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Fracture of the Subtrocanter of Femur 1

INTRODUCTION

Subtrochanteric fractures are fractures that occur in a zone extending from the lesser trochanter

to 5cm distal to the lesser trochanter, however extension into the intertrochanteric region iscommon. These fractures are more difficult to treat as compared to intertrochanteric fractures

due to the powerful muscle forces acting on the fragments as well as the tremendous stress that

is normally placed through this region. When seen in young patients, they are due to high-

energy trauma or pathologic fracture with 10% of high-energy fractures due to gun shot

wounds. In the elderly, they are often low energy injuries involving osteoporotic bone.

Pathologic fractures account for 17-35% of all subtrochanteric fractures¹. Fracture may also

occur at the site of screw placement for a previous femoral neck fracture if the inferior screw is

placed too low (below the lesser trochanter), as this creates a cortical defect and stress riser.

Classification

Fielding Classification - This is an anatomic classification based on location of the fracture and

is rarely used

Type I - at level of lesser trochanter

Type II - <2.5 cm below lesser trochanter

Type III - 2.5-5cm below lesser trochanter

Seinsheimer Classification - This system incorporates factors affecting stability and offers

management guidelines.

Type I - nondisplaced

Type II - two part fractures

Subtypes based on fracture pattern and displacement

Type III - three part spiral fracture

Subtypes based on type of fracture fragments

Type IV - comminuted

Type V - intertrochanteric extension

Russell-Taylor Classification - This classification is based on integrity of the piriformis fossa. It

was designed to guide treatment of intramedullary nails using a piriformis fossa starting point.

This system may not be as important as it used to be, due to changes in entry point techniques

and improved implant designs¹.

Type I - intact piriformis fossa

A - lesser trochanter attached to proximal fragmentB - lesser trochanter detached from proximal fragment

Type II - fracture extends into piriformis fossa

A - stable posterior-medial buttress

B - comminution of lesser trochanter

Orthopaedic Trauma Association Classification - Based on degree of comminution and mainly

used for research purposes.

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Fracture of the Subtrocanter of Femur 2

Presentation

Patients typically present in significant pain unable to ambulate with deformity of the proximal

thigh. High energy mechanisms should receive a full trauma evaluation and careful inspection

for open fracture. A detailed neurovascular exam of the extremity should be performed. Due to

the size of the thigh compartment, hypovolemic shock is possible secondary to this fracture.

Subtrochanteric Fractures and Long-Term Alendronate Use

A relationship between long-term Alendronate use and subtrochanteric fractures has been

established and is hypothesized to result from long-term suppression of bone remodeling. A

retrospective case-control study of postmenopausal women presenting with low-energy

femoral fractures reported bisphosphonate use in 15/41 subtrochanteric/shaft fractures vs. 9/82

age-, race-, and BMI-matched femoral neck and intertrochanteric fractures (odds ratio = 4.44,

95%CI = 1.77-11.35; p = 0.002). A common radiographic pattern consisting of a simple oblique

fracture with cortical thickening and beaking of the cortex on one side was highly associated

with bisphosphonate use. Patients with this fracture pattern had an average duration ofalendronate use of 7.3 years, vs. 2.8 years for those without the pattern 1 . Up to 76% of these

patients may have prodromal pain 2 . Patients with low-energy fractures who have been on

long-term bisphosphonate therapy should have imaging of the contralateral femur.

Prophylactic fixation should be considered if a contralateral stress fracture is found 3 . 

Consideration should also be given to discontinuing alendronate, in consultation with an

endocrinologist 3 . 

Diagnosis

For all hip fractures, an AP pelvis, internal rotation AP and cross-table lateral of the affected hipshould be obtained. An MRI may also be required for pathologic fractures to evaluate the

proximal femur for soft tissue extension of an underlying bone tumor. It is helpful to obtain a

contralateral femur x-ray taken with a radio-opaque ruler or scanogram for patients with highly

comminuted fractures as a means to measure the native femur length so that it may be

reproduced during ORIF of the affected extremity. Patients with low-energy fractures who have

 been on long-term bisphosphonate therapy should have contralateral femur imaging to rule out

impending fractures.

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Fracture of the Subtrocanter of Femur 3

Treatment

Initially, the limb should be stabilized with Hare traction, Buck's traction or skeletal traction. If

there will likely be a delay in surgical stabilization, femoral or tibial skeletal traction should

likely be employed.Nonoperative treatment in 90-90 skeletal traction followed by hip spica casting should only be

employed in those whom surgery is deemed very high risk. 90-90 traction attempts to

counteract the deforming muscular forces. Traction usually is required for 12-16 weeks.

Surgical stabilization is the standard of care. The treatment option include:

Intramedullary nail fixation is the preferred treatment. In general, intramedullary devices have

 been found to be almost twice as strong as extramedullary implants. First generation

interlocking nails (centromedullary) are indicated when both trochanters are intact as the

oblique locking screw is able to obtain adequate purchase. Second generation interlocking nails

with a locking screw that extends into the femoral neck (cephalomedullary) offer more stable

fixation and are indicated when the lesser trochanter is displaced or comminuted. Advantages

of intramedullary fixation include 1) Potential for closed treatment with preservation of fracture

hematoma and blood supply to fracture fragments, 2) Decreased the moment arm on the

implant compared to a lateral plate and thus decreases the tensile stress on the implant, 3)

Reaming the canal in preparation of the implant provides internal bone graft, 4) intramedullary

implants have been found to be twice as strong as traditional extramedullary implants.

Disadvantages include 1) the implant cannot be used to help facilitate reduction and the

fracture site may need to be opened to affect a reduction and guide pin insertion, thus lessening

 benefits of closed intramedullary fixation. It is nonetheless critical to achieve reduction and to

maintain this reduction (using instruments, an incision or both as needed) while the nail is

 being placed. Failure to do so will result in varus displacement during implantation.

Obtainment of proper nail starting point can be eased by lateral/lazy lateral patient positioningor the use of a trochanteric starting nail. If a trochanteric nail is chosen, it is imperative that a

very medial starting point is chosen, again to avoid varus deformity. Russell et al have reported

decreased rates of malalignment using the Minimally Invasive Nail Insertion Technique

(MINIT) 4 . 

Ninety-five degree fixed-angle devices

Historically this was the most common device used for operative fixation. This is a fixed angle

construct that provides rigid fixation. Advantages include 1) Offers a treatment option for

fractures with comminution of the trochanters that may make intramedullary implant insertion

difficult, 2) Provides for multiple points of proximal fixation. Disadvantages include 1)

Technically very demanding, 2) Extensive soft-tissue dissection, 3) High risk of implant failuredue to tremendous stress applied to the plate laterally.

Sliding hip screw

This device is indicated only for very proximal fractures. The sliding of the screw allows

medialization of the distal fragment, which reduces bending moment on fracture and implant.

The sliding mechanism must cross the fracture site to lessen the risk of implant failure and the

posteromedial cortex must be reconstructed to decrease the stress on the device.

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Fracture of the Subtrocanter of Femur 4

Post-Operative Care

Rehab: Weight bearing is guided by fracture pattern. Protected weight bearing can be started

early in fractures with posteromedial bony contact¹. Most patients should not fully bear weight

for the first 6-8 weeks.

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Fracture of the Subtrocanter of Femur 5

Personal Data and Family Background

Name: R.A.

Age: 3

Birth date: June 25, 2008

Birth Place: Manila

Sex: Male

Civil Status: Single

Religion: Roman Catholic

Address: Tondo Manila

Admission Date: 11/22/11, 01:10 AM

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Fracture of the Subtrocanter of Femur 6

Assessment Findings

General Survey

The client was assessed lying on the bed in supine position, awake, conscious and

coherent and not in respiratory distress. He is oriented to person, place and time and talks

coherently

Chief Complaint

Pain on Left Thigh

Vital Signs

The patient has a body temperature of 36.8 which is afebrile. Respiration was assessed

to be 20 cycles in one full minute and is deep and in normal pace. His pulse rate was 90 beats

per minute with a regular rhythm. His blood pressure was 100/70 mmHg taken while she was

lying on bed.

Integument

  Skin

The patient’s skin is dry with good skin turgor. Skin color is brown and has even

distribution.

  Hair 

Hair is evenly distributed and is oily and black.

  Nails 

Nails are clean and well trimmed with whitish to pink nail beds with normal

angle curvature and 3 seconds of capillary refill. Fingernails and toenails have lighter

color. Molaceous pulp with tenderness were noted on the right ring finger.

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Fracture of the Subtrocanter of Femur 7

Head

  Skull and Face

Patients head is normocephalic and proportional to body size. There are no

nodules noted. Facial features and movements are symmetrical. The patient is also able

to raise his eyebrows, close his eyes, frown and smile.

  Eyes 

Eyebrows are evenly distributed; skin is intact and symmetrically aligned with

equal movement. Skin is intact and symmetrically aligned with equal movement then

there was no scaling noted. Eyelashes are equally distributed. Eyelids close

symmetrically; discharges and discoloration were not noted. Pupil sizes are equal, with

a diameter of 3 mm when dilated and 2 mm when constricted. According to him, when

he looks straight, he can see objects in his periphery.

  Nose and Sinuses 

The external nose is symmetrical, straight and uniform in color. Color is the same

with face; there was no tenderness noted upon palpation. Lesions and tenderness were

 both absent.

Nasal mucosa was pinkish. Both nostrils are patent, with no disharges; air could

freely move in and out when the patient breathes. Nasal septum is intact and in the

midline without deviations. Sense of smell was good. He was able to differentiate water

to perfume through scent.

  Ears 

Auricles are smooth, symmetrical and no discoloration noted. External pinna are

normoset. Pinna recoils when folded; it is firm and non tender. Ears are symmetrical in

size and is normoset since both were located in the outer canthus of the eye. Normal

voice tones are able. He was able to repeat whispered sounds.

Neck

The muscles in his neck were equal in size. Movements are coordinated and there are no

difficulty noted. Lymph nodes were noted.

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Fracture of the Subtrocanter of Femur 8

Chest and Lungs

The patient has a regular and normal breathing pattern; quite and rhythmic respirations

with respiratory rate of 22 cycles in one full minute.

Abdomen

The Patient’s abdomen is rounded, rigid and has the same color with his chest. 

Genito-urinary

The patient reported that there were no lesions, tenderness and masses in her perineum

and anus.

Musculoskeletal

  Upper Extremities The patient’s radial and brachial pulses were regular. Good range of motion was

noted. Palm is able to stay in both prone and supine in good manner without difficulty.

He was able to extend both arms. Reflex on the upper extremity was good. No hand

tremors noted. Molaceous pulp with tenderness were noted on the right ring finger.

  Lower Extremities 

The patient’s popliteal and pedal pulses were regular but weak. Good range of

motion was noted.

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Fracture of the Subtrocanter of Femur 9

History

Past Health History

The patient presented no other illness during the past 6 month

Present Health History

Patient’s right ring finger was punctured by a fish fin. There was no consultation done and no

medications were taken. The aunt noticed the swelling on right ring finger which prompted

consultation.

Family History

The mother of the client is said to have asthma.

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Fracture of the Subtrocanter of Femur 10

Laboratory Results

PARAMETERS RESULTS UNIT REFERENCE RATE IMPRESSION

HEMATOLOGY:

Hemoglobin 104 g/L 127 – 183 DECREASED

Hematocrit 0.31 0.37 - 0.54 DECREASED

Platelet Count 322 x10^9/L 150 – 400 NORMAL

Differential Count

Segmenters 0.72 0.50 - 0.70 ELEVATED

Lymphocytes L 0.20 0.20-0.40 NORMAL

Monocytes 0.06 0.00-0.07 NORMAL

Eosinophils 0.02 0.00 – 0.05 NORMAL

Indices

MCV 83 fL 82 – 92 NORMAL

MCH 28 pg 28 – 32 NORMAL

MCHC 33 % 32 – 88 NORMAL

ANALYSIS:

The decrease in hematocrit and hemoglobin indicates that there is presence of bleeding.

Elevated blood segmenters signifies that there is a presence of infection.

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Fracture of the Subtrocanter of Femur 11

Anatomy and Physiology

Human Skeletal System

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The human skeleton consists of both fused and individual bones supported and

supplemented by ligaments, tendons, muscles and cartilage. It serves a

a scaffold which supports organs, anchors muscles, and protects organs such as

the brain, lungs and heart. 

The biggest bone in the body is the femur in the thigh and the smallest is the stapes bone

in the middle ear. In an adult, the skeleton comprises around 30–40% of the total body weight,

and half of this weight is water.

Fused bones include those of the pelvis and the cranium. Not all bones are

interconnected directly: there are three bones in each middle ear called theossicles that

articulate only with each other. The hyoid bone, which is located in the neck and serves as the

point of attachment for the tongue, does not articulate with any other bones in the body, being

supported by muscles and ligaments.

Subdivisions

Axial skeleton

The axial skeleton (80 bones) is formed by the vertebral column (26), the rib cage (12

pairs of ribs and the sternum) , and the skull (22 bones and 7 associated bones). The axial

skeleton transmits the weight from the head, the trunk, and the upper extremities down to the

lower extremities at the hip joints, and is therefore responsible for the upright position of the

human body. Most of the body weight is located in back of the spinal column which thereforehave the erectors spinae muscles and a large amount of ligamentsattached to it resulting in the

curved shape of the spine. The 366 skeletal muscles acting on the axial skeleton position the

spine, allowing for big movements in the thoracic cage for breathing, and the head. Conclusive

research cited by the American Society for Bone Mineral Research (ASBMR) demonstrates that

weight-bearing exercise stimulates bone growth. Only the parts of the skeleton that are directly

affected by the exercise will benefit. Non weight-bearing activity, including swimming and

cycling, has no effect on bone growth.

Appendicular skeleton

The appendicular skeleton (126 bones) is formed by the pectoral girdles (4), the upper

limbs (60), the pelvic girdle (2), and the lower limbs (60). Their functions are to make

locomotion possible and to protect the major organs of locomotion, digestion, excretion, and

reproduction.

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Fracture of the Subtrocanter of Femur 13

FUNCTION

The skeleton serves six major functions.

Support

The skeleton provides the framework which supports the body and maintains its shape.

The pelvis and associated ligaments and muscles provide a floor for the pelvic structures.

Without the ribs, costal cartilages, the intercostal muscles and the heart would collapse.

Movement

The joints between bones permit movement, some allowing a wider range of movement

than others, e.g. the ball and socket joint allows a greater range of movement than the pivot

 joint at the neck. Movement is powered by skeletal muscles, which are attached to the skeletonat various sites on bones. Muscles, bones, and joints provide the principal mechanics for

movement, all coordinated by the nervous system.

Protection

The skeleton protects many vital organs: 

  The skull protects the brain, the eyes, and the middle and inner ears. 

  The vertebrae protects the spinal cord. 

  The rib cage, spine, and sternum protect the lungs, heart and major blood vessels.   The clavicle and scapula protect the shoulder. 

  The ilium and spine protect the digestive and urogenital systems and the hip. 

  The patella and the ulna protect the knee and the elbow respectively.

  The carpals and tarsals protect the wrist and ankle respectively.

Blood cell production

The skeleton is the site of haematopoiesis, which takes place in red bone marrow. 

Storage

Bone matrix can store calcium and is involved in calcium metabolism, and bone

marrow can store iron in ferritin and is involved in iron metabolism. However, bones are not

entirely made of calcium,but a mixture of chondroitin sulfate and hydroxyapatite, the latter

making up 70% of a bone.

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Fracture of the Subtrocanter of Femur 14

Endocrine regulation

Bone cells release a hormone called osteocalcin, which contributes to the regulation

of blood sugar (glucose) and fat deposition. Osteocalcin increases both the insulin secretion and

sensitivity, in addition to boosting the number of insulin-producing cells and reducing stores of

fat.

Metacarpals

Metacarpals are the intermediate part of the hand skeleton that is located between

the phalanges (bones of the fingers) proximally and the carpus which forms the connection to

the forearm. The metacarpus consists of metacarpal bones. Its equivalent in the foot is

the metatarsus. 

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Fracture of the Subtrocanter of Femur 15

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Pathophysiology

A force that cannot be tolerated by the bone is applied.

Damage to the boneintegrity

BoneStructure

Falls

The nerve endings that surround bones contain pain fiber. These fibers may become irritated when the bone is broken or bruised.

Broken bones bleed, and the blood and associated swelling(edema) causes pain.

Muscles that surround the injured area may go into spasm when they try to

hold the broken bone fragments in place, and these spasms may cause furtherpain.

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Fracture of the Subtrocanter of Femur 17

Drug Study

Paracetamol (Biogesic

Mechanism of Action: Also known as cefazoline or cephazolin , is a first-

generation cephalosporinantibiotic. 

Indication: Treatment of variety of infections due to susceptible organisms including biliary-

tract infections, endocarditis & peritonitis. Surgical infection prophylaxis including endometritis

at caesarean section.

Contraindication: Hypersensitivity to cephalosporins. 

Side Effects: Skin rashes, urticaria, eosinophilia, fever, serum-sickness like reactions,

anaphylaxis. 

Nursing Responsibilities: Maintain skin integrity, monitor blood serum levels, perform skin

testing before drug administration.

Ibuprofen

Mechanism of Action: Ibuprofen is known to have an antiplatelet effect, though it is relatively

mild and somewhat short-lived when compared with aspirin or other better-known antiplatelet

drugs. In general, ibuprofen also acts as a vasodilator, having been shown to dilate coronary

arteries and some other blood vessels.Indication: Relief of mild to moderately severe pain of

musculoskeletal origin egmuscle pain, arthritis, rheumatism, sprain, strain, bursitis, 

tendonitis ,backache, stiff neck, tension headache, dysmenorrhea, toothache, pain after toothextraction & minor surgical operations, reduction of fever. 

Indication: Ibuprofen is used primarily for fever, pain, dysmenorrhea and inflammatory

diseases such asrheumatoid arthritis. It is also used for pericarditis and patent ductus

arteriosus. Contraindication: Patients in whom bronchospasm, angioedema or nasal polyps are

precipitated by ibuprofen, aspirin & other NSAIDs. Advanced kidney & liver diseases. 

Side Effects: GI, renal, hepatic, CNS, otic & ocular, dermatologic effects. Fluid retention,

increased BP, hypotension, CVA & palpitations. 

Nursing Responsibilities: Do not use for >10 days for pain or for >3 days for fever. Peptic ulcer,

liver & kidney impairment, heart failure & high BP. Limit alcohol intake. Pregnancy & lactation. 

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Fracture of the Subtrocanter of Femur 18

Multivitamins

Mechanism of Action: Multivitamins are a combination of many different vitamins that are

normally found in foods and other natural sources.  ̀

Indication:Contraindication: Do not take multivitamins without telling your doctor if you are pregnant or

plan to become pregnant. tooth staining, increased urination, stomach bleeding, uneven heart

rate, confusion, and muscle weakness or limp feeling. 

Side Effects: tooth staining, increased urination, stomach bleeding, uneven heart rate,

confusion, and muscle weakness or limp feeling. 

Nursing Responsibilities: Maintain oral hygiene, increase fluid intake, provision of rest. 

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Fracture of the Subtrocanter of Femur 19

Nursing Care Plan

Assessment

Objective

Molaceous pulp with tenderness were noted on the right ring finger. 

Diagnosis

Risk for Infection related to preexisting disease states

Planning

Demonstrate behaviors/lifestyle changes to reduce risk factors and protect self from injury.

Intervention

-  Identify exposure routes posing a potential hazard to client

Rationale: To determine course of action to be taken by health provider.

-  Stress importance to family members on the supervision of child.

Rationale: To facilitate independence on the client, provide health teaching and to

establish a better client – care provider relationship.

Evaluation

Was able to demonstrate behaviors/lifestyle changes to reduce risk factors and protect self

from injury.

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Health Teaching

-  Stress the importance of medications.

-  Tell the client the importance of rest.

-  Instruct proper hygiene.