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Proximal Femoral Shaft Fractures

- See:  - Subtrochanteric Fractures

- Discussion:
    - failure of nail to fill IM canal of either the proximal or distal fragment, may lead to postoperative instability;
    - tend to migrate into a varus deformity
    - requires abduction and traction for reduction;
    - tends to have an accentuated anterior bow;
    - internal rotation tends to improve this;
    - proximal 1/3 frx tend to angulate in varus w/ pt supine on table, & adjustments in pt positioning including switching to lateral position may be necessary;

- Indications for IM Nail in Proximal Frx:
    - consider nail if frx is 2.5 cm distal to lesser troch, or even more proximal fractures if the lesser trochanter is intact;
    - IM nails are well suited for proximal 1/3 shaft frx & subtrochanteric frx in which lesser trochanter is not comminuted off proximal femur;
    - if oblique bolt gains good purchase on medial cortex around lesser trochanter, excellent stability of the fracture is achieved;
    - femoral recon nails are required w/ comminution of the lesser troch;

- Reduction:
    - in subtrochanteric fractures, esp when the lesser trochanter is still attached to the proximal fragment, reduction can be achieved only be extreme
              abduction and external rotation of the leg;
    - consider placing a Steiman pin percutaneously into greater trochanter to act as a handle & thereby reduces frx much easier intraoperatively;
    - consider use of the Synthese trochanteric reduction clamp;

- Nail Insertion:
    - an accurate insertional point for the nail is critical;
    - Kuntscher among many, have advocated insertional point lateral to tip of greater trochanter to avoid risks of intra-capsular infection, AVN, and iatrogenic femoral neck fracture;
    - lateral insertion point however, may result in comminution of medial femoral cortex of proximal frag, esp in more proximal fractures;
    - lateral entry hole position (ie, in greater troch), will contribute to varus deformity;
          - this tends to be more common with the supine position;
    - note that in proximal fractures the proximal fragment is pulled into flexion, abduction, and external rotation;
          - common pitfall is to place the entry hole too far anterior, which will result in posterior comminution