In a retrospective study, we reviewed 45 peri-trochanteric fractures treated between April 1995 and November 2002. The mean age of the 24 men and 21 women was 71 years (57 to 91). There were 34 inter-subtrochanteric, four reverse obliquity intertrochanteric fractures and nine subtrochanteric fractures. On the AO classification, there were 11 type-31A2-2, 21 type-31A2-3 and four type-31A3-1 intertrochanteric fractures. The fracture extended into the femoral neck in one case and into the diaphysis in three. Cardiopulmonary diseases were present in more than 60% of patients.

In most cases, fractures were reduced by closed reduction or reduction through a short incision. In 42 cases, a Smith and Nephew femoral reconstruction nail was used. Three fractures were stabilised with AO undreamed femoral nail with spiral blade. Distal locking screws were inserted in all cases. Progressive passive hip and knee movement was introduced from day one postoperatively. Partial weight-bearing was permitted from the onset. All but two fractures healed within 3 to 6 months. Union was delayed in two subtrochanteric fractures. Functional hip and knee movement was present in all patients. There was no sepsis. Proximal screws backed out in four cases, but this was of no functional significance. In one case the superior proximal screw was too long and required removal. In one case screws backed out of the femoral neck and further surgery was required. No breakage of screws or nail was observed. Inter-subtrochanteric and subtrochanteric fractures in the elderly may be successfully managed with intramedullary femoral reconstruction nails.

Both our own experience with antegrade nailing of the humerus and reports in the literature have made us aware of some of the drawbacks of this technique. Invasion of the intact shoulder is associated with damage to the rotator cuff and possible ectopic calcification, resulting in subacromial impingement. The ‘blind’ percutaneous placement of the top locking screw may endanger the axillary nerve and/or the bicipital tendon.

From 1990 to 2000 we performed 144 retrograde nailings, 41 of which were lost to follow-up. For two years we followed up the remaining 103 patients, 71 men and 32 women, who had sustained 83 closed and 20 compound fractures, 14 of which were caused by gunshots. There were 89 recent fractures and 14 cases of nonunion, nine of them the outcome of non-surgical management. Seidel interlocking nails were used in 92 patients and Russell-Taylor in 11. Reaming was invariably done, first to prevent jamming of the nail and fracture propagation, secondly to create endosteal bone transport (equivalent to bone grafting), and thirdly to contribute to bone morphogenetic protein release.

The results were encouraging. In fresh fractures callus was present after 5 to 8 weeks and in nonunions after 10 to 14 weeks. In 10 patients, iatrogenic periportal uni-cortical fractures occurred. These healed at the same pace as the original fracture and did not affect the functional recovery. There were no vascular complications. One patient developed transient radial nerve paresis, but there was no permanent neurological damage. No sepsis developed in previously uninfected fractures. Shoulder and elbow function remained normal.