Displaced Subtrochanteric Hip Fractures with Fixed-angle Plating
Subtrochanteric fractures are common fractures that can be complicated by the presence of fracture comminution, proximal or distal extension, and poor bone quality. A complete understanding of the biomechanics is needed to guide successful treatment. Emphasis should be placed on proper implant selection and reduction to minimize the risk of construct failure. Although cephalomedullary devices can be used to effectively treat stable fracture patterns, plates merit consideration as an alternative. Outcome optimization depends on properly managing the watershed vascularity, deforming forces, and proclivity for varus malreduction. The lateral decubitus position provides an excellent platform for plate stabilization. In contrast to the supine position, the lateral decubitus position provides gravity-assisted retraction, allows manipulation of coronal and sagittal deforming forces, and improves visualization. We utilize an extensile lateral approach to expose the trochanteric and subtrochanteric segments. Generally, we reduce the subtrochanteric segment first and employ lag screws for stabilization. However, if the fracture is not suitable for lag screw stabilization, a small unicortical plate would be used to maintain reduction. For definitive stabilization, a blade plate or dynamic condylar screw plate has been used in the past; however, our preference is for a proximal femoral locking plate. Our experience indicates that the use of the lateral decubitus position for plate stabilization of subtrochanteric fractures can produce an anatomic reduction with restoration of the medial buttress.