History and Physical Examination

Physical findings at the time of injury often include a shortened extremity on the fractured side. Significant swelling is frequently present, with tenderness to palpation in the proximal thigh region. The leg may lie in internal or external rotation. The patient cannot flex the hip or abduct the leg. Hemorrhage into the injured thigh may be substantial, and the patient should be monitored for systemic shock and compartment syndrome.

In high-energy fractures, a complete system examination must be performed. Associated injuries to the cranium, thorax, and abdomen (Waddell triad) must be recognized.^[14] Pelvic, spine, and long bone injuries are also common, especially on the ipsilateral side, and these should be identified early to optimize treatment and outcomes.

Classification

A universally accepted classification system for subtrochanteric femur fractures has not been established. The Arbeitsgemeinschaft für Osteosynthesefragen–Association for the Study of Internal Fixation (AO-ASIF), along with the Orthopaedic Trauma Association, developed a complicated three-part classification system with 10 subtypes (see the image below); this system has been most useful in research settings.

The Arbeitsgemeinschaft für osteosynthesefragen–Association for the Study of Internal Fixation (AO-ASIF) classification of subtrochanteric femur fractures.

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In 2018, the OTA/AO fracture and dislocation compendium was revised and streamlined.^[15] Further information is available on the AO Foundation Web site.

In 1978, Seinsheimer presented an important classification with eight subgroups that identified fractures with loss of medial cortical stability (see the image below).^[16]

The Seinsheimer classification of subtrochanteric femur fractures.

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The Russell-Taylor classification system (see the image below) is helpful because it assists in determining the proper mode of treatment.

The Russell-Taylor classification of subtrochanteric femur fractures.

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Russell-Taylor type 1 fractures do not involve the piriformis fossa. They are subdivided into subtypes A (for fractures below the lesser trochanter) and B (for fractures involving the lesser trochanter). Type 2 fractures involve the piriformis fossa. Type 2A fractures have a stable medial buttress. Type 2B has no stability of the medial femoral cortex. These fractures may have varying degrees of proximal comminution, sometimes with extension into the femoral neck, and may present difficulty with implant choice.

Type 1 fractures can be treated with first-generation or second-generation intramedullary devices. Historically, type 2 fractures were treated by means of open reduction and internal fixation (ORIF) with plate and screw devices or fixed-angle implants. With advanced techniques and implant design, intramedullary fixation has been a successful tool with reliable rates of healing.

A study that evaluated inter- and intra-observer reliability of current classification systems for subtrochanteric femoral fracture found both the Russell-Taylor classification and the Seinsheimer classification found to be more reliable and reproducible than the AO classification in this setting.^[17]

Workup

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Media Gallery

Injury radiograph of high-energy intertrochanteric fracture with reverse obliquity.
Subtrochanteric fracture repaired with cephalomedullary nail.
The Seinsheimer classification of subtrochanteric femur fractures.
The Arbeitsgemeinschaft für osteosynthesefragen–Association for the Study of Internal Fixation (AO-ASIF) classification of subtrochanteric femur fractures.
The Russell-Taylor classification of subtrochanteric femur fractures.
Reverse obliquity subtrochanteric femur fracture malreduced with a short cephalomedullary nail
Subtrochanteric femur fracture reduction revised and stabilized with a blade plate. Patient went on to heal and return to full function without pain.
Subtrochanteric femur fracture repaired with cephalomedullary device

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Author

Mark A Lee, MD Associate Professor, Director of Orthopedic Trauma Fellowship, Department of Orthopedic Surgery, University of California at Davis School of Medicine

Mark A Lee, MD is a member of the following medical societies: Orthopaedic Trauma Association, AO Foundation

Disclosure: Received grant/research funds from Synthes, USA for none; Received honoraria from Synthes, USA for speaking and teaching; Received consulting fee from Biomet, USA for consulting; Received consulting fee from Zimmer, USA for speaking and teaching; Received grant/research funds from Spinesmith for none.

Coauthor(s)

David A Forsh, MD Chief, Orthopedic Trauma Surgery, Assistant Professor, Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai

David A Forsh, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Orthopaedic Trauma Association, AO North America

Disclosure: Nothing to disclose.

Janos P Ertl, MD Assistant Professor, Department of Orthopedic Surgery, Indiana University School of Medicine; Chief of Orthopedic Surgery, Wishard Hospital; Chief, Sports Medicine and Arthroscopy, Indiana University School of Medicine

Janos P Ertl, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Hungarian Medical Association of America, Sierra Sacramento Valley Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

B Sonny Bal, MD, JD, PhD, MBA CEO and President, SINTX Technologies, Salt Lake City, UT

B Sonny Bal, MD, JD, PhD, MBA is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: SINTX Technologies.

Chief Editor

William L Jaffe, MD Clinical Professor of Orthopedic Surgery, New York University Grossman School of Medicine; Vice Chairman, Department of Orthopedic Surgery, New York University Hospital for Joint Diseases

William L Jaffe, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, Eastern Orthopaedic Association, New York Academy of Medicine

Disclosure: Received consulting fee from Stryker Orthopaedics for speaking and teaching.

Additional Contributors

Steven I Rabin, MD, FAAOS Clinical Associate Professor, Department of Orthopedic Surgery and Rehabilitation, Loyola University, Chicago Stritch School of Medicine; Medical Director, Musculoskeletal Services, Dreyer Medical Clinic

Steven I Rabin, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Fracture Association, American Orthopaedic Association, AO Foundation, Chicago Metropolitan Trauma Society, Illinois Association of Orthopaedic Surgeons, Limb Lengthening and Reconstruction Society, Mid-America Orthopaedic Association, Orthopaedic Trauma Association

Disclosure: Nothing to disclose.