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Original Article

A Comparative Study Of Surgical Management Of Subtrochanteric
Fractures In Children

Sahu RL1, Gupta P2

Abstract:
Introduction: Subtrochateric femoral fracture is a major cause of morbidity and mortality in patients with
lower extremity injuries. There have been no studies that have specifically looked at the management of sub-
trochanteric femoral fractures in skeletally immature adolescents. It was the purpose of this study to inves-
tigate the treatment of this injury in this unique patient population. Methods: This study was conducted in
the Department of Orthopaedic surgery in M. M. Medical College from July 2006 to November 2008.
Thirty-four patients were recruited from Emergency and out patient department having closed sub-
trochanteric femoral fracture. All patients were operated under general or spinal anesthesia. All patients were
followed for twelve months. Results: All children achieved union in a mean time of 10 weeks (range from
6 - 16 weeks) depending on the type of long bone. Full weight bearing was possible in a mean time of 8.8
weeks. Mean duration of hospital stay was 9.8 days. The mean follow-up period was 28 months (17-48
months). Complications were recorded in 4 (11.77%) patients and included: two entry site skin irritations,
one protrusion of the wires through the skin and one delayed union. The results were excellent in 97.06%
and good in 2.97% patients. Conclusions: We conclude that Rigid and close interlocking nailing between
the age of 9-16 years offered excellent fracture stability allowing early mobilization (early weight bearing)
and joint motion in comparisons to the other groups and between the age of 6-8 years titanium elastic nail
and bridging plate offered excellent result.

Key wards: Subtrochanter, Fracture, Pediatric, Intramedullary.

Introduction 
Femoral shaft fractures, including subtochanteric
and supracondylar fractures, represent approximate-
ly 1.6% of all bony injuries in children 

1
. Paediatric

subtrochanteric femoral fractures are rare and have
received limited attention in the literature 

2; 3
. The

subtrochanteric femoral fracture in children is a spe-
cial type which occurs 1 to 2 cm below the lesser
trochanter. The proximal fragment tends to flex (ilio-
psoas), abduct (abductor group) and rotate external-
ly (short external rotators) 

4
. The treatment of sub-

trochanteric femoral fractures in children is contro-
versial. Different treatment options have been used:
skin traction, 90/90 skeletal traction, immediate
spica casting, cast bracing, internal fixation and
external fixation. Treatment choices are influenced
by the child’s age and size and whether the femoral
fracture is an isolated injury or part of a polytrauma.

Economic concerns, the family’s ability to care for a
child with a spica cast or external fixator, and the
advantages and disadvantages of any operative pro-
cedure are also important factors 

1
. Indications for

operative treatment include multiple trauma, head
injury, open fracture, floating knee, vascular or neu-
rological injuries, failure of conservative treatment,
older child or adolescent and social
indications 

5 ,6, 7, 8
. Methods of internal fixation

include; intramedullary nails, compression plating
and external fixator 

5, 7, 9, 10
.

Methods:
This prospective study was carried out at
Orthopaedics department of M.M. Medical college
from July 2006 to November 2008. It was approved
by institutional medical ethics committee. A total of
34 patients with subtrochanteric femur fracture

Bangladesh Journal of Medical Science Vol. 11 No. 03 July’12

178

1. Dr Ramji Lal Sahu MS, Associate Professor, Department of Orthopedics, SMS and RI, Sharda
University., Greater Noida, U. P.,India

2. Dr Pratiksha gupta MD, Associate professor, PGIMSR,ESIC, Basaidarapur, New-Delhi, India
Corresponds to: Dr Ramji Lal Sahu, House number 11284 Laj building,No 1, doriwalan new rohtak
road,Karol bagh New, Email drrlsahu@gmail.com



admitted to our institute were included in present
study. A written informed consent was obtained from
all the patients; they were explained about treatment
plan, cost of operation, and hospital stay after sur-
gery, and complications of anaesthesia. They were
followed up after surgery, were clinically and radio-
logically assessed for fracture healing, joint move-
ments and implant failure. According to the criteria
the results are graded as excellent when the fractures
unites within 16 weeks without any complication,
good when union occur within 24 weeks with treat-
able complications like superfi cial infection and
knee stiffness and poor when union occur before or
after 24 weeks with one or more permanent compli-
cations like infection (osteomyelitis), implant fail-
ure, non-union, limb shortening and permanent knee
stiffness. Delayed union was recorded when the
fracture united between three to six months while
nonunion was noted when union had not occurred
after eight months of treatment Follow-up was done.
Patients with closed subtrochanteric femoral fracture
with age between 6-16 years and presented within a
week of the injury and did not have any previous
surgical treatment for the fracture was included in
the study. Malnourished patients and those with
open fractures, pathological fractures and fracture
nonunion were excluded from the study.
Examination of patients was done thoroughly at the
time of admission to exclude other injuries. Patients
were included when part of the fracture was within
the inferior aspect of the lesser trochanter and 5 cm
below it, Patients underwent skin traction till their
operation. Anteroposterior and lateral radiographs
were obtained from the hip to the knee. Fractures
were classified according to Seinsheimer classifica-
tion ( In type I there were 6 patients, in type II a-10
patients, in type II b- 8 patients, in type II c- 4
patients, in type III a-3 patients, in type III b-2
patients, in type IV-1 patient and in type V- 0 patient)

(Table II). In all the patients surgical management of
subtrochater of the femur was performed on seventh
to fourteenth day after the injury. In patients who
were not fit for surgery due to associated injuries to
vital organs, were haemodynamically unstable or
due to active infection at injury site, or were pyrexi-
al delayed surgical management was performed
when their over-all condition improved. All patients
were operated under general or spinal anesthesia.
First generation cephalosporin was administered at
the time of induction of anesthesia as prophylaxis.
Patients were laid supine on the fracture table with
traction pin in condyles of fractured femur. The frac-
ture was reduced by traction and manipulation under
image intensifi cation.  After preparing the femur in
standard manner, internal fixation with implants
were done. Rehabilitation such as touch down
weight bearing was started on 2nd post-operative
day and sutures were removed on 14th post-opera-
tive day. These patients were assessed clinically and
radio logically for union timing at nine months fol-
lowing surgery. Patients were assessed for delayed
union (more than 4-6 weeks postoperative) and non
union (nine months following surgery). Stastical
analysis was limited to calculation of percentage of
patients who had unions, malunions, delayed unions,

A Comparative Study Of Surgical Management Of Subtrochanteric Fractures In Children

179

Table I. Age and sex variations in study group (n=34) 
Age 
(years)        

Male    R        L Female    R     L Total 

6-8 
9-12 
13-16 

4 
6 
12 

3 
3 
7 

 1 
3 
5 

2 
4 
6 

1 
2 
4 

1 
2 
2 

6 
10 
18 

Total 22       13       9 12            7       5 34 
Table I. Age and sex variations in study group (n=34) 
Age 
(years)        

Male    R        L Female    R     L Total 

6-8 
9-12 
13-16 

4 
6 
12 

3 
3 
7 

 1 
3 
5 

2 
4 
6 

1 
2 
4 

1 
2 
2 

6 
10 
18 

Total 22       13       9 12            7       5 34 

Implant 
Group A Group 

B 
Group 

C 
Group 

D 
Group 

E 
Group 

F 
Group 

G 

 
Age 
(years)        
 ESIN PFN ILN ENDERS DHS DCS LCDCP 
6-8 
9-12 
13-16 

1 
2 
2 

 

0 
2 
3 

0 
2 
3 

1 
2 
2 
 

1 
2 
3 

1 
1 
3 

1 
2 
3 

Total 5 5 5 4 5 5 5 

Table III: Implant used in subtrochanteric fractures (n=34), Elastic Stable Intra-medullary Nailing 
(ESIN),Proximal femoral nail (PFN), Interlocking nail (ILN), Dynamic hip screw (DHS), Dinamic 
condylar screw (DCS),Low  contact dynamic compression screw (LCDCP).



or non unions and Excellent, Good, and poor out-
comes (Table IV).

Ethical and legal procedure
The protocol was approved by an ethics committee
and thus meets the standards of the Declaration of
Helsinki in its revised version of 1975 and amend-
ments made to it in 1983, 1989 and 1996 (JAMA
1997; 277:925–6).

Results:
There were 22 (64.70%) male and 12 (35.29%)
female patients (Table I). The mechanism of injury
was road traffic accident in 80% of patients, fall
from height 10% and industrial accident was 10%.
Injury to left lower limb was seen in 41.18% and
right lower limb in 58.82% of patients. The average
hospital stay was 18 days. In group A, patients were
having fracture according to seinsheimer classifica-
tion, type I (6 fractures), type II A (10 fractures),
type IIB (8 fractures), type IIC (4 fractures), type
IIIA (3 fractures), type IIIB (2 fractures), type IV (1
fracture) and type V (0 fracture). These patients were
divided into seven groups. Patients in A group were
fixed with Elastic stable intramedullary nailing,
group B with proximal femoral nailing, group C
with interlocking nailing, group D with Enders nail-
ing, group E with dynamic hip screws, group F with
dynamic condylar screws and group G with low-
contact dynamic compression plates (Table III)
(FigureI-IV). In group A, complication of titaneum
elastic nails was skin irritation at the nail entry site
and in group D there was protrusions of the wires
through the skin and malunion. In group B,C, E,F
and G found no significant  complication.  Flexible
nails are not suitable for proximal fractures and can
withstand only 40% of the body weight and recom-
mend starting of weight bearing to be delayed until

the appearance of early callus formation at three to
four weeks time following the fixation. In group B
and C, between the age of 9-16 years, Rigid and
close interlocking  nailing on the other hand offered
excellent fracture stability even in heavier adoles-
cents especially those with a comminuted fracture
pattern allowing early mobilization and joint motion
in comparisons to the other groups. We placed the
nails through the lateral aspect of the trochanter
between the apophysis and the tip of the trochanter
and avoid the piriformis fossa and the tip of the
trochanter. No patient developed any significant
complications such as alterations in the proximal
femoral anatomy or a vascular necrosis. Physical
therapy was started immediately if it was possible
because of related injuries. Post-operatively, mean
follow-up was 28 months (17 -48 months). No major
complications were observed in relation to surgery.
Complications as a result of the procedure were
recorded in 4(11.77%) patients and included one
patient (2.97%) were labeled as delayed union
because of obvious gap at the fracture site in subse-
quent radiographs (Table V). This was due to over
distraction of fracture during operation, and was
treated by bone graft, two entry site skin irritations;
one protrusion of the wires through the skin although
they had been buried during the procedure. This nail
required removal 2–3 weeks prior to the planned
date of removal. There was no instance of loss of
reduction, or nail migration during the post-opera-
tive period. No clinically significant deformities
were ob-served. There were no cases of nonunion or
mal-union. All patients achieved complete radi-
ographic healing at a mean of 10 weeks (range from
6 -16 weeks).In a subjective measure of outcome at
follow-up, 33(97.06%) of the patients were excellent
and 1 (2.97%) good; no patients or parents reported
their out-come as not satisfied (Table IV). At follow-
up all patients went on to osseous union and
regained a full range of movement after rehabilita-
tion. 

Discussion
Paediatric subtrochanteric femoral fractures present
a special unstable type which receives no special
attention in the literature 

2, 3
. Patient’s age may be the

most important single variable regarding pediatric
femoral fracture treatment. The treatment for chil-
dren between the ages 6-12 years is the most contro-
versial. Treatment options include traction followed
by hip spica cast, immediate spica casting, cast brac-
ing, internal fixation and external fixation

11
. Traction

Sahu RL, Gupta P

180

Out comes  No  Percentage  
Excellent  
Good  
Poor  

33 
1 
0 

97.06% 
2.97% 
0% 

Table IV: Out come of results of subtrochanteric
fractures (n=34)

Complications  No  

1 entry site skin irritations  
2 protrusions of the wires through the ski n  
3 delayed union  

2 
1 
1 

Table V: Complications (n=34)



followed by hip spica cast is the method preferred by
many surgeons for the treatment of children aged 6-
10 years 

8
. Aronson et al

12
studied 54 children who

had been treated in distal femoral 90/90 traction for
an average of 24 days before being placed in a 1 1/2
hip spica cast. At an average follow-up of 4.3 years,
all children were functionally normal and showed a
symmetric range of motion of hip and knee.
However, this method requires a relatively long hos-
pitalization and accurate control of fracture align-
ment with frequent radiographs and adjustment in
traction as needed. 90/90 skeletal traction with post
traction spica is not suitable in children weighing
more than 45 kg or in children older than 10 years of
age as it will be associated with an unacceptable
high incidence of femoral shortening and malrota-
tion 

13, 14
. Immediate spica casting, popularized by

Staheli and Sheridan 
15

is indicated for isolated
femoral shaft fractures in children under 6 years of
age. Infante et al 

16
expanded the indications for spica

casts to children up to age 10 and up to 50 kg. Its pri-
mary advantages are simplicity, low cost, and gener-
ally good results. Ferguson and Nicol 

17
conducted a

prospective study of early spica casting in children
less than 10 years of age. They found that age greater
than 7 years was a variable predictive of a higher
risk of failure of this technique to achieve satisfacto-
ry alignment. Martinez et al

18
reported excessive

shortening and angular deformity in 26 of 51
patients after immediate spica casting. Several stud-
ies have documented superior results with internal
fixation compared to non operative treatment 

19, 20, 21
.

According to Kregor et al 
5

the indications for oper-
ative fixation of paediatric femoral fractures were
presence of associated closed head injury and/or
multiple injuries, open fractures and failure of con-
servative treatment. We applied the indications to
include isolated paediatric subtrochanteric femoral
fractures as we believe that it is difficult to maintain
such fractures in an accepted position by non opera-
tive means. Methods of internal fixation of paedi-
atric subtrochanteric fractures include
intramedullary nails, compression plating and exter-
nal fixators 

5, 7, 9, 10
. Awareness of the advantages and

disadvantages of intramedullary nails, compression
plates and external fixator and the skill to apply each
method safely are requisites to the ideal management
of such fractures

4
. Good results were reported with

external fixators, but the rates of pin tract infection,
refracture and loss of reduction are high 

7, 11, 22, and 23.
We preferred not to use the external fixator in the
treatment of paediatric subtrochanteric femoral frac-
tures as there is no sufficient room for application of
the pins into the proximal femoral fragment.
Flexible intramedullary nailing is nowadays the
treatment of choice in paediatric femoral fractures.

A Comparative Study Of Surgical Management Of Subtrochanteric Fractures In Children

181

Figure 1: Pre and post operative radiograph of sub-
trochanter fracture of 5 years old child Treated with
titanium elastic nail.

Figure 2: Pre and post operative radiograph of sub-
trochanter fracture of 15 years old child
Treated with proximal femoral nail.

Figure 3: Pre and post operative radiograph of sub-
trochanter fracture of 16 years old child Treated with
95 0 dynamic condyler plate

Figure 4: Pre and post operative radiograph of sub-
trochanter fracture of 9 years old child Treated with
low contact dynamic compression plate.



Patients are able to partially weight bear early
because a rod is a load-sharing device, there is rapid
fracture healing and a low incidence of malunion
and non union 

6, 9, 19, 20, 24
. Disadvantages of

intramedullary nailing are lack of rotational control,
exposure to irradiation and backing out of implants
5. Fixation of subtrochanteric fractures in children
using intramedullary nails need special experience
and may be difficult to achieve. Plate fixation,
despite the negative report of Ziv and Rang 

25
, has

been shown to work well in the paediatric age group
5, 10, 14, 26, 27

. The disadvantage of plating are the need
for plate removal, poor cosmetic appearance of the
scar, blood loss associated with exposure and reduc-
tion of the fracture and reported higher degree of
overgrowth induced by the plates compared with
intramedullary fixation 

25, 28
. On the other hand,

patients treated with a plate require less assistance,
can walk with crutches within ten days postopera-
tively and return to school sooner than children treat-
ed in 90/90 skeletal traction 

21
. Ward et al 

27
reported

the use of a 4.5 mm AO dynamic compression plate
for the treatment of femoral shaft fractures in 25
children, 6 to 16 years of age, 22 of whom had asso-
ciated fractures or multisystem injury. The primary
indication for this technique was simplification of
nursing care and rehabilitation of children with an
associated head injury or polytrauma. The average
time to fracture union was 11 weeks. There were no
infections and no angular deformities. Kregor et al 5
reported on 12 patients who had 15 femoral fractures
treated with compression plating. All fractures
healed at an average of 8 weeks. The mean healing
time in our study was the same as that reported by
Kregor et al 

5
. Ziv and Rang 

25
reported three deep

infections among five children with head injuries
and with femoral shaft fractures. They believed that
infec-tions were related to the large number of tubes
attached to these patients and their decreased resist-
ance. Eren et al 

26
reported one case of osteo-

myelitis (2.1%) which occurred in a child with poly-
trauma. In our study, we encountered no deep infec-
tions. Many other reports documented no deep infec-
tion with plate fixation

5, 10, and 27
. Flynn et al reported

two deep infections (3%) with titanium elastic nails
9
.

Extensive dissection and periosteal stripping during
plate application may lead to overgrowth.
Overgrowth was not a significant problem in the
series of Kregor et al

5
, with an average increase in

length of 0.9 cm (ranging between 0.3 and 1.4 cm),
but Ward et al 

27
reported several patients

with considerable overgrowth (approximately 2.5
cm), and Hansen 

29
reported overgrowth of 2.5 cm in

a 12-year-old boy, suggesting that over- growth is
possible in children over 10 years of age. Eren et al

26
reported a series of 40 children aged 4 to 10 years

with significant lengthening on the operated side in
40% of patients, averaging 1.2 cm (range, 0.4-1.8
cm). In agreement with Kregor et al 

5
, overgrowth

was not a significant problem in our study.
Scanograms revealed overgrowth of the injured
femur with an average of 0.9 cm (range, 0.5 to 1.2
cm) in twelve patients (72.2%). Hardware failure is
a possible complication with any implant. In the
series of Ward et al 

27
, there was one broken plate

postoperatively in a boy who began full weight bear-
ing a few days postoperatively. Fyodorov et al 10
reported hardware failure in 2 of 23 femoral frac-
tures treated with dynamic compression plating.
Hardware failure occurred at 6 weeks. One was
treated with revision plating and the other with spica
casting; both fractures healed uneventfully. No other
complications were noted in their patients. In this
study, implant failure did not occur in any patient.
The need for hardware removal is controversial 

26, 27

and30
. Refracture is rare distal to the plate or through

screw holes and whether bone atrophy under the
plate is caused by stress shielding or by avascularity
of the cortex is unknown 

1 and 31
. In the series of Ward

et al 
27
, there was a refracture through a screw hole in

one of 15 patients who had the plate removed. They
do not recommend plate removal in asymptomatic
children. Eren et al 

26
also reported one patient (out

of 40 patients) who sustained a refracture 9 years
after plate removal. This occurred with a minor trau-
ma while he was playing basketball. On the other
hand, Bransby- Zachary

30 
recommended plate

removal because they had five late fractures 20 to 60
months after internal fixation. In this study, we
encountered no refracture or problems leaving the
implants in place during the follow-up period.

Conclusion:
Subtrochanteric femoral fractures in children can be
managed successfully in a variety of ways.
Ultimately, many factors play a role in the choice of
management, including the age and size of the child,
fracture pattern, associated injuries and surgeon and
family preferences. Operative management whether
intramedullary or extramedullary devices both give
better results because when operative treatment is
undertaken, it should be by experienced surgeons
using the technique with which they are most famil-
iar. Children between the ages of 6 and 8 years are
typically managed with TENs, but submuscular
bridge plating is also an option, particularly for com-

Sahu RL, Gupta P

182



minuted fractures. For children older than 8 years,
rigid antegrade nails using a lateral trochanteric
entry site have been successful and without reported
major complications, although more studies are
needed. In length-unstable fractures and in older,
heavier patients, trochanteric entry nailing or plating
is recommended. Traditional plating has excellent
results reported in the literature, but involves a larg-
er surgical approach and scar.

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A Comparative Study Of Surgical Management Of Subtrochanteric Fractures In Children

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Sahu RL, Gupta P

184


