Fragility fracture proximal femur Case for small group

Fragility fracture (proximal femur) Case for small group discussion: Decision making in difficult fracture problems and polytrauma patients AO Trauma Advanced Principles Course

Discussion points • Management of atypical subtrochanteric femoral fractures • Pitfalls in intrameduallary nailing of A 3 type proximal femoral fractures • Management of failure in intramedullary nailing in A 3 type proximal femoral fractures

82 -year-old woman • Over 5 years on alendronate for osteoporosis, walked unaided • Pain in the left thigh for 1 year, then a fall injury occurred in 12/2010 • Also has diabetes, hypertension, hyperlipidaemia

Postoperative X-rays: Trochanteric femoral nail with open reduction

1 -month postoperative X-rays

Comments • Varus reduction • Minimal healing at fracture site

2 -month postoperative X-rays

• Back to Hong Kong • Left thigh pain, significant limping 6 -month postoperative x-rays

• Back to Hong Kong • Left thigh pain, significant limping Normal erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), white cell count, no clinical evidence of infection

What is the cause? • Poor biology? • Poor stability? • Both?

What should we do? • Observe and protected weight bearing • Give teriparatide • Removal of nail and refixation with bigger nail • Removal of nail, correct varus malalignment, and refixation with angle blade plate • Bone graft?

Angled blade plate refixation with allograft to femoral head in August 2011

2 -month postoperative x-rays

2 -year follow-up • Unaided walking

Summary and take-home message • Bisphonate-related subtrochanteric fractures should be treated with a long cephalomedullary device • Keys to successful healing: • Anatomical realignment of the neck-shaft angle • Good protection of the fracture biology • Keys to successful revision of failed union: • Understand the cause: biology versus stability • Exclude infection • Compression at nonunion site