Date: Wed, 2 Feb 2005 19:04:12 -0800

From: Barnaby Dedmond

Subject: Subtroch Fracture above retrograde nail with femoral neck nonunion

This is the case of a 73 yo male involved in MVC 18 months ago. Sustained ipsilateral femoral shaft and tibial plateau fractures. Underwent ORIF of tibial plateau and retrograde nail for femur fracture. Femoral neck fracture was apparently unrecognized at time of original injury and ultimately went on to nonunion. Fell 3 days ago sustaining fracture above his retrograde nail. He is currently in bony skeletal traction. Images (traction films and CT scan of entire femur) are attached. Medical history is significant for CAD and pacemaker and mild pulmonary dysfunction. Prior to fall, had obtained medical clearance for proposed 5 hour total hip arthroplasty for femoral neck nonunion. Any thoughts on how to proceed at this point? Type of implant? Need to remove retrograde nail? Fixation into head across neck nonunion? Your suggestions are appreciated.


Barnaby Dedmond, MD
University of South Carolina

Reply at: Orthopaedic Trauma Association forum

Date: Thu, 3 Feb 2005 14:37:35 EST

From: Tadabq

There appear to be four fractures of this femur at different levels in this 73 year old:

1.  femoral neck (old)
2.  oblique fx at lesser trochanter (no fixation)
3.  femur midshaft (retrograde nail)
4.  supracondylar distal femur (retrograde nail)

- in addition to the proximal tibia fracture.  

The femur shaft and supracondylar fracture are nicely aligned but only partly healed. The proximal femur fractures are not well aligned. The femoral neck fracture appears to be a nonunion. The lesser trochanter level fracture appears more acute. You may not be able to make him better.

Consider "osteotomy arthroplasty" with a THR after nail removal remove the femoral head (femoral neck fx treated)     skewer the trochanter segment with the femoral prosthesis consider long stem prosthesis to span the midshaft fracture too might have to supplement fixation of the supracondylar fracture with something. see: