Traditionally there have been multiple options for the treatment of subtrochanteric fractures ranging from conventional plate fixation, dynamic condylar or blade plating, intramedullary nailing with various locking options, and more recently locked plating. External fixation is rather seldom in use in this skeletal region. When making a decision as to which operative option to use, it is essential to consider the nature of the injury, the specific fracture pattern as well as the general health condition of the patient.

Open reduction and internal fixation has the advantage of enabling direct anatomical reduction of the fracture fragments. We nonetheless mean that anatomical reduction is not a prerequisite for uneventful healing of these fractures. Disadvantages of open reduction and internal fixation are the more invasive procedure with larger devascularisation of fracture fragments, the longer operating time, the higher infection rates, the later weight bearing, and the higher risk of re-fracture after plate removal.

Advances in the technology of intramedullary devices have expanded the indications for intramedullary nailing to nearly all subtrochanteric fracture patterns. Nailing has become the gold standard of treatment. Intramedullary nailing has the benefits of being a minimally invasive procedure preserving extra-cortical blood supply, with less blood loss and a shorter operation time. In addition, as a load sharing implant, the nail-bone construct has biomechanically shown to be very strong in unstable fracture patterns [6], enabling earlier patient mobilisation and a short hospital stay. The disadvantages consist of a difficult closed reduction due to important muscular forces displacing the main fracture fragments. A prerequisite to achieve the benefits of the intramedullary devices is the expertise of the performing surgeon with the procedure and the implant [7–9].

Subtrochanteric fractures tend to displace due to the muscle forces working on the fracture fragments. In the subtrochanteric region, there is a large intramedullary canal. Unlike in nailing of shaft fractures, the fracture fragments will not automatically reduce by nail insertion. It is essential that correct alignment, length and rotation of the main fracture segments are obtained before the nailing procedure is started. General anaesthesia and the use of muscle relaxants are beneficial to facilitate reduction. Displacing forces will also have to be neutralized during nail insertion. Secondary reduction of displaced fragments is very difficult, may even be impossible once the nail has been inserted. When the proximal and distal fragments are fixed in a non-reduced position with minimal or no bone contact in the fracture area, there will be a high risk of delayed union, non-union or implant failure.

The patient is placed in either a supine or lateral position depending on the surgeon’s choice. The operating table should enable skeletal traction to assist with reduction. An image intensifier is required to assess position of the fracture fragments in two planes. In most cases, correct alignment, length and rotation can be achieved by closed means using skeletal traction (Fig. 18.4a–h). If this is not the case, the nailing procedure should not be started. Reduction then needs the use of reduction aids such a ball spiked pusher, a bone hook or an additional Schanz’ screw connected to a T-handle as a joystick. The Schanz’ screw is placed proximal or distal to the fracture through one cortex only, depending on the fragment which is the most difficult to reduce. Proximally, the Schanz’ screw can be inserted from lateral in the lateral cortex just below the greater trochanter, or from anterior medial to the trajectory of the nail in the lesser trochanteric region. Distally, the Schanz’ screw is positioned from lateral and can be used for pushing or pulling, for rotation or for elevation of the distal segment. Experience is required to decide whether and how often these leverage manoeuvres are appropriate, especially in osteoporotic bone. Too aggressive manipulation can produce secondary soft tissue damage or iatrogenic fractures. When correct alignment cannot be achieved with these percutaneous manoeuvres, limited open fracture reduction is performed. The utilisation of a pointed reduction clamp with or without an additional cerclage wire can be helpful (Fig. 18.5a–c). Carefully applied cerclage wires secure proper reduction and do not increase the postoperative complication rate [10, 11]. They are especially helpful in long oblique and spiral fractures (Fig. 18.6a–l).

The correct entry point for intramedullary nailing of a subtrochanteric fracture is crucial to a smooth and successful operation. The surgeon should spend time to ensure accuracy of this step to obtain correct alignment, to avoid loss of reduction during nail insertion and to protect patients from possible bone healing complications. Despite the fracture being reduced to an anatomical position, the result of the stabilization procedure can be compromised by the insertion of the nail through a false entry point. The ideal location is depending on the anatomy of the femur and on the specific implant used. There is no singular unique ideal entry point for intramedullary nailing despite using one common implant because the anatomy of the trochanteric region varies significantly from individual to individual. It is therefore vital to take into account the shape of the femur including anteversion and greater trochanter offset. Various intramedullary nails with different angles between the proximal and shaft section are on the market. They vary between 0° and 12°. As a consequence, the ideal entry portal will be different for these nails. A more medial entry point will require the dissection of more soft tissues. In doing so, there is a higher risk of damaging structures including the insertion sites of important abductor muscles (gluteus medius and minimus muscles), the short external rotator muscles (piriformis, obturator internus and gemelli) inserting into the trochanteric fossa; and the deep branch of the medial femoral circumflex artery. Patients may complain of postoperative weakness in abductive strength of the hip joint related to disruption of the gluteus medius and minimus muscle insertion [12].

Mechanical stability of the nail in the proximal fragment is important, particularly in osteoporotic bone. In high subtrochanteric and inter-trochanteric fractures, when fracture lines come close to the greater trochanter, a more medial entry point might contribute to added stability to the nail in the proximal fragment. In type II injuries of the Russell-Taylor classification, where the proximal fracture reaches the piriformis fossa, then a more lateral entry point might be beneficial avoiding the entry point being at the fracture level and at an area, which is critical for bone healing because of its tension stress [3, 13, 14].

It should be kept in mind that the more medial the entry point is chosen on the anteroposterior view, the more anterior the entry point will have to be in the lateral view. The reason for this is that the neck of femur is anteverted, its central axis being directed towards medially and anteriorly. When the femoral neck screw should be located in the centre of the femoral neck, the nail, through which this femoral neck screw is inserted, should be situated more anteriorly, the more medial it is placed.

Also the neck-shaft angle of the broken femur must be analysed and a nail chosen, which fits best to it. The axis of the femoral neck is defined by a line which unites the centre of the femoral head with a middle point found between the proximal lateral and distal medial cortex of the neck [15]. The femoral shaft axis is identified by uniting the centre of the intramedullary canal on its anteroposterior radiograph at two levels: the narrowest point of the isthmus and 8 cm more proximal. Templating the contralateral hip for the implant is technically easier and more reliable as generally the contralateral anatomy does not differ significantly. To be well prepared, anteroposterior and lateral radiographs of the contralateral side can therefore be considered. Templating enables defining the right nail length and size as well as the exact entry point and position of the nail (Fig. 18.7a–k). The template has to be adapted for recon nail locking implants as they have two femoral head locking screws.

The decision which implant needs to be taken asks for careful evaluation and will be based on the three-dimensional shape of the femur. The ultimate goal is to achieve an ideal fit of the shaft fragment of the implant and a femoral neck screw or blade which is in perfect alignment with the femoral neck [16–20]. This implies that the treating surgeon ideally has a range of different cephalomedullary or recon nails available in his or her hospital.

There are no limitations for intramedullary nailing of any type of isolated subtrochanteric fracture in a healthy adult with a maximum of Gustilo Grade III A soft tissue damage. Lee et al. showed equal outcomes for biologic plating using a Dynamic Condylar Screw as compared to intramedullary nailing in young healthy adults with good bone quality, but intramedullary nailing required a sophisticated screw positioning in the head and neck fragment [21]. In fractures with comminution and/or instability in the medial cortex, there is a higher risk of implant failure after plate osteosynthesis [22].

Limitations are confined when the following considerations apply (Table 18.1).