Retrospective Study Of Proximal Femoral Nail In Management Of Unstable Trochanteric Fractures Of Femur

Prakriti Raj Kandel1

1 Department of Orthopaedics and Trauma Surgery, Universal College of Medical Sciences Teaching Hospital, Bhairahawa, Rupandehi, Nepal.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http: //creativecommons.org/licenses/by-nc/4.0/

Correspondence to: Prakriti Raj Kandel, Associate Professor, Department of Orthopaedics, Universal College of Medical Sciences &Teaching Hospital, Bhairahawa, Nepal.
Email: pratul22@gmail.com

Received: August 12, 2019
Revised: September 4, 2019
Accepted: September 7, 2019
Published online: December 28, 2019


INTRODUCTION: Proximal femoral nails (PFN) have been introduced relatively recent but have begun to compete the traditional Dynamic Hip Screw (DHS). The mechanical strength of the nail and less invasive procedure has made the procedure preferable. This is a short retrospective review of 48 cases operated in the last 3 years.

MATERIAL AND METHODS: A retrospective review of 48 cases operated in the last three years which have completed at least a year of follow up with us. All have been treated using a PFN for unstable intertrochanteric fractures of femur. A radiological assessment was made with serial X-rays.

RESULTS: The operating time was found to be short, less blood loss was seen during surgery and few early complications were noted. All cases were relatively free from long term complications.

CONCLUSION: PFN is a suitable implant for unstable intertrochanteric femoral fractures needing open reduction internal fixation. It has low per operative and post operative morbidity.

Key words: Intertrochanteric fractures; Proximal femur; PFN

© 2019 The Author(s). Published by ACT Publishing Group Ltd. All rights reserved.

Kandel PR. Retrospective Study Of Proximal Femoral Nail In Management Of Unstable Trochanteric Fractures Of Femur. International Journal of Orthopaedics 2019; 6(6): 1205-1210 Available from: URL: http://www.ghrnet.org/index.php/ijo/article/view/2652


Hip fracture is defined as a femoral fracture that occurs in the proximal end of the femur and leads to serious physical and cognitive difficulties[1-4]. The number of hip fractures and hip surgeries continues to increase, as osteoporosis of the bone and poor balance ability affect the growing worldwide elderly population[5-9]. It is commonly associated trivial trauma in older age patient; high energy trauma in younger age patient will result in fractures configuration[10].

Dynamic hip screw (DHS) with trochanteric buttress plate stabilizes the trochanteric fracture but at the cost of open procedure with significant blood loss[11]. Intramedullary nailing has become a popular method of stabilization of unstable trochanteric fractures in adults[12-13]. Biomechanically it is a better choice of implant for fixation of unstable fractures as nail itself gives support to posteromedial wall and resists excessive collapse[14-15].

The analysis is retrospective and follow up period is from 1year to 18 months.

Material and Method

This Retrospective study was conducted in Universal College of Medical Sciences and Teaching Hospital (UCMS&TH) from the records of patients underwent PFN fixation for trochanteric fracture of femur after taking permission from Institutional ethical committee over a period of three years from September 2012 to October 2015. Patients of both sexes with unstable intertrochanteric fracture with Boyd & Griffin classification Type III and IV where X- rays at least 1 year after surgery were available for review or the patient who could come back for review and American Society of Anesthesiologist (ASA) physical status I and II were included in this study whereas patients with stable intertrochanteric fractures, poly trauma, pathological fractures, sub trochanteric fractures of femur with ipsilateral femoral shaft or neck fractures, compound fracture, those whose detail records were incomplete and ASA more than II were excluded from the study. Serial X-rays were used to assess progress of union postoperatively.

After taking written informed consent from patient and fitness given for anesthesia, all patients were pre-medicated with tablet Lorazepam 1 mg a night before surgery and then Nil per Oral. All patients were operated upon under spinal or epidural anesthesia in a supine position on a radiolucent traction table. After sensitivity test, a single prophylactic anti-biotic Cefuroxime 1gram intravenously was given 15 minutes before skin incision.

The skin over the hip was properly painted and draped by placing the towel clips away to prevent superimpose on the fracture on subsequent imaging. The C-arm was also draped separately. A small incision 2 cm above the greater trochanter area was made and the tip of greater trochanter was opened using the femoral awl. Using the guide wire and the cannulated reamers the proximal femur was prepared to receive the relatively wide bore PFN. Having seated the nail in the proximal femur the compression and anti-rotation screws was introduced under fluoroscope guidance. The distal interlocking screws were placed through the jig provided with the instrumentation. The final positions were checked under the image intensifier. Fascia and subcutaneous tissues were sutured with absorbable suture and skin was closed with non-absorbable suture.

Duration of surgery was noted. Intra operative blood loss was measured. Hemoglobin level was checked on the first post-operative day. Epidural analgesia with mixture of 1mg preservative free morphine and 0.125% bupivacaine diluted with Normal Saline to make total volume of 10 mL was given for post-operative pain 12 hourly through Lumber Epidural Catheter by Anesthesia team till 3rd postoperative day. First dose of epidural analgesia was given at the time of skin closure. Injection Paracetamol 1 gram intravenously over half an hour was given for rescue analgesia on patient’s demand. Total days of hospital stay and any complication recorded in the patient’s file was noted. Post-operative radiography was reviewed for evaluation of fracture reduction and screw position. All patients were reviewed on 6th, 12th, 24th and 48th week. Both clinical and radiological evaluation was done. Functional outcome of the operated hip joint was evaluated by calculating Harris Hip Score during follow up visits. Pain, function, deformity, range of motion and limb length discrepancy were noted and scored accordingly.

Figure 1 Painting & draping and Pre Op x-ray 1.

Figure 1 Making entry point with bone awl and Pre op x-ray 2.

Figure 3 Entry point with bone awl. Figure 4 Guidewire insertion. Figure 5 Reamer insertion.

Figure 6 Nail insertion. Figure 7 Proximal screws guidewire insertion. Figure 8 Proximal screw insertion. Figure 9 Distal locking bolt screw.

Figure 10 Closure.

Figure 11 Post Op x-ray. Figure 12 6weeks follow up Figure 13 12wks follow-up.

Figure 14 6months follow. Figure 15 2yrs follow-up.


Records of 48 patients underwent PFN fixation for intertrochanteric fracture with 1 year follow up were studied, among which 30 patients were male and 18 were female with mean age 59.75 years ranging from 18 to 90 years. 26 fractures were in right side and 22 in left. The highest rate of fracture was seen in age group between 60-70 years, accounted for 27.08 %. The incidence of the injury was high among farmer which was 35.41% and housewife which was 33.3%. The records also showed 58.3% (28 cases) patients sustained fractures due to slippage on ground, 22.9% (11 cases) patients sustained fractures due to road traffic accident (RTA) and only 18.8% (9 cases) sustained fracture due to fall from height.

Mean operating time was 42.08 minutes ranging from 30-60 minutes. Mean per operative blood loss and reduction in post-operative hemoglobin as compared to baseline value was 114.58 mL and 1.56 gm/dL respectively. Suction drain output on average was 85.10 mL.

All patients were started on isometric and toe mobility exercise on 1st post-operative day. Sitting and knee ROM exercise was started on average 3rd post-operative day for majority of cases [40 cases, 8 cases delay ROM (6th -8th POD)]. Antibiotics were used on average for 7 days except for 7 cases (8-14 days). Systemic analgesics were given for 1-day post-operative (except 5 cases, 2 days). Oral analgesics was given on average for 6 days (4-14 days).

Non-weight bearing crutch walking was started on average 6th postoperative day (4th -13th post-operative day). Toe touch partial weigh bearing was started on average 5.5 weeks post-operative (3rd- 10th post-operative week). Full weight bearing was on average 10th post-operative week (6th - 13th post-operative week)

The mean duration of hospital stay was 6 days (5-9 days). Migration of screws in opposite directions (Z-effect and reverse Z-effect) was seen in 4 cases, shortening of less than 2cm in 2 cases. Cutout of the neck screw, wrong length or inability to apply the hip pin or the distal screws, breakage of the implant or fracture of the femoral shaft below the nail tip, AVN was not seen in any case. Stitch infection was seen in 2 patients, bed sore in 3 patients. There were no records of complications like joint infection, delayed union, deformity and stiffness in any of these patients.

The functional status measured according to Harris Hip Score system at 6th &12th postoperative month was 78 and 89 respectively.


The trochanteric femoral fracture is common in elderly patients; with societies growing continuously older, the incidence has increased markedly in recent years[16]. The successful treatment of intertrochanteric fractures depends on many factors: the age of the patient, the patient’s general health, the time from fracture to treatment, the adequacy of treatment, concurrent medical treatment, and the stability of fixation[17]. Intertrochanteric fracture is one of the most common fractures of the hip especially in the elderly with osteoporotic bones, usually due to low-energy trauma like simple falls[18]. Breaking of the proximal femur requires greater energy than that generated in a simple fall for most young adults[19].

In our study, the mean age of the patient was 59.75 years and the highest incidence (33.33%) of injury was seen among the age group of 60-70 years due to poor vision, osteoporotic bone quality, menopausal ladies, slippery mud and negligence by the family members as noted by history. Various studies also showed mean age more than 60 years[20-23]. Around 62% patients were male and 38% were female. Male preponderance might be due to more activity and mobility as compared to females who mostly confined to household activities in our country and thus are less prone to sustain an extra capsular fracture of hip.

Simmermacher in their study the mean duration of surgery (skin to skin) was 68.7 min (range 25-240 min)[24]. Pajarinan et al in their comparative study of DHS and PFN in proximal femoral fracture, the average time of surgery in DHS was 45 min (range 20-105 min) and in PFN was 55 min (35-200 min)[25]. Wang in their study, the average operating time was 90 min (Range 60-155 min)[26]. In our study mean duration of surgery was 42.08 minutes ranging from 30-60 minutes.

Mean intraoperative blood loss was 114.58 mL, comparable to studies carried out by Lindsokg et al, Weil et al & Pajarinen et al[27-29].

Our study did not show major post- operative complication except stitch infection in 2 cases and bed sore in 3 cases comparable to study conducted by Dominngo et al[30]. Migration of screws in opposite directions (Z-effect and reverse Z-effect) was seen in 4 cases, comparable to study conducted by Kakkar et al[31] and Herrera et al[32]. Shortening less than 2 cm was seen in 2 cases, comparable to study conducted by Herrera et al[32]. Cut-out of the neck screw, wrong length or inability to apply the hip pin or the distal screws, breakage of the implant or fracture of the femoral shaft below the nail tip, AVN was not seen in any case.

The functional status measured according to Harris Hip Score system at 6th and 12th postoperative month was 78 and 89 respectively, which were “Fair” at 6 months post operative and “Good” at the end of 12 months post operative, which are almost same to similar studies[30,33-35].


PFN is a suitable implant for unstable intertrochanteric femoral fractures needing open reduction internal fixation. It has low per operative and post operative morbidity with good post operative outcome.

Limitations of study

Small sample size.


1. Kannus P, Parkkari J, Siev¨anen H, Heinonen A, Vuori I, J¨arvinen M. Epidemiology of hip fractures. Bone. 1996 Jan; 18(1) (Suppl): 57S-63S. [PMID: 8717549]; [DOI: 10.1016/8756-3282(95)00381-9]

2. Wolinsky FD, Fitzgerald JF, Stump TE. The effect of hip fracture on mortality, hospitalization, and functional status: a prospective study. Am J Public Health. 1997 Mar; 87(3): 398-403. [PMID: 9096540]; [PMCID: PMC1381011].

3. Bentler SE, Liu L, Obrizan M, Cook EA, Wright KB, Geweke JF, Chrischilles EA, Pavlik CE, Wallace RB, Ohsfeldt RL, Jones MP, Rosenthal GE, Wolinsky FD. The aftermath of hip fracture: discharge placement, functional status change, and mortality. Am J Epidemiol. 2009 Nov 15; 170(10): 1290-9. Epub 2009 Oct 4. [PMID: 19808632]; [PMCID: PMC2781759]; [DOI: 10.1093/aje/kwp266]

4.  Neuman MD, Silber JH, Magaziner JS, Passarella MA, Mehta S, Werner RM. Survival and functional outcomes after hip fracture among nursing home residents. JAMA Intern Med. 2014 Aug; 174(8): 1273-80. [PMID: 25055155]; [PMCID: PMC4122620]; [DOI: 10.1001/jamainternmed.2014.2362]

5. Brauer CA, Coca-Perraillon M, Cutler DM, Rosen AB. Incidence and mortality of hip fractures in the United States. JAMA. 2009 Oct 14; 302(14): 1573-9. [PMID: 19826027]; [PMCID: PMC4410861]; [DOI: 10.1001/jama.2009.1462]

6. Dy CJ, McCollister KE, Lubarsky DA, Lane JM. An economic evaluation of a systems-based strategy to expedite surgical treatment of hip fractures. J Bone Joint Surg Am. 2011 Jul 20; 93(14): 1326-34. [PMID: 21792499]; [DOI: 10.2106/JBJS.I.01132]

7. Mariconda M, Costa GG, Cerbasi S, Recano P, Aitanti E, Gambacorta M, Misasi M. The determinants ofmortality andmorbidity during the year following fracture of the hip: a prospective study. Bone Joint J. 2015 Mar; 97-B(3): 383-90. [PMID: 25737523]; [DOI: 10.1302/0301-620X.97B3.34504]

8. Haentjens P, Magaziner J, Col´on-Emeric CS, Vanderschueren D, Milisen K, Velkeniers B, Boonen S. Meta-analysis: excess mortality after hip fracture among older women and men. Ann Intern Med. 2010 Mar 16; 152(6): 380-90. [PMID: 20231569]; [PMCID: PMC3010729]; [DOI: 10.7326/0003-4819-152-6-201003160-00008]

9. Moppett IK, Parker M, Griffiths R, Bowers T, White SM, Moran CG. NottinghamHip Fracture Score: longitudinal and multi-assessment. Br J Anaesth. 2012 Oct; 109(4): 546-50. Epub 2012 Jun 22. [PMID: 22728204]; [DOI: 10.1093/bja/aes187]

10. Terry canale S, James Beaty H. Campbell’s Textbook of Operative orthopaedics. 2008; 3(11): 3237

11. Babst R, Renner N, Biedermann M, Rosso R, Hebere M, Harder F, Regazzoni P. Clinical results using the trochanter stabilizing plate (TSP): the modular extension of the dynamic hip screw (DHS) for internal fixation of selected unstable intertrochanteric fractures. J Orthop Trauma 1998; 12: 392-399. [PMID: 9715446]

12. Anglen JO, Weinstein JN, American Board of Orthopaedic Surgery Research Committee. Nail or plate fixation of intertrochanteric hip fractures: changing pattern of practice. A review of the American Board of Orthopaedic Surgery Database. J Bone Joint Surg Am 2008; 90: 700-707. [PMID: 18381305]; [DOI: 10.2106/JBJS.G.00517]

13. Chou DT, Taylor AM, Boulton C, Moran CG. Reverse oblique intertrochanteric femoral fractures treated with the intramedullary hip screw (IMHS). Injury 2012; 43(6): 817-821. [PMID: 22040693]; [DOI: 10.1016/j.injury.2011.09.011]

14. Gadegone WM, Salphale YS. Proximal femoral nail - an analysis of 100 cases of proximal femoral fractures with an average follow up of 1 year. Int Orthop 2007; 31(3): 403-408. [PMCID:  PMC2267603]; [PMID: 16823585]; [DOI: 10.1007/s00264-006-0170-3]

15. Gadegone WM, Salphale YS. Short proximal femoral nail fixation for trochanteric fractures. J Orthop Surg (HongKong) 2010; 18: 39-44. [PMID: 20427832]; [DOI: 10.1177/230949901001800109]

16. Evans PJ, McGrory BJ. Fractures of the proximal femur. Hospital Physician 2002; 38: 30-38

17. Dean GL, David S, Jason HN. Osteoporotic per trochateric fractures; management and concurrent controversies. J Bone Jt Surg (Am) 2004; 72-B: 737-752

18. Dimon JH, Hughston JC. Unstable intertrochanteric fractures of the hip. J Bone Joint Surg Am. 1967; 49(3): 440-50. [PMID: 6022353]

19. Courtney AC, Wachtel EF, Myers ER, et al. Age-related reduction in the strength of the femur tested in a fall-loading configuration. J Bone Joint Surg Am. 1995 Mar; 77(3): 387-95. [PMID: 7890787]; [DOI: 10.2106/00004623-199503000-00008]

20. Christian Boldin, Franz J Seibert, Florian Fankhauser, Gerolf Peicha, Wolfgang Grechenig & Rudolf Szyszkowitz; The proximal femoral nail (PFN) - a minimal invasive treatment of unstable proximal femoral fractures: A prospective study of 55 patients with a follow-up of 15 months, Acta Orthopaedica Scandinavica. 2003; 74(1): 53-58. 

21. Bridle SH, Patel AD, Bircher M, Calvert PT. Fixation of intertrochanteric fractures of the femur. A randomised prospective comparison of the gamma nail and the dynamic hip screw. The Bone & Joint Journal April 1991; 73(2): 330-4. [PMID: 2005167]; [DOI: 10.1302/0301-620X.73B2.2005167].

22. Saudan M1, Lübbeke A, Sadowski C, Riand N, Stern R, Hoffmeyer P. Peritrochanteric fractures. Is there an advantage of intramedullary nail? J Orthop Trauma 2002; 16: 386- 393. [PMID: 12142826]

23. LeungWy, Tsang Wl. Conventional muscle-reflection approach vs mini-incision muscle-splitting approachin DHS fixation. J. Orthosur 2008; 16(2): 156-61. [PMID: 18725663]; [DOI: 10.1177/230949900801600205]

24. Simmermacher RK, Bosch AM, Van der Werken C. The AO/ASIF-proximal femoral nail (PFN): A new device for the treatment of unstable proximal femoral fractures. Injury. 1999; 30: 327-32. [PMID: 10505125]; [DOI: 10.1016/s0020-1383(99)00091-1]

25. Pajarinen J, Lindahl J, Michelsson O, Savolainen V, Hirvensalo E. Pertrochanteric femoral fractures treated with a dynamic hip screw or a proximal femoral nail. A randomised study comparing post-operative rehabilitation. J Bone Joint Surg Br. 2005; 87(1): 76-81. [PMID: 15686241]

26. Wang WY, Yang TF, Fang Y, Lei MM, Wang GL, Liu L. Treatment of subtrochanteric femoral fracture with long proximal femoral nail antirotation. Chin J Traumatol. 2010; 13(1): 37-41. [PMID: 20109366]

27. Lindskog DM, Baumgaertner MR. Unstable intertrochanteric hip fractures in the elderly. J Am Acad Orthop Surg 2004; 12: 179-190. [PMID: 15161171]

28. Weil YA, Gardner MJ, Mikhail G, Pierson G, Helfet DL, Lorich DG. Medial migration of intramedullary hip fixation devices: a biomechanical analysis. Arch Orthop Trauma Surg 2008; 128: 227-234 [PMID: 17985147]; [DOI: 10.1007/s00402-007-0497-2]

29. Pajarinen J, Lindahl J, Michelsson O, Savolainen V, Hirvensalo E. Pertrochanteric femoral fractures treated with a dynamic hip screw or a proximal femoral nail. J Bone Joint Surg [Br] 2005 Jan; 87(1): 76-81. [PMID: 15686241]; [DOI: 10.1302/0301-620X.87B1. 15249]

30. Domingo LJ, Cecilia D, Herrera A, Resines C. Resines Trochanteric fractures treated with a proximal femoral nail. International Orthopaedics (SICOT) 2001; 25: 298-301. [PMID:11794263] [PMCID:PMC3620810] [DOI:10.1007/s002640100275]

31. Rahul Kakkar S, Kumar AK. Singh Cephalomedullary nailing for proximal femoral fractures. International Orthopaedics (SICOT). 2005; 29: 21-24. [PMID: 15647914]; [PMCID: PMC3456955]; [DOI: 10.1007/s00264-004-0624-4]

32. Herrera A, Domingo LJ, Calvo A, Martinez A, Cuenca J. A comparative study of trochanteric fractures treated with the Gamma nail or the Proximal Femoral nail. Int Orthop 2002; 26: 365-369. [PMID: 12466870]; [PMCID: PMC3620972]; [DOI: 10.1007/s00264-002-0389-6]

33. Dipak S. Parmar, Milind M. Porecha, Shilpa L. Chudasama Long proximal femoral nails versus short proximal femoral nails for the management of proximal femoral fractures: a retrospective study of 124 patients. Eur J Orthop Surg Traumatol 2011; 21: 159-164. [DOI: 10.1007/s00590-010-0683-8]

34. Boblee James, Ram Prasath and Vijayakumaran Functional outcome of proximal femoral nailing in intertrochanteric fractures of the femur: A prospective study. International Journal of Orthopaedics Sciences 2017; 3(2): 513-518. [DOI: 10.22271/ortho.2017.v3.i2e.48]

35. Reddy KR, Dasaraiah CV, Shaik M,Ramesh Kumar CK. A study on the management of extracapsular trochanteric fractures by proximal femoral nail. J Orthop Allied Sci 2016; 4(2): 58-64. [DOI: 10.4103/2319-2585.193754]


  • There are currently no refbacks.

Creative Commons License
This work is licensed under a Creative Commons Attribution 3.0 License.