Diaphyseal Femoral Fracture After Long Unlocked Cephalomedullary Nailing of an Intertrochanteric Fracture of the Femur: A Case Report and Review of the Literature.

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With the geriatric population growing in the United States, there has been a substantial increase in the incidence of hip fractures. Over 280,000 hip fractures, including femoral neck and intertrochanteric varieties, are evaluated each year in the United States1,2. The primary goals of surgical treatment of intertrochanteric hip fractures are stable fixation and immediate weight-bearing. The biomechanics of intertrochanteric hip fractures have been clarified in the literature, and stable fractures are those in which posteromedial comminution is absent. The lack of comminution allows for compressing of the two fracture fragments with implants, conferring stability to the construct3-5. The overwhelming majority of stable intertrochanteric hip fractures are treated with one of two designs: a sliding hip screw with a side plate or a cephalomedullary nail6. Various nail lengths are available, including short, intermediate, and long. Certain fracture patterns necessitate the use of a long nail, while stable intertrochanteric hip fractures can be treated successfully with all three lengths, depending on surgeon preference. Recently, in response to reports of fractures occurring at the end of short intramedullary nails7-17, opinion has shifted toward the use of long cephalomedullary nails in an unlocked fashion for stable intertrochanteric hip fractures. The rationale is that intertrochanteric fractures categorized as stable only require fixation across the fracture site to convert shear force into compressive force. As there is no rotational instability distal to the fracture, the helical blade or screw through the intramedullary nail crossing the fracture site is sufficient when coupled with the intact or reduced posteromedial cortex to act as a buttress against rotational instability, negating the need for distal interlocking screws18. Moreover, these fractures are usually seen in the elderly with osteopenic …