High-energy proximal femur fractures are difficult to treat. It can be challenging to obtain and maintain an acceptable reduction until bony union. High energy fractures of the proximal femur are evaluated and managed differently from elder hip fractures.1 The muscular envelope leads to predictable displacement patterns, which can be difficult to reduce. When closed or percutaneous reduction methods prove unsuccessful, proximal femur fractures benefit from an open reduction.
The proximal femur is eccentrically loaded and high stresses occur in this region.2,3 Implants must withstand these stresses and maintain their integrity during fracture healing. In addition, the reduction must be maintained until union is achieved. Although numerus implants have an indication for use in the proximal femur, none are considered the “gold standard” for fixation of all fractures. Both intramedullary nails and laterally based plates have been used to treat these fractures. In consideration of implant choice, each fracture must be assessed individually. Regardless of the implant used, reduction is critical and avoiding varus alignment is paramount.
The 95-degree angled blade plate is a dated, fixed angle device that has been used since its development in the 1960s. Despite a reliable history, it is no longer commonly used for acute fractures. Proximal femur locking plates can be inserted in a percutaneous manner, have multiple fixed angle screws, and are considered easier to use than blade plates. However, recent reports show high failure rates of proximal femur locking plates.4 The 95-degree angled blade plate continues to be a reliable implant for appropriately selected acute fractures. This video (see Video 1, Supplemental Digital Content 1, http://links.lww.com/JOT/A396) shows a technique of using a 95-degree angled blade plate to treat a high-energy proximal femur fracture.
The patient is positioned supine on a radiolucent table. A bump is placed under the hip and entire leg to aid in implant application and fluoroscopic imaging. A lateral, subvastus approach to the proximal femur is performed. The fracture is exposed and cleaned. Reduction of the fracture is obtained and provisionally held with clamps or wires that are strategically positioned remote to where the definitive fixation will be placed. Screws can also be inserted to aid in reduction/fixation. We highlight the importance of fracture reduction; malreduction should not be accepted. An anatomic reduction better allows the plate and the bone to share in load transmission.
Next, a guide wire for the cannulated chisel is inserted into the caudal half of the femoral head and neck. It is inserted at slightly less than 95 degrees (relative to the femoral shaft) and is centered on the lateral image. Accurate wire placement is important. The length of the blade is measured. The triple drill guide is used with either a 3.2- or 4.5-mm drill to prepare a pathway for the chisel. Next, the cannulated chisel is used to prepare a channel for the blade. It is important to advance the chisel slowly, with frequent “back-slaps” to prevent incarceration of the chisel. The slotted mallet is used to control rotation and maintain the chisel perpendicular to the femoral shaft axis.
When preparing for plate application, it is important to note that the implant shape is fixed; as such, it does not allow for adjustments once the blade has been inserted. For this and other reasons, the blade plate has been referred to as “unforgiving.” The blade of the implant must be positioned precisely perpendicular to the femoral shaft in the sagittal plane. A poorly positioned blade will introduce a malreduction of the fracture once the plate is centered on the femur distally.
Once preparation of the proximal femur is completed, the guide wire is removed and the plate is inserted. Frequent orthogonal fluoroscopic images are used to ensure precise positioning of the blade. The insertion jig is removed, and the terminal impactor is used to fully seat the plate.
In the coronal plane, for loadable fracture patterns, the blade can be placed at an angle slightly less than 95 degrees. Once the blade is inserted and the plate is clamped to the femur distally, a subtle valgus deformity is introduced. We have found this technique to facilitate union.
One of the advantages of this implant is the ability to load the fracture using the articulated tension device (ATD). This is a critical step of the procedure and should not be overlooked. A Verbrugge clamp is used to secure the plate to the femur, and a bicortical screw is placed to secure the ATD. The ATD is then used to compress the fracture. Plate screws are then placed in the shaft and the ATD is removed. The patient is limited to toe-touch weight bearing and progressed at 6 weeks. At the most recent follow-up, the patient had returned to all activities and was considered clinically and radiographically healed.
The 95-degree blade plate is a reliable device for the treatment of appropriately selected proximal femur fractures. The injury should have a “loadable fracture pattern”—after reduction, there should be sufficient contact between the fragments such that the construct can tolerate compression. Relative contraindications for use of a blade plate include fractures with comminution, subtrochanteric extension, unreconstructable medial calcar, and bone quality that cannot tolerate compression. For these fracture patterns, strong consideration should be given to an intramedullary device.
Intramedullary nails are the implants of choice for most surgeons in consideration of fractures about the proximal femur. Intramedullary nails offer mechanical advantages and surgeons' familiarity with insertion techniques.5 Although intramedullary implants offer several advantages, there are potential problems associated with them as well. Fractures near a nail insertion site can lead to fracture propagation, iatrogenic comminution, and instability after fixation. Malpositioned start points will negatively affect fracture stability and can lead to malreductions.5,6
High-energy proximal femur fractures are difficult to treat, and open reduction of the fracture is often necessary. Although both plates and nails can be acceptable treatment options, reduction of the fracture is critical because this restores anatomy, offloads the implant, and can aid in fracture healing.7 For appropriately selected injuries, high-energy proximal femur fractures can be reliably treated with the 95-degree angled blade plate.
1. Whitelaw GP, Segal D, Sanzone CF, et al. Unstable intertrochanteric/subtrochanteric fractures of the femur. Clin Orthop Relat Res. 1990;252:238–245.
2. Toridis TG. Stress analysis of the femur. J Biomech. 1969;2:163–174.
3. Rybicki EF, Simonen FA, Weis EB. On the mathematical analysis of stress in the human femur. J Biomech. 1972;5:203–215.
4. Collinge CA, Hymes R, Archdeacon M, et al. Unstable proximal femur fractures treated with proximal femoral locking plates: a retrospective, multicenter study of 111 cases. J Orthop Trauma. 2016;30:489–495.
5. Johnson KD, Tencer AF, Sherman MC. Biomechanical factors affecting fracture stability and femoral bursting in closed intramedullary nailing of femoral shaft fractures, with illustrative case presentations. J Orthop Trauma. 1987;1:1–11.
6. Bazylewicz DB, Egol KA, Koval KJ. Cortical encroachment after cephalomedullary nailing of the proximal femur: evaluation of a more anatomic radius of curvature. J Orthop Trauma. 2013;27:303–307.
7. Kinast C, Bolhofner BR, Mast JW, et al. Subtrochanteric fractures of the femur. Results of treatment with the 95 degrees condylar blade-plate. Clin Orthop Relat Res. 1989;238:122–130.