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Subtrochanteric fracture

92 citationsUpdated Sep 2026
Illustration: hip

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Subtrochanteric femur fractures are demanding to treat, carrying an increased risk of fixation failure [2]. Operative management is the mainstay of treatment, with intramedullary nails serving as the gold standard due to their biologic and biomechanical superiority over extra-medullary implants [40, 141]. While both operative and non-operative management can yield acceptable results [1], intramedullary fixation is preferred for its biomechanical advantages and reduced complication rates [141]. For unstable trochanteric and subtrochanteric fractures, intramedullary nailing demonstrates a lower reoperation rate compared to sliding hip screws, though this advantage is not observed in stable fractures [56]. Specifically for subtrochanteric fractures, a long intramedullary nail is associated with a lower rate of major reoperations than a short intramedullary nail [33].

Optimizing outcomes relies heavily on achieving an adequate reduction, which requires a thorough understanding of deforming forces and various fracture patterns [8]. Patients sustaining these fractures can expect similar outcome profiles regardless of specific fracture type, despite differences in demographic and injury characteristics [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]. When comparing fixation methods, proximal femoral locking compression plate (PFLCP) fixation can offer better functional outcomes and fewer complications [9], while generic and name-brand fixation devices demonstrate equivalent 90-day and 6-month outcomes [14].

Complication rates vary by implant choice and fracture morphology. The Zickel nail is not recommended for subtrochanteric fractures with marked comminution because it does not provide sufficient rotational and axial stability [28], though it has been associated with a non-union rate of approximately 5 per cent [5]. In small patients, the AO tibial nail can be used safely as an alternative for simple pure subtrochanteric fractures without trochanteric extension [23]. For pathologic subtrochanteric femur fractures arising from radioresistant tumor types, primary proximal femur replacement may be preferred over intramedullary nailing, as it offers local tumor control and function restoration with a cumulative incidence of revision no different than nailing [161]. Further clinical studies with larger sample sizes are required to establish the advantage of biologic plating for these fractures [133].

Anatomy & Pathophysiology

Anatomical Definition and Epidemiology

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]. Subtrochanteric fractures account for 10–34% of all hip fractures [39]. These injuries exhibit 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, while low-energy fractures occur in older patients and are associated with dementia and obesity [91]. The incidence of atypical subtrochanteric femoral fractures secondary to long-term diphosphonate use or other metabolic abnormalities is increasing among older patients [91].

Osseous Anatomy and Vascularity

The subtrochanteric region is composed predominantly of cortical bone with poor vascularity, which accounts for longer healing time after a fracture [39]. The subtrochanteric area of the proximal femur is composed of very dense bone that is difficult to fracture in a young person [57]. The calcar is a vertical sheet of bone in the medial femur that projects from the posteromedial side of the femur just inferior to the lesser trochanter and extends proximally to the posteroinferior femoral neck [57]. The hip joint capsule extends anteriorly to the intertrochanteric crest but posteriorly only partially across the femoral neck, making the basicervical and intertrochanteric crest regions extracapsular [65].

The medial femoral circumflex artery is the main blood supply to the femoral head, terminating in the posterior aspect of the extracapsular arterial ring [78]. The lateral femoral circumflex artery gives rise to the anterior aspect of the extracapsular arterial ring [78]. The superior and inferior gluteal arteries contribute branches to the extracapsular arterial ring [78]. The ascending cervical arteries originate from the extracapsular arterial ring and are divided into lateral, medial, posterior, and anterior groups based on their anatomic relationship to the femoral neck [78]. The lateral group of ascending branches is the main blood supply to the femoral head [78]. The artery of the ligamentum teres arises from either the obturator or medial femoral circumflex artery and does not provide sufficient blood supply to maintain the viability of the femoral head [78].

Biomechanics and Stress Distribution

The subtrochanteric portion of the femur contends with the highest compressive and tensile forces in the human skeleton [95]. The concentration of stresses in this region has been estimated to be up to 1200 lb/sq inch, the highest of the human skeleton [39]. The medial side of the subtrochanteric region is subject to high compressive stresses, while high tensile stresses are exerted on the lateral side [39]. 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]. Compressive stresses in the femur are greatest in the medial cortex of the subtrochanteric region below the lesser trochanter, where they can exceed 1,200 lb per square inch [91]. 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].

Varus malreduction leads to increased 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].

Deforming Muscular Forces

The proximal segment of a subtrochanteric fracture 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]. Significant fracture displacement occurs secondary to the pull of the iliopsoas, gluteus medius, and short external rotators on the proximal fracture segment [95]. The distal segment of a subtrochanteric fracture 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]. The deforming forces of flexion and external rotation from the iliopsoas, abduction from the gluteal medius, and adduction and shortening of the shaft from the hamstrings and adductors constitute a surgical challenge for the orthopaedic surgeon [39].

Pathophysiological Consequences

Any internal fixation device in the subtrochanteric 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]. The large biomechanical stresses in the subtrochanteric area may result in the failure of internal fixation devices [41]. The subtrochanteric area is composed of cortical bone and often is comminuted, both factors that may result in a slower rate of union [41]. A subtrochanteric fracture in elderly patients had a substantial negative effect on both their short and long-term health-related quality of life [4]. 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].

Classification

Anatomical and Biomechanical Basis

The subtrochanteric region extends distally from the lesser trochanter for a distance of 5 cm [39]. This area is composed of predominantly cortical bone with poor vascularity [39]. The bone in this region is very dense, making it difficult to fracture in young individuals [57]. Biomechanical forces in this zone are substantial; Koch reported in 1917 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 shaft fractures exhibit a bimodal age distribution [39]. Younger patients typically sustain these injuries from high-energy mechanisms, such as motor vehicle collisions or falls from a height [57]. Older patients, who often have osteoporotic bone, are usually injured by low-velocity trauma, such as ground-level falls, or secondary to metastatic pathological lesions [39, 57]. Demographic data indicates that Black patients were more likely than white patients to have a subtrochanteric, open, or femoral neck fracture [30]. In a Swedish fracture register study of 10,548 entries, 22% of cases were classified as subtrochanteric (S72.2) and 78% as trochanteric (S72.1) [151].

Classification Systems

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

OTA/AO: The Orthopaedic Trauma Association (OTA) has adapted the alphanumeric fracture classification scheme initially developed by the AO group [137]. This system 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 proximal femur region 31 [137]. Unstable intertrochanteric fractures include types A2.2, A2.3, and A3 [137]. These unstable patterns are defined by significant disruption of the posteromedial cortex due to comminution, or by reverse oblique or subtrochanteric fracture lines [137]. In the reverse oblique fracture (A3.1), the fracture line runs perpendicular to the intertrochanteric line and parallel to the direction of sliding of conventional compression hip screws [137]. In the intertrochanteric-subtrochanteric fracture (A3.2 and A3.3), there is a fracture of the lateral cortex distal to the greater trochanter, leaving a solely diaphyseal fragment [137].

Other Considerations: The utility of the OTA/AO classification in predicting outcomes among subgroups is questionable [137]. Many surgeons recommend classifying intertrochanteric fractures simply as stable or unstable, as management strategies and patient outcomes are more predictable with this 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 serves as a useful communication tool for diagnosing intertrochanteric fractures [145]. Unsupervised clustering can achieve identification of the type of intertrochanteric fractures with clinical significance [48]. The RUSH scoring system enhances interobserver agreement and intraobserver consistency when evaluating subtrochanteric fracture healing [135]. There is no single unifying scale in widespread use for proximal femoral fracture patients [150]. Additional studies are required to establish a classification system with clear treatment recommendations for unstable intertrochanteric fractures [6].

Clinical Presentation

Subtrochanteric fractures present as extremely unstable injuries characterized by difficult reduction and fixation [50]. The clinical course is frequently complicated by delayed union, which occurs frequently in this fracture pattern [22]. Despite the mechanical instability, patients who sustain a subtrochanteric femur fracture can expect similar outcome profiles regardless of the specific fracture type [3].

In the context of atypical bisphosphonate-related proximal femoral fractures, management can be complex due to the potential for delayed or non-union [12]. Prodromal symptoms are common in these patients, often preceding the acute fracture event [12].

Peri-implant subtrochanteric femur fractures represent a specific complication associated with the use of FNS for femoral neck fractures [32]. This complication is observed exclusively in patients with incomplete nondisplaced fractures [32].

For patients over 70 years of age presenting with equivocal proximal femoral fractures, MRI is efficient and sensitive for diagnosis and appropriate management [47]. The use of MRI in this demographic is particularly significant where management change is most likely [47].

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 are integral to fracture assessment and can be supplemented with CT to investigate suspected occult fractures, define fracture morphology, and assist in preoperative planning [43]. They also allow for serial assessment of hardware positioning and evaluation of symptomatic hardware related to open reduction and internal fixation [43]. 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]. 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].

CT: Computed tomography 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 in the setting of negative radiographs 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]. There is a high incidence of coronal fragments in intertrochanteric femur fractures when analyzed with 3D CT reconstructions [59]. Radiological evaluation of the full femur length and avoiding hammering are recommended to prevent complications from mismatch between PFNa and the medullary canal [200].

MRI: 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]. For patients suspected of soft tissue or intra-articular pathology, MRI is the modality of choice, given its superior sensitivity and specificity [85]. Conventional MRI is effective at identifying osteochondral injuries, musculotendinous pathologies, and inflammation [85]. Magnetic resonance arthrography (MRA) is more appropriate to determine injuries to the labrochondral structures and the ligamentum teres and identify the presence of loose bodies and synovial chondromatosis [85]. In the accurate detection and staging of articular cartilage lesions, the utility of MRA is reduced, with sensitivity reported to be less than 50% compared with arthroscopic findings [85]. Recent advances in MRI imaging techniques, such as delayed gadolinium-enhanced MR imaging and T2* mapping, allow for a more in-depth analysis of the structure of articular cartilage [85]. Noncontrast MRI at 3T is generally adequate for diagnosing intra-articular pathology [89]. If 3T imaging is unavailable, MRA can be considered at 1.5T for increased diagnostic accuracy [89].

Ultrasonography: Ultrasonography provides real-time dynamic assessment of the hip and is useful in diagnosing soft-tissue abnormalities about the hip joint [70]. It is particularly useful in providing real-time guidance during diagnostic and therapeutic procedures [70]. Although ultrasonography is a valuable tool to examine pediatric hip conditions, its utility in evaluating the adult hip is limited [85]. Ultrasonography can be an effective modality to identify musculotendinous disruptions, effusions associated with intra-articular pathology, or inflammatory conditions, such as bursitis [85]. It is also being increasingly used for targeted injections into muscles, tendons, or intra-articularly around the hip [85]. Ultrasonography cannot image inside bone because bone cortex reflects almost all sound waves [90]. Internal joint structures are not well visualized unless they are in a superficial location [90].

Other Considerations: The complexity of the hip and pelvic region can make accurate diagnosis of painful conditions difficult, necessitating a thorough understanding of normal anatomy and biomechanics [42]. A comprehensive clinical examination is required to determine a differential diagnosis because many hip conditions present with similar symptoms [42]. Findings from imaging studies should complement clinical examination findings to provide the most accurate diagnosis [42]. A thorough history is essential to differentiating between common causes of hip pain [42]. Clinical examination tests and imaging findings should be used to confirm a suspected clinical diagnosis [42].

Treatment

Non-Operative

Nonoperative treatment for subtrochanteric femur fractures is indicated in extremely limited circumstances, primarily when surgical consent is refused or the patient is an unfit surgical candidate due to prohibitive medical comorbidity [98]. The inherent deformity and instability of the fracture pattern, combined with poor outcomes associated with conservative management, make operative treatment the recommendation in all other instances [98]. While nonambulators or hemi- and quadriplegic patients may be considered candidates for nonoperative care, operative fixation in these scenarios may still decrease rates of pulmonary complications and decubitus ulcers while facilitating hygiene and patient transport [98]. Non-operative treatment is not a reliable method for managing incomplete fractures; prophylactic intramedullary nailing should be considered if the patient experiences intractable pain [153].

Operative

Indications: Operative management is the mainstay of treatment for subtrochanteric femur fractures [40]. Good outcomes cannot be achieved with traction alone for femoral intertrochanteric fractures [115]. Despite initial enthusiasm, many new treatment options for proximal femoral fractures have proved inferior to older, traditional methods [37].

Surgical Approach / Technique: The deforming forces on the proximal and distal segments of a subtrochanteric fracture are difficult to control, particularly given the short length of the proximal 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]. Conversely, 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 with results at least comparable to other series [124]. A minimally invasive clamp-assisted reduction technique is simple, reliable, and effective in reducing and maintaining subtrochanteric fractures, particularly when intertrochanteric fractures are irreducible [116].

Implant Selection: Intramedullary nails have become the gold standard for subtrochanteric femur fractures due to biologic and biomechanical superiority [40]. The Long IMHS is an effective device for sub-trochanteric and proximal femoral fractures, achieving a high rate of union with a low complication rate [26]. The Long Gamma3 nail has proved a safe and efficient implant for subtrochanteric fractures [31]. The proximal femoral nail is useful for unstable trochanteric and subtrochanteric fractures, with low rates of femoral shaft fractures and failure of fixation [110]. The Zickel nail can be used for subtrochanteric fractures, with complications including a rate of non-union of approximately 5 per cent [5]. Caution should be used before the greater use of very short (< 200 mm) intramedullary nails for the treatment of trochanteric hip fractures [109].

Extramedullary fixation options include the PFLCP, which 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 subtrochanteric fractures, but the complication rate is high [21]. The AMBI remains the gold standard for fractures of the trochanteric region [7]. The availability of polyaxial locking implants widened the range of indications for plate fixation in femoral fractures [123]. 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].

Other Considerations: The subtrochanteric region of the femur experiences mechanical forces several multiples of the patient's weight, placing substantial demand on implanted hardware [94]. The medial side of the subtrochanteric region is subject to high compressive stresses, whilst high tensile stresses are exerted on the lateral side [39].

Revision: The clinical and radiographic results of salvage treatment for failed fixation of intertrochanteric fractures were satisfactory [36]. Cementless THA is a beneficial and effective procedure for salvaging failed treatment of subtrochanteric fractures, with the Wagner conical prosthesis showing satisfactory function outcomes and survival rate [106]. 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; if revision surgery is performed at a long time distance, osteotomy of the non union is mandatory to achieve the reduction [122]. It seems advisable to be prepared for bone grafting or for defects after correction, which can be appreciated during revision of subtrochanteric non-union [122].

Outcomes and Complications: Despite differences in demographic and injury characteristics, patients who sustain a subtrochanteric femur fracture can expect similar outcome profiles regardless of fracture type [3]. 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].

Complications

Union and Healing Complications

Management of atypical bisphosphonate-related proximal femoral fractures is complex, with a potential for delayed or non-union [12]. In subtrochanteric fractures, delayed union or nonunion may occur following suboptimal reduction [156].

Implant and Mechanical Failures

Fixation of subtrochanteric fractures using the Zickel nail has been associated with a non-union rate of approximately 5 per cent [5]. When poor reduction is present, delayed union or nonunion often results in implant breakage [156]. Additionally, displaced trochanter fragments lead to poor outcomes in pertrochanteric fractures treated by cephalomedullary nails [18].

Malalignment and Deformity

Reports of angulation and shortening in patients with fractures of the proximal third of the femur suggest that cast-brace treatment is less satisfactory in this group [41]. Torsional malalignment occurred in 25.7% of patients undergoing internal fixation for trochanteric fractures [29]. Unstable fractures and delayed operative time are identified as major risk factors for torsional malalignment in these injuries [29]. Two cases of coxa vara occurred as complications during the use of the nail-plate method for trochanteric fractures [159].

Peri-implant and Secondary Fractures

Peri-implant subtrochanteric femur fractures are a complication associated with the use of femoral neck systems (FNS) for femoral neck fractures, observed exclusively in patients with incomplete nondisplaced fractures [32]. 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]. 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]. Subchondral positioning of the hip screw might diminish the incidence of femoral neck fractures after internal fixation of trochanteric fractures [13]. There was decreased load to failure when the distal-most screw was started distal to the lesser trochanter in femoral neck fixation [15].

Mortality and Morbidity

A subtrochanteric fracture in elderly patients has a substantial negative effect on both short and long-term health-related quality of life (HRQoL) [4]. Proximal femoral fractures in the 10th decade of life are associated with high postoperative mortality within the first 6 months [55]. In a series of trochanteric fractures, four deaths (16.6 per cent) occurred, with the mean age of patients who died being 77.7 years [159].

Infection

Three cases of infection occurred in a series of trochanteric fracture treatments despite the routine use of antibiotics [159].

Recovery

Light activity (weeks): The evidence provided does not specify a typical week range for light activities such as desk work, driving, or light ADLs. However, early geriatric intervention may lead to better function in geriatric hip fracture patients [108].

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

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

Rehabilitation protocol: The first scheduled visit within ten weeks after internal fixation of a proximal femoral fracture leads to no changes in treatment [197]. 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].

Functional milestones: Patient-reported outcomes of lower limb long bone shaft fractures do not return to normal at one year despite modern treatment [138]. Subtrochanteric fractures in elderly patients have a substantial negative effect on both short-term and long-term health-related quality of life [4]. Patients sustaining a subtrochanteric femur fracture can expect similar outcome profiles regardless of whether the fracture is atypical or typical [3].

Other Considerations: Both operative and non-operative management yield acceptable results for subtrochanteric fractures of the femur [1]. Subtrochanteric fractures carry an increased risk of fixation failure [2]. The rate of non-union for subtrochanteric fractures treated with the Zickel nail was approximately 5 per cent [5]. Management of bisphosphonate-related subtrochanteric fractures can be complex with the 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]. 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]. Proximal femoral fractures in patients in the 10th decade of life are associated with high postoperative mortality within the first 6 months [55]. Displaced trochanter fragments lead to poor functional outcome in pertrochanteric fractures treated by cephalomedullary nails [18]. Intertrochanteric fractures with ≥10 mm of lesser trochanter displacement are associated with poorer short-term functional and patient performance outcomes compared with less displacement, although these differences diminish over time [34]. Unstable fractures and delayed operative time are major risk factors for torsional malalignment in trochanteric fractures [29]. Osteoporosis influences the late period of fracture healing in femoral shaft fractures treated with intramedullary nailing [208].

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)
  • [L5] Additional studies are required to specify the influence of fracture characteristics on complication rate and function and to establish a classification system with clear treatment recommendations for unstable intertrochanteric fractures. [6] (10.1007/s11999-013-2834-9)
  • [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)
  • [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)
  • [L5] The Appropriate Use Criteria for the Management of Hip Fractures in the Elderly provide a framework for clinicians to determine the appropriateness of various treatments and rehabilitation interventions based on specific patient scenarios, with 52% of treatment items rated as rarely appropriate and 76% of rehabilitation items rated as appropriate. [27] (10.2106/jbjs.16.00260)
  • [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)
  • [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)
  • [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)
  • [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 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)
  • [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)
  • [L3] Further clinical studies with a larger sample size are required to show the advantage of biologic plating for the treatment of subtrochanteric fractures. [133] (10.1016/j.injury.2017.08.028)
  • [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)
  • [L2] There is no single unifying scale in widespread use for proximal femoral fracture patients. [150] (10.1016/j.injury.2010.12.016)
  • [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)
  • [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] 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)
  • [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] Radiological evaluation of the full femur length and avoiding hammering are recommended to prevent complications. [200] (10.1007/s00402-008-0736-1)
  • [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)
  • [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] 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)

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2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.