M.E.Müller: Atlas: Fracture 32-B3

Femur, Diaphysis,
wedge fracture, fragmented wedge 0,98% of the total
1,61% of the femur
6,72% of the segment

122 fractures
23,0% group
75%M, 25%F

331 fractures
62,3% group
78%M, 22%F

78 fractures
14,7% group
75%M, 25%F

Subtrochanteric section + Q Middle section + Q Distal section + Q

These are fractures of the proximal third of the femoral diaphysis (subtrochanteric) with several intermediate fragments corresponding to a fragmented wedge. Once reduced, the main fragments maintain some contact. Ref. Manual of Internal Fixation:
535 - 547. 254 - 265.
Surgeon. RO.

We think that the 95º condylar blade plate is the implant of choice for the majority of the subtrochanteric fractures. In these fragmented wedge fractures the surgical technique is identical to the one described for the simple wedge fractures and the accurate placement of the blade in the femoral neck as the first surgical step is even more crucial. The distal fragment is then reduced to the plate and the intermediate fragments will spontaneously reduce by some distraction, applied with the reverse tension device. This is the time to obtain anatomic reduction of the main intermediate fragments with

clamps, without devitalizing them, and lag screw fixation if possible. The small fragments must be preserved. The reduction of the lesser trochanter is not essential.

If the surgical technique has been careful, without devitalization of the fragments (biologic internal fixation), and the reduction reconstitutes the medial cortex, bone grafting is not necessary. If in doubt, it is better to add bone graft. In the illustrated case no bone graft was used.

preoperative postoperative

+ 6 months + 2 years + 2 years

preoperative preoperative

postoperative postoperative

+ 5 months + 5 months

These are diaphyseal fractures with a fragmented wedge, located at the middle third of the femur. Once the fracture is reduced, there is contact between the two main proximal and distal fragments. Ref. Manual of Internal Fixation:
535 - 547. 232 - 251.
Surgeon. RO, RO.

By definition of the group, once these fractures are reduced, the proximal and the distal fragments must be in contact. The plating treatment of these fractures is based on the anatomic reduction and axial compression of the cortical contact zone. Previously, it is necessary to apply some distraction in order to gather together the intermediate fragments, which should be internally fixed or not depending on their size.

The technical procedure is simple. The straight plate is first fixed to the postero-lateral aspect of the proximal fragment, perfectly aligned with its axis. Distraction is applied, either manually or with the distraction device, in order to obtain the reduction of the distal fragment to the plate, which is provisionally maintained with clamps. Axial compression is then applied and the plate is fixed with screws. The large intermediate fragments may have been previously reduced and fixed to the distal fragment. The small intermediate fragments must not have been manipulated.

This is the time to take the crucial decision: whether to add autologous cancellous bone graft or not. The decision will depend on the degree of fragmentation of the wedge, the lenght of the intermediate fragments, the amount of cortical bone loss concentrated in a short segment, the devitalization of the fragments and whether reduction is spontaneous or by manipulation.

The illustrated cases show both possibilities. In the first case no bone graft was used because there was a broad cortical segment contact and the small fragments regrouped together spontaneously, without manipulation, during the reduction. In the second case generous cancellous bone grafting was performed because the wedge was quite long, the fragmentation was concentrated in a short proximal segment and the cortical contact area between the two main fragments was rather small.

preoperative postoperative + 3 months + 6 months

preoperative postoperative + 1 months + 4 months

These are diaphyseal fractures with a fragmented wedge. Once the fracture is reduced, there is contact between the two main fragments. Ref. Manual of Internal Fixation:
535 - 547. 232 - 251.
Surgeon. RO, RO.

The same treatment principles of the B3.1 and B3.2 subgroups apply for these fractures. In the distal zone of the femur, where the diaphysis flares like a trumpet and the cortices are thinner, it is necessary to use straight plates, previously contoured, or condylar plates.

In the first illustrated case, the posterior fragmented wedge was not devitalized during the surgical procedure and reduced spontaneously when the two main fragments were aligned. This is why no cancellous bone graft was added. As can be observed in the images,

the healing callus evolved quicker in the posterior aspect (indirect callus) than in the anterior aspect where there was cortical contact. The implant used was a contoured straight plate.

In the second case, the largest fragment of the wedge was anatomically reduced and fixed with an interfragmentary compression lag screw. The implant used was a 95º condylar plate and bone graft was added to the area of comminution.

preoperative + 4 months + 1 year + 1 year

preoperative + 4 months + 1 year + 1 year




						Femur, Diaphysis, wedge fracture, fragmented wedge	0,98% of the total 1,61% of the femur 6,72% of the segment






These are fractures of the proximal third of the femoral diaphysis (subtrochanteric) with several intermediate fragments corresponding to a fragmented wedge. Once reduced, the main fragments maintain some contact.		Ref. Manual of Internal Fixation: 535 - 547. 254 - 265. Surgeon. RO.

We think that the 95º condylar blade plate is the implant of choice for the majority of the subtrochanteric fractures. In these fragmented wedge fractures the surgical technique is identical to the one described for the simple wedge fractures and the accurate placement of the blade in the femoral neck as the first surgical step is even more crucial. The distal fragment is then reduced to the plate and the intermediate fragments will spontaneously reduce by some distraction, applied with the reverse tension device. This is the time to obtain anatomic reduction of the main intermediate fragments with	clamps, without devitalizing them, and lag screw fixation if possible. The small fragments must be preserved. The reduction of the lesser trochanter is not essential. If the surgical technique has been careful, without devitalization of the fragments (biologic internal fixation), and the reduction reconstitutes the medial cortex, bone grafting is not necessary. If in doubt, it is better to add bone graft. In the illustrated case no bone graft was used.






These are diaphyseal fractures with a fragmented wedge, located at the middle third of the femur. Once the fracture is reduced, there is contact between the two main proximal and distal fragments.		Ref. Manual of Internal Fixation: 535 - 547. 232 - 251. Surgeon. RO, RO.

By definition of the group, once these fractures are reduced, the proximal and the distal fragments must be in contact. The plating treatment of these fractures is based on the anatomic reduction and axial compression of the cortical contact zone. Previously, it is necessary to apply some distraction in order to gather together the intermediate fragments, which should be internally fixed or not depending on their size. The technical procedure is simple. The straight plate is first fixed to the postero-lateral aspect of the proximal fragment, perfectly aligned with its axis. Distraction is applied, either manually or with the distraction device, in order to obtain the reduction of the distal fragment to the plate, which is provisionally maintained with clamps. Axial compression is then applied and the plate is fixed with screws. The large intermediate fragments may have been previously reduced and fixed to the distal fragment. The small intermediate fragments must not have been manipulated.	This is the time to take the crucial decision: whether to add autologous cancellous bone graft or not. The decision will depend on the degree of fragmentation of the wedge, the lenght of the intermediate fragments, the amount of cortical bone loss concentrated in a short segment, the devitalization of the fragments and whether reduction is spontaneous or by manipulation. The illustrated cases show both possibilities. In the first case no bone graft was used because there was a broad cortical segment contact and the small fragments regrouped together spontaneously, without manipulation, during the reduction. In the second case generous cancellous bone grafting was performed because the wedge was quite long, the fragmentation was concentrated in a short proximal segment and the cortical contact area between the two main fragments was rather small.






These are diaphyseal fractures with a fragmented wedge. Once the fracture is reduced, there is contact between the two main fragments.		Ref. Manual of Internal Fixation: 535 - 547. 232 - 251. Surgeon. RO, RO.

The same treatment principles of the B3.1 and B3.2 subgroups apply for these fractures. In the distal zone of the femur, where the diaphysis flares like a trumpet and the cortices are thinner, it is necessary to use straight plates, previously contoured, or condylar plates. In the first illustrated case, the posterior fragmented wedge was not devitalized during the surgical procedure and reduced spontaneously when the two main fragments were aligned. This is why no cancellous bone graft was added. As can be observed in the images,	the healing callus evolved quicker in the posterior aspect (indirect callus) than in the anterior aspect where there was cortical contact. The implant used was a contoured straight plate. In the second case, the largest fragment of the wedge was anatomically reduced and fixed with an interfragmentary compression lag screw. The implant used was a 95º condylar plate and bone graft was added to the area of comminution.