M.E.Müller: Atlas: Fracture 32-A3

Femur, Diaphysis,
simple fracture, transverse 3,87% of the total
6,40% of the femur
26,60% of the segment

260 fractures
12,4% group
54%M, 46%F

1576 fractures
75,0% group
69%M, 31%F

266 fractures
12,6% group
69%M, 31%F

Subtrochanteric section Middle section Distal section

These are simple fractures with a transverse fracture line, located at the middle third of the femoral diaphysis. The fracture line is considered transverse when the angle formed by the perpendicular to the diaphyseal axis and the fracture line is smaller than 30º. Ref. Manual of Internal Fixation:
232 - 251. 291 - 331. 546 - 547.
Surgeon. RO, RO.

The fractures located at the middle third are the most classical indication for the non-interlocked reamed intramedullary nailing technique. The length of the nail must be accurate: from the tip of the greater trochanter to the superior pole of the patella. The diameter of the nail, which should also be preoperatively planned, may vary depending on the resistence found during the reaming. The nail curvature must be aligned with the anatomical curvature of the diaphysis.

Internal fixation with a postero-laterally placed tension plate may be considered. In such case, interfragmentary application of at least one lag screw and autogenous

cancellous bone graft on the medial aspect of the femur (contralateral to the plate) are mandatory. If one of these two requirements is omitted, the plate will certainly suffer fatigue failure and breakage within 5 months. In linear fractures, loading of the plate is concentrated in one spot.

The bone graft is incorporated after 6 weeks and protects the plate by neutralizing the repeated flexion stresses. The plate, because of its fracture immobilization effect, inhibits the resorption of the bone graft and favors its incorporation and new bone mass formation within the healing callus framework.

preoperative + 7 months + 7 months

+ 7 months + 7 months

preoperative + 7 months + 7 months

+ 7 months

These are simple fractures with a transverse fracture line, located at the proximal and middle thirds of the femoral diaphysis. For pedagogical reasons of treatment discussion, we have placed the 32-A3.1 fractures following the 32-A3.2 subgroup. Ref. Manual of Internal Fixation:
291 - 331. 546 - 547.
Surgeon. RO, RO.

Since the arrival of the interlocking techniques, there is a general trend towards forcibly extending the indications of intramedullary nailing for fractures of the proximal femur. The two illustrated cases are intended to demonstrate the X-ray appareance of the healing process that occurs under those circumstances.

The more proximal is the fracture the greater it is the huge flexion load suffered by the femur because of its crozier shape and of the mechanical and functional axis pathways. Wolff´s law is fulfilled and the cortex under

tension suffers bone resorption that can take many months or years to regenerate. This phenomenon is especially worrisome in the C3 fracture group (as we will demonstrate later) and takes place equally in all of these fractures treated by nailing, whether interlocked or not.

Because of all of the above reasons, for subtrochanteric fractures we prefer to use the 95º condylar blade plate with a tension band effect since, in agreement with Pauwels´ columns theory, it turns the flexion loads into uniform compression throughout the fracture surface.

preoperative postoperative

+ 4 months + 11 months + 1 year

preoperative + 0 months + 6 months

+ 2 year + 2 year

preoperative postoperative + 6 months + 1 year

preoperative + 1 months + 1months

+ 1 year + 1 year




						Femur, Diaphysis, simple fracture, transverse	3,87% of the total 6,40% of the femur 26,60% of the segment






These are simple fractures with a transverse fracture line, located at the middle third of the femoral diaphysis. The fracture line is considered transverse when the angle formed by the perpendicular to the diaphyseal axis and the fracture line is smaller than 30º.		Ref. Manual of Internal Fixation: 232 - 251. 291 - 331. 546 - 547. Surgeon. RO, RO.

The fractures located at the middle third are the most classical indication for the non-interlocked reamed intramedullary nailing technique. The length of the nail must be accurate: from the tip of the greater trochanter to the superior pole of the patella. The diameter of the nail, which should also be preoperatively planned, may vary depending on the resistence found during the reaming. The nail curvature must be aligned with the anatomical curvature of the diaphysis. Internal fixation with a postero-laterally placed tension plate may be considered. In such case, interfragmentary application of at least one lag screw and autogenous	cancellous bone graft on the medial aspect of the femur (contralateral to the plate) are mandatory. If one of these two requirements is omitted, the plate will certainly suffer fatigue failure and breakage within 5 months. In linear fractures, loading of the plate is concentrated in one spot. The bone graft is incorporated after 6 weeks and protects the plate by neutralizing the repeated flexion stresses. The plate, because of its fracture immobilization effect, inhibits the resorption of the bone graft and favors its incorporation and new bone mass formation within the healing callus framework.






These are simple fractures with a transverse fracture line, located at the proximal and middle thirds of the femoral diaphysis. For pedagogical reasons of treatment discussion, we have placed the 32-A3.1 fractures following the 32-A3.2 subgroup.		Ref. Manual of Internal Fixation: 291 - 331. 546 - 547. Surgeon. RO, RO.

Since the arrival of the interlocking techniques, there is a general trend towards forcibly extending the indications of intramedullary nailing for fractures of the proximal femur. The two illustrated cases are intended to demonstrate the X-ray appareance of the healing process that occurs under those circumstances. The more proximal is the fracture the greater it is the huge flexion load suffered by the femur because of its crozier shape and of the mechanical and functional axis pathways. Wolff´s law is fulfilled and the cortex under	tension suffers bone resorption that can take many months or years to regenerate. This phenomenon is especially worrisome in the C3 fracture group (as we will demonstrate later) and takes place equally in all of these fractures treated by nailing, whether interlocked or not. Because of all of the above reasons, for subtrochanteric fractures we prefer to use the 95º condylar blade plate with a tension band effect since, in agreement with Pauwels´ columns theory, it turns the flexion loads into uniform compression throughout the fracture surface.