M.E.Müller: Atlas: Fracture 31-B3

Femur, Proximal, extra-articular fracture, neck, subcapital,
displaced, non-impacted 11,36% of the total
18,79% of the femur
26,85% of the segment

3139 fractures
50,9% group
24%M, 76%F

2551 fractures
41,4% group
18%M, 82%F

476 fractures
7,7% group
11%M, 89%F

Moderate displacement in varus and external rotation Moderate displacement with vertical translation and external rotation Marked displacement +Q

These are subcapital fractures with moderate displacement in varus and external rotation. The fracture line originates proximally allways at the border of the articular cartilage and occur through the area where the main blood supply to the femoral head penetrates. They are, therefore, high risk fractures. Ref. Manual of Internal Fixation :
260 - 265. 522 - 527.
Surgeon. RO, JG.

Reduction and internal fixation must be attempted in young patients. The choice of the implant will depend on the size of the femoral head and the degree of osteoporosis. The 130º angled blade-plate, with or without the addition of a cancellous screw, is still considered by us the ideal implant.

The DHS, currently considered the universal implant, should not be used in small femoral heads since, because of its volume, it destroys excessive bone stock. Moreover, the insertion of the sliding screw will rotate the femoral head unless it has been previously transfixed

with Kirschner wires. The cancellous screws, either cannulated or not, are more proportionate implants for these fractures. When using blade-plates or the DHS, 2 to 4 cortices will suffice to fix the plate to the diaphysis.

In some cases, when compromise of the blood suply of the femoral head is suspected, the addition of a valgus osteotomy may be useful to stabilize the fracture because it horizontalizes the fracture line. We have reported a technique that only internally fixes the osteotomy without penetrating the femoral head in cases of vascular risk (Orozco).

preoperative postoperative + 1 year

preoperative + 6 weeks + 1 year

preoperative preoperative

0 months 0 months

These are subcapital fractures with varus displacement. The subgroup .2 includes fractures with a vertical fracture line. The subgroup .3 involves subgroups .1 and .2 with marked displacement, either in varus or vertical translation. The vascular risks of the previous subgroup are, therefore, increased. Ref. Manual of Internal Fixation :
270 - 275. 522 - 527.
Surgeon. MV, RO, MS.

Anatomic reduction and stable internal fixation is mandatory in young patients. In patients between 65 and 75 years of age, total joint replacement is preferable while partial (unipolar) replacement is kept in reserve for patients with a biologic age over 80 years or with associated serious pathologies (oncologic, Alzheimer, Parkinsonism, alcoholism, etc.).

The 31-B3.2 case demonstrates adequate indication for a DHS because of the great size of the femoral head. In these large heads, the addition of a proximal cancellous screw for torsional stability is also possible. The dynamic screw should be placed below the hard core of the femoral head but, in general, with good quality trabecular bone, the DHS threads get a better hold in the center of the hard core. When the screw threads are placed below the hard core, its function is that of support just as it would be if a 130º angled blade-plate had been used.

preoperative postoperative + 1 year

preoperative preoperative 0 months

0 months + 8 months + 8 months

preoperative postoperative

preoperative postoperative

preoperative + 5 months + 5 months




						Femur, Proximal, extra-articular fracture, neck, subcapital, displaced, non-impacted	11,36% of the total 18,79% of the femur 26,85% of the segment






These are subcapital fractures with moderate displacement in varus and external rotation. The fracture line originates proximally allways at the border of the articular cartilage and occur through the area where the main blood supply to the femoral head penetrates. They are, therefore, high risk fractures.		Ref. Manual of Internal Fixation : 260 - 265. 522 - 527. Surgeon. RO, JG.

Reduction and internal fixation must be attempted in young patients. The choice of the implant will depend on the size of the femoral head and the degree of osteoporosis. The 130º angled blade-plate, with or without the addition of a cancellous screw, is still considered by us the ideal implant. The DHS, currently considered the universal implant, should not be used in small femoral heads since, because of its volume, it destroys excessive bone stock. Moreover, the insertion of the sliding screw will rotate the femoral head unless it has been previously transfixed	with Kirschner wires. The cancellous screws, either cannulated or not, are more proportionate implants for these fractures. When using blade-plates or the DHS, 2 to 4 cortices will suffice to fix the plate to the diaphysis. In some cases, when compromise of the blood suply of the femoral head is suspected, the addition of a valgus osteotomy may be useful to stabilize the fracture because it horizontalizes the fracture line. We have reported a technique that only internally fixes the osteotomy without penetrating the femoral head in cases of vascular risk (Orozco).






These are subcapital fractures with varus displacement. The subgroup .2 includes fractures with a vertical fracture line. The subgroup .3 involves subgroups .1 and .2 with marked displacement, either in varus or vertical translation. The vascular risks of the previous subgroup are, therefore, increased.		Ref. Manual of Internal Fixation : 270 - 275. 522 - 527. Surgeon. MV, RO, MS.

Anatomic reduction and stable internal fixation is mandatory in young patients. In patients between 65 and 75 years of age, total joint replacement is preferable while partial (unipolar) replacement is kept in reserve for patients with a biologic age over 80 years or with associated serious pathologies (oncologic, Alzheimer, Parkinsonism, alcoholism, etc.).	The 31-B3.2 case demonstrates adequate indication for a DHS because of the great size of the femoral head. In these large heads, the addition of a proximal cancellous screw for torsional stability is also possible. The dynamic screw should be placed below the hard core of the femoral head but, in general, with good quality trabecular bone, the DHS threads get a better hold in the center of the hard core. When the screw threads are placed below the hard core, its function is that of support just as it would be if a 130º angled blade-plate had been used.