Functional Outcome of Ipsilateral Intertrochanteric and Femoral Shaft Fractures

8/13/2019 Functional Outcome of Ipsilateral Intertrochanteric and Femoral Shaft Fractures

1/5

ORGINAL ARTICLE

Functional Outcome of Ipsilateral Intertrochantericand Femoral Shaft Fractures

Christopher Peskun, MD,* Michael McKee, MD, FRCS(C), Hans Kreder, MD, FRCS(C),

David Stephen, MD, FRCS(C), Alison McConnell, MEng,* and Emil H. Schemitsch, MD, FRCS(C)*

Objectives: The purpose of this study was to compare thefunctional outcome of patients with ipsilateral intertrochanteric and

femoral shaft fractures treated with a reconstruction nail versus

a sliding hip screw and retrograde nail.

Design: Retrospective cohort study.

Setting: Two level 1 trauma centers.

Participants: Twenty-six patients with ipsilateral intertrochantericand femoral shaft fractures treated between 1993 and 2003 with a

reconstruction nail (n = 13) or with a sliding hip screw and retrograde

nail (n = 13).

Intervention: Internal fixation with a reconstruction nail or asliding hip screw and retrograde nail.

Main Outcome Measurements: Functional outcome wasmeasured using the Short Form-36 (SF-36), Short Musculoskeletal

Functional Assessment (SMFA), and Lower Extremity Functional

Scale (LEFS).

Results:The average time to follow-up was 49.6 months. Functionaloutcome was significantly better in the sliding hip screw with

retrograde nail group for the role emotional (P= 0.001) and mental

component scores (P= 0.016) of the SF-36. This group also scored

better on the LEFS, although not reaching statistical significance

(P= 0.099).

Conclusions: For most outcome measures, no significant differ-ences in functional outcome scores were observed between the 2 treat-

ment groups. The results of this study suggest the need for a

randomized controlled trial with a larger sample size to more defin-

itively compare the 2 fixation constructs.

Key Words: ipsilateral, fracture, intertrochanteric, femur, outcome

(J Orthop Trauma2008;22:102106)

INTRODUCTION

The combination of ipsilateral hip and femoral shaftfractures is an uncommon pattern associated with high-energytrauma such as motor vehicle accidents, falls from height, and

pedestrian versus motor vehicle accidents.13 The mechanismis believed to be a longitudinal compressive force directedretrograde through a flexed knee and flexed hip.4 Of the hipfractures, approximately one fourth of them can be classified

as intertrochanteric1,57

with the remainder being femoral neckfractures.8 Males aged 1934 years are most commonlyaffected, often presenting with multisystem trauma and elevatedInjury Severity Scores (ISS).9

Numerous surgical fixation constructs have beendescribed4,1016 to manage ipsilateral intertrochanteric andfemoral shaft fractures, although evidence for which to chooseis lacking. Two of the more common fixation constructs usedare a reconstruction nail and a combination sliding hip screwand retrograde nail. The reconstruction nail allows fixation of

both fractures with the same implant, whereas the combinationof sliding hip screw and retrograde intramedullary nail allowsindependent fixation of both the intertrochanteric fracture andthe femoral shaft fracture. The decision to use 1 fixation

construct as opposed to the other has been based largely on thepreference of the attending orthopaedic surgeon.

A number of studies in the literature have evaluatedthe functional outcome of patients sustaining complex hipfractures.1724 However, to the authors knowledge, there areno published studies comparing the use of a reconstruction nailversus a sliding hip screw and retrograde nail in the treatmentof ipsilateral intertrochanteric and femoral shaft fractures.

The purpose of this study was to compare the functionaloutcome of patients with ipsilateral intertrochanteric and femoralshaft fractures treated with a reconstruction nail versus a slidinghip screw and retrograde nail. It is hypothesized that the abilityto independently fix the intertrochanteric and shaft fractures witha sliding hip screw and retrograde nail will result in improvedfunctional outcomes compared with a reconstruction nail.

PATIENTS AND METHODS

All patients with ipsilateral intertrochanteric hip andfemoral shaft fractures treated between 1993 and 2003 at2 level 1 trauma centers were identified using a fracture data-

base and hospital medical records. Review of preoperativeradiographs was undertaken to confirm fracture pattern andexclude those patients sustaining ipsilateral femoral neck andshaft fractures. All eligible patients were contacted and asked

Accepted for publication November 19, 2007.From the *Martin Orthopaedic Biomechanics Laboratory, St. Michaels

Hospital, Toronto, Ontario, Canada; and Division of Orthopaedics,Department of Surgery, University of Toronto, Toronto, Ontario, Canada.

None of the authors obtained personal financial gain as a result of this study.No commercial funding was received for this study.

The devices that are the subject of this manuscript are FDA approved.Reprints: Dr. Emil H. Schemitsch, MD, FRCS(C), Division of Orthopaedics,

Department of Surgery, University of Toronto, St. Michaels Hospital,Suite 800, 55 Queen Street East, Toronto, Ontario, Canada M5C 1R6(e-mail: [email protected]).

Copyright 2008 by Lippincott Williams & Wilkins

102 J Orthop Trauma Volume 22, Number 2, February 2008


2/5

to complete the Short Form-36 (SF-36),25,26 Short Musculo-skeletal Functional Assessment (SMFA),27 and Lower Extre-mity Functional Scale (LEFS).28 All domains for the SF-36and the LEFS are such that higher scores indicate betterfunction, whereas with the SMFA, lower scores indicate betterfunction. Those patients unwilling to or incapable of com-

pleting the questionnaires were excluded from the study.Following Research Ethics Board approval, patient

contact was initiated via mail through an introductory letterand study information package. Approximately 1 week fol-lowing mailing of these materials, a phone call was placed to

prospective patients and consent was obtained. Patients weregiven the option of completing questionnaires and returningthem via mail or completing the questionnaires over the phonewith the assistance of the primary study investigator.Responses were reviewed and verified in duplicate when thequestionnaires were administered over the phone.

Hospital charts and postoperative radiographs werereviewed for each study subject by the primary study inves-tigator. A data abstraction form was used to gather information

regarding patient age, gender, mechanism of injury, ISS,number of days spent in the hospital, number of days spent inthe intensive care unit (ICU), length of surgery, and time tofollow-up. Time to follow-up was defined as the length of time

between surgical fixation and completion of the question-naires. The following postoperative complications wererecorded: delayed union, malunion, nonunion, infection, hard-ware removal, exchange nail placement, and periprostheticfracture. Delayed union, nonunion, and malunion weredetermined based on the status of both the intertrochantericfracture and the femoral shaft fracture.

Statistical analysis of data was performed using thecomputer program MiniTab. Means, ranges, and confidenceintervals were calculated for continuous variables andcompared using Students t-tests. Frequencies were calculatedfor categorical variables and compared using chi-square tests.A significance level ofP, 0.05 was chosen with considerationfor a trend toward significance in the case of 0.05 , P, 0.1.

To control for statistically significant differences in ISS andtime to follow-up between treatment groups, linear multivariateregression analysis was performed using ISS, time to follow-up, and treatment group as predictor variables. The responsevariables were the domain scores for the SF-36, SMFA, andLEFS. The categorical variables were not subject to mul-

tivariate regression analysis. For comparison of patient SF-36scores to Canadian normative data, a z-test was used.

RESULTS

Database Search

A search of the hospitals ICD-9 diagnosis codedatabase yielded 1167 femoral fractures treated between1993 and 2003 (Fig. 1). Of these, 40 patients sustaining 41ipsilateral intertrochanteric and femoral shaft fractures wereidentified. Twenty-two patients were treated with a reconstruc-tion nail and 18 were treated with a sliding hip screw andretrograde nail. Three patients, 1 from the reconstruction nail

group and 2 from the sliding hip screw with retrograde nailgroup, died in the hospital shortly following fracture fixation.One potential participant from the reconstruction nail groupwas incapable of completing outcome questionnaires becauseof mental incapacity. Three eligible patients declined to

participate, and 7 patients were lost to follow-up. In total, 14(35%) eligible patients did not complete questionnaires, 1 ofwhich had bilateral ipsilateral intertrochanteric and femoralshaft fractures (both treated with sliding hip screws andretrograde nails). Of the 26 eligible patients who completed thequestionnaires, 13 were treated with a reconstruction nail (9 atinstitution 1) and 13 were treated with a sliding hip screw andretrograde nail (9 at institution 1). All patients were treatedwithin 24 hours of injury, except for 1 patient in the sliding hipscrew with retrograde nail group who was treated within48 hours of injury. There were 5 different surgeons (3 atinstitution 1) with senior experience in trauma. There were nostatistically significant differences, with respect to age, gender,

FIGURE 1. Patient identificationflow chart.

q 2008 Lippincott Williams & Wilkins 103

J Orthop Trauma Volume 22, Number 2, February 2008 Ipsilateral Intertrochanteric and Femoral Shaft Fractures


3/5

mechanism of injury, or ISS, among those patients included inthe study and those lost to follow-up.

The total number of males in the study was 16 (62%).Average age of all participants was 43.7 years (range 2076).The majority of injuries 17 (65%) were caused by motorvehicle collisions. Other mechanisms of injury included falls

from height 5 (19%) and pedestrian versus motor vehicleaccidents 1 (4%). The demographic data for the 2 treatmentgroups were comparable for age, gender, and mechanism ofinjury (Table 1).

The groups were similar with respect to fracture severity(Table 1), but the average ISS score was higher for patients inthe sliding hip screw with retrograde nail group [meandifference = 16.3, 95% CI (5.5, 27.2), P= 0.003]. In addition,the sliding hip screw with retrograde nail group had more

patients sustaining polytrauma (ISS . 16) compared to thereconstruction nail group (P= 0.01) and spent more days in theICU [mean difference = 6.8, 95% CI (1.5, 12.1),P= 0.008]. Thesurgical time for the sliding hip screw and retrograde nail groupwas longer than that for the reconstruction nail group by an

average of 126 minutes [95% CI (21.5, 255.4),P= 0.03]. Theoverall average time to follow-up was 49.6 months (range 13120 months). There was a statistically significant difference intime to follow-up [95% CI (9.0, 48.1),P= 0.003] with the grouptreated with a reconstruction nail having an average follow-upof 63.9 months and the sliding hip screw and retrograde nailgroup having an average follow-up of 35.3 months.

Functional Outcome

Functional outcome was significantly better in thesliding hip screw with retrograde nail group for the role

emotional (P= 0.001) and the mental component scores (P=0.016) of the SF-36, after adjusting for ISS and time to follow-up (Table 2). The sliding hip screw and retrograde nail groupscored higher on 7 of the 10 domains and components of theSF-36, although only the statistically significant results arenoted here. Even without adjustment for ISS and time to

follow-up, the sliding hip screw with retrograde nail group hadbetter role emotional (P = 0.007) and mental componentscores (P= 0.035).

The sliding hip screw and retrograde nail group scoredequivalently or higher on 5 of the 6 domains of the SMFA afteradjusting for ISS and time to follow-up, although none of thesedifferences reached a level of significance. Without adjustmentfor ISS and time to follow-up there were no statistically sig-nificant differences between the treatment groups with respectto SMFA domain scores.

The sliding hip screw with retrograde nail groupshowed a trend toward significance for the LEFS score (P=0.099) after adjustment for ISS and time to follow-up. Withoutadjustment for ISS and time to follow-up there were no sta-

tistically significant differences between the treatment groupswith respect to LEFS score.

Comparison to Canadian population normative data forSF-36 physical and mental component scores was conductedfor each treatment group.26 The sliding hip screw with retro-grade nail group had a significantly lower physical componentscore (mean = 36.2, z = 25.74, P, 0.0001), although themental component score (mean = 49.0, z= 21.06, P= 0.29)was comparable to population norms. The reconstruction nailgroup had significantly lower physical component (mean =38.6, z = 24.75, P , 0.0001) and mental component

TABLE 1. Characteristics of Treatment Groups

Fixation Device Group

Characteristic DHS (n = 13) Recon (n = 13) PValue

Age 41.4 (20 to 76) 46.0 (24 to 72) 0.21

Gender (male) 7 (54) 9 (69) 0.42

Mechanism (MVA) 8 (62) 9 (69) 0.62

Displaced fracture 8 (62) 8 (62)

Open fracture 2 (15) 3 (23) 0.62

Soft tissues involved 6 (46) 5 (38) 0.69

Nerve injury 1 (8) 1 (8)

ISS 30.5 (9 to 66) 14.2 (9 to 34) 0.003

Polytrauma 11 (85) 4 (31) 0.01

ICU days 8.4 (0 to 30) 1.3 (0 to 4) 0.008

Hospital days 22.7 (5 to 68) 14.6 (5 to 56) 0.11

Length of surgery (min) 401.5 (140 to 745) 274.6 (175 to 540) 0.03Time to follow-up (months) 35.3 (13 to 63) 63.9 (13 to 120) 0.003

Time to radiographic union (months) 4.5 (3 to 14) 4.9 (3 to 15) 0.383

Healing complications Delayed union 2 (15) 3 (23) 0.62

Malunion 10 (0) 10 (0)

Nonunion 10 (0) 10 (0)

Subsequent surgery Exchange nail 1 (8) 1 (8)

Hardware removal 1 (8) 3 (23) 0.28

Complications Infection 1 (8) 10 (0) 0.21

Periplate fracture 1 (8) n/a

*All stated values are number (percentage) or mean (range).

104 q 2008 Lippincott Williams & Wilkins

Peskun et al J Orthop Trauma Volume 22, Number 2, February 2008


4/5

(mean = 38.0, z= 25.42, P, 0.0001) scores compared withpopulation norms.

Clinical Outcome

Both treatment groups were comparable for time toradiographic union (P = 0.383). There were no differences

between the groups with respect to delayed union (P= 0.62),malunion, nonunion, exchange nail placement, hardwareremoval (P = 0.28), infection (P = 0.21), or peri-implantfracture, after adjustment for ISS and time to follow-up.

DISCUSSION

The results of this study indicate that there is nosignificant difference, with respect to functional outcome,

between the use of a sliding hip screw and retrograde nail asopposed to a reconstruction nail, in the treatment of ipsilateralintertrochanteric and femoral shaft fractures. The sliding hipscrew with retrograde nail group scored equivalently or higheron 13 of the 17 functional outcome measures used, although

statistical significance was reached across only 2 domains inboth raw and adjusted analysis. The fact that the slidinghip screw group had a higher ISS than the reconstructionnail group would bias the results against the sliding hipscrew group, although this bias was corrected for with the useof multivariate regression analysis.

SF-36 physical and mental component scores weredecreased compared with Canadian population norms withmean scores falling greater than 1 standard deviation beyond

population means except in the mental component score of thesliding hip screw with retrograde nail group. These findingsare to be expected considering the mechanism necessary to

cause this injury pattern, the associated potential formultisystem trauma, and the increased risk of long-termmorbidity.29

The theoretic advantage of the sliding hip screw andretrograde nail is based on the fact that this construct providesthe surgeon with the ability to fix the 2 fractures independently.A reconstruction nail, in contrast, is a solitary implant with the

potential for compromised fixation at 1 of the fracture sites.However, this advantage of the sliding hip screw and retro-grade nail must be weighed against the longer operative timeswhen using a 2-device construct and the fact that in the presentstudy there were no differences with respect to malunion ornonunion between the treatment groups. In addition to

biomechanical considerations, previous studies suggest thesurgical outcome between antegrade and retrograde femoralnailing appears to be similar,30,31 with some evidence tosuggest clinical advantages in retrograde nailing of femoralshaft fractures in polytrauma patients.32,33 These patients oftenhave significant chest and abdominal injuries requiring

multiple surgeons to operate simultaneously. This mayincrease the risk that the field required to introduce a recon-struction nail would become obstructed. Although simul-taneous multisurgeon operations were not encountered in thisstudy, the use of a sliding hip screw and retrograde nail in thissituation may make the surgery technically less difficult andresult in better surgical outcome.

This retrospective cohort study has several limitations.First, the decision for surgical treatment and the fixation con-struct used were made arbitrarily by the attending orthopaedicsurgeon based largely on individual surgeon preference.As a result of this uncontrolled treatment group designation,

TABLE 2. Functional Outcome Results

Fixation Device Group

Raw Scores Regression Analysis

DHS (n = 13) Recon (n = 13) PValue Coefficient PValue

SF-36

Physical Functioning 46.5 50.8 0.374 9.0 0.610

Role Physical 56.3 45.2 0.211 24.1 0.186

Bodily Pain 43.4 38.9 0.321 6.9 0.560

General Health 55.9 56.2 0.488 12.8 0.318

Vitality 50.5 43.8 0.245 13.1 0.315

Social Functioning 67.3 50.0 0.110 29.1 0.150

Role Emotional 78.2 44.9 0.007 55.8 0.001

Mental Health 67.7 60.4 0.246 19.8 0.154

Physical Component Scale 36.2 38.6 0.301 0.0 0.999

Mental Component Scale 49.0 38.0 0.035 18.8 0.016

SMFA

Daily Activites 36.4 37.5 0.460 215.2 0.319

Emotional Status 43.1 43.1 0.500 23.9 0.708

Arm and Hand Function 7.5 11.8 0.217 23.3 0.668

Mobility 42.7 37.6 0.289 27.8 0.505

Function Index 32.6 32.6 0.500 28.1 0.451

Bothersome Index 37.0 39.1 0.428 211.0 0.481

LEFS

Total score 45.8 38.7 0.205 19.2 0.099

q 2008 Lippincott Williams & Wilkins 105

J Orthop Trauma Volume 22, Number 2, February 2008 Ipsilateral Intertrochanteric and Femoral Shaft Fractures


5/5

there were statistically significant differences between the 2treatment groups with respect to ISS, number of patientswith polytrauma, and days spent in the ICU. These values werehigher in the group treated with a sliding hip screw andretrograde nail, but, as noted earlier, this should have biasedthe results against the sliding hip group, suggesting that the

observed difference might be even greater had the groups beencomparable at baseline with respect to injury severity. Second,there were no standard protocols for device implementation,which may be of significance when using fixation constructswith multiple components, such as a sliding hip screw andretrograde nail. Finally, the relatively uncommon incidenceand potential for mortality associated with ipsilateralintertrochanteric and femoral shaft fractures resulted in a smallnumber of study participants and limited generalizability ofresults. Despite these limitations, we believe there is importantinformation contained within this study with respect tofunctional outcome following surgical fixation of ipsilateralintertrochanteric and femoral shaft fractures.

There is little debate over the fact that ipsilateral

intertrochanteric and femoral shaft fractures require surgicalfixation with intramedullary nailing of the shaft component.However, there is some question as to which surgical fixationmethod provides optimal patient outcomes. The findings ofthis study suggest there is no significant difference between theuse of a sliding hip screw and retrograde nail or a recon-struction nail for the treatment of ipsilateral intertrochantericand femoral shaft fractures. However, a randomized controlledtrial with an adequate number of participants is required todraw firm conclusions.

REFERENCES

1. Alho A. Concurrent ipsilateral fractures of the hip and shaft of the femur.A systematic review of 722 cases.Ann Chir Gynaecol. 1997;86:326336.

2. Alho A. Concurrent ipsilateral fractures of the hip and femoral shaft:a meta-analysis of 659 cases. Acta Orthop Scand. 1996;67:1928.

3. Barquet A, Fernandez A, Leon H. Simultaneous ipsilateral trochantericand femoral shaft fracture. Acta Orthop Scand. 1985;56:3639.

4. Casey MJ, Chapman MW. Ipsilateral concomitant fractures of the hip andfemoral shaft. J Bone Joint Surg Am. 1979;61:503509.

5. Leung KS, So WS, Lam TP, et al. Treatment of ipsilateral femoral shaftfractures and hip fractures.Injury. 1993;24:4145.

6. Geissler WB, Savoie FH, Culpepper RD, et al. Operative management ofipsilateralfractures of the hip and femur.J Orthop Trauma. 1988;2:297302.

7. Friedman RJ, Wyman ET Jr. Ipsilateral hip and femoral shaft fractures.Clin Orthop Relat Res. 1986;208:188194.

8. Peljovich AE, Patterson BM. Ipsilateral femoral neck and shaft fractures.J Am Acad Orthop Surg. 1998;6:106113.

9. Laporte C, Benazet JP, Scemama P, et al. Ipsilateral hip and femoral shaftfractures: components of therapeutic choice.Rev Chir Orthop Reparatrice

Appar Mot. 1999;85:2432.

10. Majeed SA, Leithy M. Internal fixation of ipsilateral trochanteric andfemoral shaft fractures by staples and Kuntscher nail.J Orthop Trauma.1988;2:3335.

11. Wellin DE, Galloni L, Gelb RI. Ipsilateral intertrochanteric and diaphysealfemoral fractures. Four patients treated by one technique. Clin Orthop

Relat Res. 1984;183:7175.

12. Ashby ME, Anderson JC. Treatment of fractures of the hip and ipsilateralfemur with the Zickel device: a report of three cases. Clin Orthop Relat

Res. 1977;127:156160.13. Barquet A, Francescoli L, Rienazi D, et al. Intertrochanteric-subtrochan-

teric fractures: treatment with the long Gamma Nail. J Orthop Trauma.2000;14:324328.

14. Hung SH, Hsu CY, Hunag PJ, et al. Surgical treatment for ipsilateralfractures of the hip and femoral shaft. Injury. 2004;35:165169.

15. Jain P, Maini L, Mishra P, et al. Cephalomedullary interlocked nailfor ipsilateral hip and femoral shaft fractures. Injury. 2004;35:10311038.

16. Oh CW, Oh JK, Park BC, et al. Retrograde nailing with subsequent screwfixation for ipsilateral femoral shaft and neck fractures. Arch OrthopTrauma Surg. 2006;126:448453.

17. Chen CM, Chiu FY, Lo WH, et al. Ipsilateral hip and distal femoralfractures. Injury. 2000;31:147151.

18. Harrington P, Nihal A, Singhania AK, et al. Intramedullary hip screwversus sliding hip screw for unstable intertrochanteric femoral fractures inthe elderly. Injury. 2002;33:2328.

19. Lunsjo K, Cedar L, Thorngren KG, et al. Extramedullary fixation of 569unstable intertrochanteric fractures: a randomized multicentre trial of theMedoff sliding plate versus three other screw-plate systems. Acta OrthopScand. 2001;72:133140.

20. Garnavos C, Peterman A, Howard PW. The treatment of difficult proximal

femoral fractures with the Russell-Taylor reconstruction nail.Injury. 1999;30:407415.21. Seif-Asaad SS, Nargol AV, Port A. Unstable intertrochanteric fractures

treated with the Variwell reconstruction nail. Injury. 1995;26:367372.22. Habernek H, Wallner T, Aschauer E, et al. Comparison of Ender nails,

dynamic hip screws, and Gamma nails in the treatment of peritrochantericfemoral fractures. Orthopedics. 2000;23:121127.

23. Butt MS, Krikler SJ, Nafie S, et al. Comparison of dynamic hip screw andgamma nail: a prospective, randomized, controlled trial. Injury. 1995;26:615618.

24. OBrien PJ, Meek RN, Blachut PA, et al. Fixation of intertrochanteric hipfractures: Gamma nail versus dynamic hip screw. A randomized,

prospective study. Can J Surg. 1995;38:516520.25. Jenkinson C, Coulter A, Wright L. Short form 36 (SF-36) health survey

questionnaire: normative data for adults of working age. BMJ. 1993;306:14371440.

26. Hopman WM, Towheed T, Anastassiades T, et al. Canadian Normative

Data for the SF-36 Health Survey. Canadian Multicentre OsteoporosisStudy Research Group. CMAJ. 2000;163:265271.

27. Swiontkowski MF, Engelberg R, Martin DP, et al. Short musculoskeletalfunctional assessment questionnaire: validity, reliability, and responsive-ness. J Bone Joint Surg Am. 1999;81:12451260.

28. Binkley JM, Stratford PW, Lott SA, et al. The lower extremity functionalscale (LEFS): scale development, measurement properties, and clinicalapplication. North American Orthopaedic Rehabilitation Research

Network.Phys Ther. 1999;79:371383.29. Bernstein SM. Fractures of the femoral shaft and associated ipsilateral

fractures of the hip. Orthop Clin North Am. 1974;5:799818.30. Ostrum RF, Agarwal A, Lakatus R, et al. Prospective comparison of

retrograde and antegrade femoral nailing. J Orthop Trauma. 2000;14:496501.

31. Ricci WM, Bellabarba C, Evanoff B, et al. Retrograde versusantegrade nailing of femoral shaft fractures. J Orthop Trauma. 2001;15:161169.

32. Moed BR, Watson JT. Retrograde intramedullary nailing, withoutreaming, of fractures of the femoral shaft in multiply injured patients.

J Bone Joint Surg Am. 1995;77:15201527.33. Ostrum RF. Retrograde femoral nailing: indications and techniques. In: Fu

FH, ed.Operative Techniques in Orthopaedics. Vol. 13. St. Louis: Mosby;2003:7984.

106 q 2008 Lippincott Williams & Wilkins

Peskun et al J Orthop Trauma Volume 22, Number 2, February 2008

Documents

Functional Outcome of Ipsilateral Intertrochanteric and Femoral Shaft Fractures