Intertrochanteric fracture with distal extension: When is the short proximal femoral nail antirotation too short?

• Published in: Injury Vol. 52; no. 4; pp. 926 - 932
• Main Authors: Lee, Wu Chean, Chou, Siaw Meng, Tan, Chee Wei, Chng, Li Sing, Yam, Gui Jie Michael, Chua, Tjun Huat Ivan
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier Ltd 01.04.2021
• Subjects: Distal extension; Finite element analysis; Intertrochanteric fracture; Long nail; Short nail; Long nail; Finite element analysis; Distal extension; Short nail; Intertrochanteric fracture
• ISSN: 0020-1383; 1879-0267
• DOI: 10.1016/j.injury.2020.10.059

•Multifragmentary intertrochanteric femur fracture may have a lesser trochanter (LT) fragment which extends distally and affects stability.•The exact length of distal extension of the LT fragment that may be tolerated by a short proximal femoral nail antirotation (PFNA) is not known.•Using finite element analysis, we determined that a long PFNA should be considered if the LT fragment extends 4cm below the base of LT. The lesser trochanter (LT) fragment in the multifragmentary intertrochanteric femur fracture (AO 31A2.2) may extend distally. If the fragment extends too distally, fixation with a short proximal femoral nail antirotation (PFNA-II) device may not be sufficient. The exact length of distal extension that can be tolerated by the short PFNA-II is not known, therefore it is our objective to determine it. A finite element analysis was performed on AO 31A2.2 fracture fixed with a 200mm length size 10 PFNA-II. The construct was loaded vertically to clinical failure of 10mm displacement. This was repeated with the size of the LT fragment increasing distally at intervals, up to 120mm from the base of the LT. The process was also repeated with the bone properties substituted with osteoporotic properties. The stiffness, maximum vertical reaction force, and the plastic deformation area were investigated. In both non-osteoporotic and osteoporotic model, the stiffness and the maximum vertical reaction force of the construct dropped significantly when the LT fragment is larger than 40mm. Beyond 40mm of LT fragment size, there was a rapid increase in the area of plastic deformation of the cortical bone distal to the intertrochanteric fracture, signifying structural failure of the construct. A long PFNA-II should be considered when fixing a multifragmentary intertrochanteric fracture if the LT fragment extends 40mm distal to the distal base of the LT as the construct fails rapidly upon uniaxial load to failure. Clinically, this threshold may be smaller to account for the multi-axial and dynamic stresses.