femur fractures with generic and name-brand fixation. [14] (10.5435/jaaosglobal-d-23-00186)
• [L5] Additionally, there was decreased load to failure when the distal-most screw was started distal to the lesser trochanter. [15] (10.1097/corr.0000000000000945)
• [L4] All 4 subtrochanteric fractures united without implant failure. [16] (10.1016/0020-1383(84)90059-7)
• [L4] Patients with subsequent contralateral proximal femoral fracture were of advanced age, had a higher proportion of intertrochanteric femoral fractures, had more severe osteoporosis, and had longer hospital stays. [17] (10.1186/s13018-023-03621-y)
• [L3] Displaced trochanter fragments lead to poor outcome in pertrochanteric fractures. [18] (10.1016/j.injury.2015.06.040)
• [L4] Total hip arthroplasty is a satisfactory salvage procedure after failed treatment of an intertrochanteric fracture in elderly patients with few serious orthopaedic complications and acceptable clinical outcomes. [19] (10.1007/s00264-009-0834-x)
• [L4] The AO DCS can be successfully used to manage the subtrochanteric fracture, but the complication rate is high. [21] (10.1016/0020-1383(95)90042-x)
• [L3] Delayed union after subtrochanteric femur fracture occurs frequently. [22] (10.1186/s12891-019-2775-x)
• [L4] We believe that this method can be used safely as an alternative method for the fixation of a simple pure subtrochanteric fracture without trochanteric extension in small patients. [23] (10.1016/s0020-1383(05)80004-x)
• [L4] The Long IMHS is an effective device for the treatment of sub-trochanteric and proximal femoral fractures with a high rate of union achieved and a low complication rate. [26] (10.1016/j.injury.2003.12.011)
• [L4] However, the authors no longer recommend its use in subtrochanteric fractures with marked comminution because it does not give sufficient rotational and axial stability. [28] (10.1016/0020-1383(93)90196-d)
• [L3] 25.7% of patients undergoing internal fixation for trochanteric fractures experienced torsional malalignment, with unstable fractures and delayed operative time identified as major risk factors. [29] (10.1016/j.injury.2015.07.015)
• [L3] Black patients were more likely than white patients to have a subtrochanteric, open, or femoral neck fracture, and the overall rate of hip fractures was highest in white women. [30] (10.2106/00004623-199305000-00016)
• [L3] The Long Gamma3 nail has proved a safe and efficient implant for the treatment of subtrochanteric fractures. [31] (10.1016/j.otsr.2015.06.018)
• [L4] This case series identifies peri-implant subtrochanteric femur fractures as a previously unreported complication associated with the use of FNS for femoral neck fractures, observed exclusively in patients with incomplete nondisplaced fractures. [32] (10.1186/s12891-023-06872-2)
• [L3] For subtrochanteric fractures, a long intramedullary nail has a lower rate of major reoperations compared with a short intramedullary nail. [33] (10.2106/jbjs.20.01904)
• [L2] Intertrochanteric fractures with ≥10 mm of lesser trochanter displacement were associated with some poorer short-term functional and patient performance outcomes compared with patients with less displacement, although these differences diminished over time. [34] (10.1097/corr.0000000000003574)
• [L1] In view of the overall results, routine use of intramedullary fixation devices is not to be recommended for stable trochanteric fractures. [35] (10.1016/s0020-1383(03)00287-0)
• [L3] The clinical and radiographic results of the salvage treatment for the failed fixation of intertrochanteric fracture were satisfactory. [36] (10.1016/j.injury.2019.12.004)
• [L5] Despite initial enthusiasm, many new treatment options have been proved inferior to older, traditional methods, and physicians should be cautious when it comes to managing these fractures. [37] (10.1016/j.injury.2008.09.001)
• [L4] [39] (10.1016/s0020-1383(13)70017-2)
• [L5] Operative management is the mainstay of treatment for subtrochanteric femur fractures, with intramedullary nails having become the gold standard due to biologic and biomechanical superiority. [40] (10.1302/2058-5241.6.200048)
• [L4] [41] (10.2106/00004623-198163050-00012)
• [L3] MRI is efficient and sensitive for diagnosing and appropriately managing patients over 70 years with equivocal proximal femoral fractures, where management change is most significant. [47] (10.1016/j.injury.2005.07.012)
• [L3] The unsupervised clustering can achieve identification of the type of intertrochanteric fractures with clinical significance. [48] (10.1016/j.injury.2019.03.032)
• [L3] MRI evaluation of apparently isolated greater trochanter fractures is useful to diagnose the extent of occult fracture and determine the treatment strategy. [49] (10.1016/j.injury.2018.03.017)
• [L4] Subtrochanteric fractures are extremely unstable with difficult reduction and fixation. [50] (10.1016/0020-1383(74)90176-4)
• [L1] Clinicians should take in to account these findings when managing patients with long bone fractures, particularly the femur and tibia in order to minimise the risk of non-union. [51] (10.1016/s0020-1383(15)30049-8)
• [L4] Minimally invasive treatment is feasible for most patients with old femoral fractures of the trochanter and femoral shaft. [53] (10.1016/j.injury.2019.03.002)
• [L4] There remains conflicting evidence to guide the choice of implant for intertrochanteric fractures. [54] (10.1302/0301-620x.99b1.bjj-2016-0134.r1)
• [L3] Proximal femoral fractures in the 10th decade of life are associated with high postoperative mortality within the first 6 months. [55] (10.1016/j.injury.2015.06.048)
• [L2] This national register-based study indicates a lower reoperation rate for IMN than SHS for unstable trochanteric and subtrochanteric fractures, but not for stable fractures or individual fracture types. [56] (10.1302/0301-620x.104b2.bjj-2021-1078.r1)
• [L5] [57] (10.5435/00124635-200711000-00005)
• [L4] Nine cases of subtrochanteric fracture occurred following Garden screw fixation of subcapital fractures, with six attributed to technical operative errors such as extra guidewire holes or inadequate screw placement. [58] (10.1016/0020-1383(84)90154-2)
• [L4] There is a high incidence of coronal fragments in intertrochanteric femur fractures when analyzed with 3D CT reconstructions. [59] (10.1016/j.injury.2016.12.015)
• [L3] The PRDS group presented better clinical effects for managing irreducible extracapsular hip fractures than the LOR group. [60] (10.1186/s12891-022-05390-x)
• [L2] Fracture union occurred in 82 per cent of patients. [62] (10.1016/0020-1383(94)90131-7)
• [L3] Adverse fracture-implant motions were detected in stable trochanteric hip fractures treated with intramedullary nails with high resolution. [63] (10.1016/j.injury.2018.01.005)
• [L3] The 95° angled blade plate was shown to be an effective fixation modality for nonunion of atypical subtrochanteric fractures with a high rate of union and functional improvement, comparable to those after fractures not associated with bisphosphonate treatment. [104] (10.1302/0301-620x.100b11.bjj-2018-0306.r1)
• [L4] Cementless THA is a beneficial and effective procedure for salvaging the failed treatment of subtrochanteric fractures, with the Wagner conical prosthesis showing satisfactory function outcomes and survival rate. [106] (10.1186/s12891-021-04268-8)
• [L3] This paper shows the frustrating long-term outcome of geriatric hip fracture patients but it also suggests that an early geriatric intervention may lead to better function. [108] (10.1007/s00402-011-1313-6)
• [L1] Caution should be used before the greater use of very short (< 200 mm) intramedullary nails for the treatment of trochanteric hip fractures. [109] (10.1302/0301-620x.102b3.bjj-2019-0776.r3)
• [L4] The low rates of femoral shaft fractures and failure of fixation suggest the proximal femoral nail is useful for treatment of unstable trochanteric and subtrochanteric fractures. [110] (10.1097/01.blo.0000176448.00020.fa)
• [L3] The incidence of irreducible trochanteric fractures was 15.4%, while the incidence of irreducible subtrochanteric fractures was 84.6%. [114] (10.1186/s13018-023-03635-6)
• [L3] Good outcomes cannot be achieved with traction alone for femoral intertrochanteric fractures. [115] (10.1016/j.injury.2019.10.087)
• [L4] This reduction technique is simple, reliable, and effective in reducing and maintaining subtrochanteric fractures, particularly when intertrochanteric fractures are irreducible. [116] (10.1186/s12891-023-06363-4)
• [L4] Treatment with a PFLCP can provide good-to-excellent healing for pertrochanteric fractures, with a limited occurrence of complications. [118] (10.1016/j.injury.2011.01.030)
• [L4] The proposed novel classification system could achieve accurate diagnosis and guidance for clinical management of aseptic femoral shaft nonunion after intramedullary nailing. [119] (10.1186/s12891-025-08576-1)
• [L3] The authors recommend considering extramedullary implants for stable intertrochanteric fractures, especially in patients who are anemic or at high risk for hospital readmission. [121] (10.5435/jaaos-d-21-00657)
• [L5] [122] (10.1016/j.injury.2018.11.038)
• [L4] The availability of polyaxial locking implants widened the range of indications for plate fixation in femoral fractures. [123] (10.1016/j.otsr.2012.05.014)
• [L4] Minimally invasive clamp reduction without cerclage wires is a safe, reproducible, and effective surgical technique for subtrochanteric fractures, with results at least comparable to other series. [124] (10.1016/j.injury.2015.01.019)
• [L4] The RUSH scoring system enhances interobserver agreement and intraobserver consistency when evaluating subtrochanteric fracture healing. [135] (10.1186/s12891-024-07902-3)
• [L5] [137] (10.5435/00124635-200405000-00006)
• [L3] Despite modern treatment, the patient-reported outcomes of lower limb long bone shaft fractures do not return to normal at one year. [138] (10.1016/j.injury.2014.06.025)
• [L4] The diamond concept for optimising mechanics and bone biology is a successful method for managing complex sub-trochanteric non-unions with failed metalwork. [139] (10.1016/s0020-1383(11)70086-9)
• [L5] Intramedullary fixation is the preferred method of treatment for subtrochanteric fractures due to biomechanical advantages and reduced complications compared to extra-medullary implants. [141] (10.1016/j.injury.2017.09.001)
• [L4] The new classification focusing on the relationship between the attachment of the iliofemoral ligament and the course of the fracture line is a useful communication tool for medical professionals in the diagnosis of fractures. [145] (10.1016/j.injury.2016.05.015)
• [L4] [146] (10.1016/j.otsr.2013.12.013)
• [L3] The short-term survivorship of conversion hip arthroplasty after surgical treatment of an IT fracture is excellent regardless of original fracture fixation method. [149] (10.1016/j.arth.2017.06.032)
• [L3] [151] (10.1186/s12891-018-2276-3)
• [L2] Non-operative treatment does not appear to be a reliable way of treating an incomplete fracture: prophylactic intramedullary nailing should be considered if the patient is in intractable pain. [153] (10.1302/0301-620x.99b3.bjj-2016-0276.r2)
• [L4] [156] (10.1016/s0020-1383(11)70120-6)
• [L4] [159] (10.2106/00004623-195537040-00003)
• [L1] Extramedullary fixation of stable intertrochanteric fractures significantly reduces perioperative blood loss but affords similar functional outcomes and times to union compared to intramedullary fixation. [160] (10.1186/s12891-016-1333-z)
• [L3] Primary proximal femur replacement may be preferred for pathologic subtrochanteric femur fractures arising from radioresistant tumor types, as the cumulative incidence of revision was no different than for intramedullary nailing while restoring function and offering local tumor control. [161] (10.1097/corr.0000000000003291)
• [L5] Several factors led to a subtrochanteric femur fracture after core decompression with placement of a tantalum strut, including full weight bearing before adequate bony in-growth, poor patient selection, and implant placement at the level of the lesser trochanter. [163] (10.1016/j.arth.2009.08.008)
• [L4] Greater trochanter fractures that do not cross > 50% of the intertrochanteric line and do not have a fracture angle between 35 and 42 degrees do not require further imaging as they will not have complete intertrochanteric extension. [166] (10.1016/j.injury.2017.01.017)
• [L4] [168] (10.1016/j.injury.2019.01.053)
• [L4] Non-union develops significantly more frequently in femoral shaft fractures with fragments 8 cm or longer or when the displacement in the proximal area is 20 mm or greater and 10 mm or greater in the distal area. [170] (10.1016/j.otsr.2015.11.014)
• [L4] Four of the first 158 patients treated with Gouffon pinning suffered subtrochanteric fractures at the site of the distal pins (2.5 per cent). [178] (10.1016/0020-1383(90)90120-j)
• [L3] Age older than 90 years, a Parker score below 6, and a history of heart disease are risk factors for a second proximal femoral fracture within 3 years after the first fracture. [179] (10.1016/j.otsr.2021.102887)
• [L4] The first scheduled visit within ten weeks after internal fixation of a proximal femoral fracture leads to no changes in treatment. [197] (10.1016/j.injury.2016.12.020)
• [L4] If conventional X-rays cannot be evaluated, a CT scan should be considered. [201] (10.1007/bf00393714)
• [L3] More proximal femoral fractures are treated surgically within 48 hours of hospitalization with a reduced mortality rate, and 1-year mortality has improved for early surgery only. [203] (10.5435/jaaos-d-22-00785)
• [L4] The authors advise close clinical and radiographic surveillance of patients with unstable hip fracture patterns who undergo osteosynthesis with use of a TFNA implant. [205] (10.2106/jbjs.18.00997)
• [L5] Delayed unions and non-unions of fractures continue to be of great interest and are associated with significant patient morbidity. [207] (10.1016/j.injury.2017.04.019)
• [L3] Osteoporosis influences the late period of fracture healing in femoral shaft fractures treated with intramedullary nailing. [208] (10.1016/j.injury.2008.10.035)
• [L4] No complication was observed in pathological fractures, which may be because of a high mortality in the first 4 months after surgery due to co morbidity. [209] (10.1016/s0020-1383(03)00118-9)
• [L1] Biochemical markers of bone resorption increased in a time-dependent pattern during the first 14 days postoperatively, reflecting fracture healing. [210] (10.1097/01.blo.0000180891.03042.8d)
• [L4] Fracture union occurred in all patients at an average of 9 months post revision. [211] (10.1016/j.injury.2020.05.030)
• [Paper] However, a prolonged time to achieve union and a long follow-up duration should be expected. [212] (10.1016/j.injury.2020.09.051)

See Also

• Intertrochanteric fracture

References

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