Nailing proximal femur fractures: how to choose starting point and proximal screw configuration

Fractures of the proximal femur can be a challenging treatment dilemma for the orthopaedic surgeon. Complex mechanical forces and anatomic variables in this region combine to make treatment of these injuries difficult and can often result in serious complications. The decision to treat this fracture with an intramedullary device requires the surgeon evaluate many variables in the context of the specific fracture pattern. These include the choice of implant, starting portal location, and positioning of the patient. Assessment of the fracture pattern and its 3 dimensional orientation is usually accomplished with the aid of advanced imaging. The patient's physiological status, body habitus and bone quality must also be incorporated into the treatment algorithm. We review these issues and how they factor into the decision making process in order to develop a successful operative plan for these injuries. We will review the starting portal selection, reduction and insertion techniques and examine options for proximal locking screw configurations.