Epidemiology in Sub-Saharan Africa

• Increasing due to urbanization, motorization, and aging populations.
• Many rural patients present late due to travel distances, financial constraints, and reliance on traditional bone setters.
• Female sex, osteoporosis, and nutritional deficiencies (vitamin D and calcium) are contributing factors.
• HIV-related bone loss and chronic steroid use in comorbidities such as TB may increase fracture risk.

Aetiology

They are commonly seen following ground level falls in the elderly population for pertrochanteric femoral fractures.

Subtrochanteric fractures occur in low energy (in the elderly) or high energy (in young individuals) trauma.

In elderly patients, rule out pathologic or atypical femur fracture. Pathologic fracture may occur due to primary or metabolic bone disease.

Clinical Presentation

Hip pain: This usually has an acute onset following trauma. It is an antecedent in the presence of pathological fracture.

Inability to ambulate on the affected limb or raise it up.

Physical Findings may include: 

• Shortening of the affected lower limb and externally rotated 
• Thigh swelling or bruising.
• Deformity of the thigh
• Tenderness over the fracture site, groin, hip or upper thigh
• Neurovascular assessment.
• Rule out associated injuries, especially in polytrauma

Different Diagnosis

• Femoral neck fracture.
• Femoral shaft fracture.

Investigation

• Plain radiograph: Thigh x-ray.  Anteroposterior pelvis and lateral hip X-rays. Full-length femur X-ray to exclude shaft extension. The whole extent of the thigh must be visible. Figures 1 and 2

Figure 1. Pertrochanter fracture. Picture credit Dr AROJURAYE Soliudeen Adebayo.

Figure 2. Pertrochanter fracture. Picture credit Dr AROJURAYE Soliudeen Adebayo.

Figure 3 Pertrochanter fracture Picture credit Dr AROJURAYE Soliudeen Adebayo

• CT scan of the femur helps to better characterise the fracture pattern and helps in surgical planning for the patient.
• MRI: in occult hip fracture
• Blood tests: Full blood count, electrolyte urea and creatinine. Glucose checks in adults to rule out diabetes mellitus.

Classification

Pertrochanteric Fractures

• Occur between the greater and lesser trochanters.
• Usually extracapsular.
• AO/OTA classification: 31-A1 to A3.
• Russel classification

Subtrochanteric Fractures

• Occur below the lesser trochanter, up to 5 cm distally.
• Often associated with high-energy trauma in young adults or pathological fractures in elderly.
• AO/OTA classification: 32-A to 32-C.

Treatment

In major trauma, manage the patient using ATLS protocol to identify life threatening conditions in the patient and treat such conditions first.

Goals of Fracture Treatment 

• Save life
• Save limb
• Restore function.

Pain Management

• Multimodal
• Parenteral analgesics
• Nerve block
• Apply skin traction which helps to reduce pain and further injury to the surrounding soft tissue especially neurovascular bundles from fracture edges.

Surgical Management

• Children < 5 years old hip spica or Gallow splint are recommended. Skin traction can be used initially to ensure adequate length is achieved and in hip spica can be applied once the fracture is sticky.
• In older children, treat with ORIF with plates and screws or TENS nailing or intramedullary nails.
• Adults subtrochanteric fractures closed or open reduction with proximal femoral nail or proximal locked femoral plate plus screw or dynamic hip screw.

NB- The choice of implants depends on the fracture pattern and surgeon’s preference. 

• Non-operative may be indicated in patients who are bedridden or non-ambulatory with many co-morbidities because they are high anaesthetic risk patients thus poor candidates for anaesthesia or high-risk patients or lack of surgical access. Skeletal traction or skin traction, analgesia, and nursing care. Risk of complications: pressure sores, DVT, pulmonary infections.

Pertrochanteric Fracture Management

Indications for conservative non-operative management include non-ambulatory patients, high risk for perioperative mortality.

Operative Treatment (Figures 4 and 5)

• Closed reduction and intramedullary nailing.
• Open reduction and internal fixation with proximal femur locking plates, sliding hip compression or angle blade plate.
• Arthroplasty is indicated as a salvage for failed internal fixation or in severe comminution of fracture or a preexisting hip osteoarthritis.

Figure 4 Pertrochanteric fracture treated with DHS Picture credit Dr AROJURAYE Soliudeen Adebayo.

Figure 5: Post op plan radiograph who had CRIF with PFN on account of reverse oblique. Picture credit Dr AROJURAYE Soliudeen Adebayo.

Postoperative Care

• Early mobilization (within 48 hours) reduces morbidity.
• DVT prophylaxis: low-molecular-weight heparin (where available) or mechanical methods.
• Antibiotic prophylaxis for surgical patients.
• Calcium and vitamin D supplementation for all elderly fracture patients.

Rehabilitation and Follow-up

• Physiotherapy services are often limited—community-based rehab programs are essential.
• Encourage caregiver involvement and use of walking aids.
• Monitor for implant failure, malunion, or infection.

Complications

• Non-union or malunion, especially in poorly reduced subtrochanteric fractures.
• Deep infections, particularly in settings with inadequate sterile conditions.
• Implant failure if poor technique or inferior implant quality.
• Avascular necrosis is rare in extracapsular fractures but must be considered.

Public Health and Contextual Considerations

• Lack of trained orthopedic surgeons at the district level.
• The cost of surgery and implants are often unaffordable to patients without subsidies or insurance.
• Cultural preferences for traditional bone-setting delay appropriate care.
• Encourage task-shifting (training general surgeons in basic ortho procedures).
• Advocacy for orthopedic implant donations and surgical training.

Prevention Strategies

• Fall prevention in elderly (home safety, vision checks, balance training).
• Nutritional programs to address osteoporosis.
• Calcium + Vitamin D supplementation in high-risk populations.
• Public education on avoiding delays in hospital presentation after trauma.

Key Takeaways

• The management of pertrochaneric and subtrochanteric fractures should be patient centered depending on their condition, the type of fracture and previous comorbidities. 
• Timely and appropriate management of pertrochanteric and subtrochanteric fractures can restore function and prevent long-term disability.
• In sub-Saharan Africa, challenges include delayed presentation, resource constraints, and limited surgical capacity.
• Strengthening trauma systems, investing in training, and improving access to implants are crucial for improving outcomes.