European Journal of Cardiovascular Medicine

Proximal femoral fractures constitute a major public health problem and are among the most common causes of hospitalization following trauma, particularly in the elderly population. Their incidence has increased significantly over recent decades due to improved life expectancy, a rising geriatric population, and a higher prevalence of osteoporosis¹. These fractures are associated with considerable morbidity, mortality, loss of independence, and socioeconomic burden. Although low-energy trauma such as trivial falls is the most common mechanism in elderly patients, younger individuals typically sustain proximal femoral fractures following high-energy trauma such as road traffic accidents or falls from height.² Anatomically, proximal femoral fractures include fractures of the neck of femur, intertrochanteric fractures, and subtrochanteric fractures, each presenting unique biomechanical characteristics and clinical challenges.The proximal femur is subjected to complex biomechanical forces, including axial loading, bending, and rotational stresses during routine activities such as standing and walking^3,-5. The integrity of the posteromedial cortex plays a crucial role in load transmission, and disruption of this region, particularly in unstable fracture patterns, leads to increased instability and a higher risk of mechanical failure. Intertrochanteric and subtrochanteric fractures are frequently associated with comminution, loss of cortical support, and varus displacement, which further complicate fracture management³. In addition, poor bone quality in elderly patients compromises implant purchase and increases the risk of fixation failure.The primary goals in the management of proximal femoral fractures are early anatomical stabilization, restoration of limb alignment and length, and early mobilization of the patient. Delayed mobilization is associated with serious complications, including deep vein thrombosis, pulmonary embolism, pneumonia, pressure sores, muscle wasting, and increased mortality^4,5. Therefore, timely surgical intervention is widely accepted as the cornerstone of management, as it facilitates early rehabilitation and improves functional outcomes. Achieving and maintaining stable fracture reduction is critical, as inadequate reduction has been shown to be a major contributor to complications such as malunion, non-union, limb shortening, and poor functional recovery⁶.Clinical outcome following proximal femoral fractures is influenced by multiple factors, including patient age, bone quality, fracture pattern, associated comorbidities, timing of surgery, and the quality of reduction and fixation achieved⁷. Elderly patients often present with medical comorbidities such as diabetes mellitus, hypertension, and cardiovascular disease, which may adversely affect postoperative recovery and overall outcome. Functional outcome is commonly assessed using standardized scoring systems such as the Harris Hip Score, which evaluates pain, mobility, and daily activity performance^8,9. Despite advances in surgical techniques and perioperative care, proximal femoral fractures continue to be associated with significant functional impairment, particularly in older patients.proximal  femoral fractures remain a challenging orthopedic problem due to their high incidence, complex biomechanics, and association with substantial morbidity and mortality.¹⁰ Successful management requires a comprehensive understanding of fracture anatomy, biomechanics, patient factors, and principles of early stabilization and rehabilitation¹¹. A structured approach aimed at restoring stability and enabling early mobilization is essential to achieve favorable functional outcomes and reduce complication rates.

Keywords: Proximal fractures, PFN , Outcome

AIM

To evaluate the functional outcome and complications following treatment of proximal femoral fractures using proximal femoral nailing.

This prospective observational study was conducted in the Department of Orthopaedics at a tertiary care teaching hospital at Bikaner, over a period of 1 yr, from oct 2024 to sept 2025. A total of 75 patients with proximal femoral fractures who presented to the emergency department or outpatient department during the study period were included. All patients were evaluated clinically and radiologically using standard anteroposterior radiographs of the pelvis with both hips and additional views as required. Fractures were classified based on anatomical location and standard fracture classification systems. After obtaining informed written consent, patients underwent surgical management as per institutional protocol and surgeon discretion. Postoperatively, patients were followed up at regular intervals for clinical assessment, radiological union, functional outcome, and complications. Functional outcome was assessed and radiological union was evaluated . Data regarding demographic profile, fracture pattern, time to surgery, duration of hospital stay, complications, and final outcome were recorded and analyzed.

Patients aged 18 years and above with radiologically confirmed proximal femoral fractures, including intertrochanteric and subtrochanteric fractures, who were medically fit for surgery and willing to participate in the study were included. Patients with pathological fractures, periprosthetic fractures, fractures associated with polytrauma requiring prolonged intensive care, patients with previous ipsilateral hip surgery, and those who were unfit for surgery or lost to follow-up were excluded from the study.

Table 1: Demographic Profile of Patients (n = 75)

The age of patients in the present study ranged from 18 to over 70 years. The most common age group affected was 51–60 years (24.0%), followed by 61–70 years (22.6%).

Table 2: Gender distribution of patients

Out of 75 patients included in the study, 46 (61.3%) were males and 29 (38.7%) were females, showing a male predominance.

Table 3:Fracture Pattern Distribution

Intertrochanteric fractures constituted the majority of cases in the present study, accounting for 62 patients (82.7%), while 13 patients (17.3%) sustained subtrochanteric fractures.

Table 4: Time to Surgery

Most patients underwent surgery within 24–48 hours (42.7%), followed by 28.0% who were operated on within 24 hours of admission. A smaller proportion of patients experienced surgical delay beyond 48 hours.

Table 5:Duration of Hospital Stay

The majority of patients had a hospital stay of 8–10 days (41.3%), followed by 37.3% who were discharged within 7 days. Prolonged hospitalization beyond 14 days was required in only a small proportion of patients.

Table 6: Complications Observed

Complications were observed in a minority of patients, with 51 patients (68%) experiencing no complications. Among those affected, hip stiffness (10.7%) and limb shortening (8.0%) were the most common.

Table 7:Time of radiological outcome

Radiological union was achieved within 13–16 weeks in the majority of patients (42.7%), followed by 34.7% who united within 12 weeks. Delayed union occurred in 13.3% of cases, while non-union was observed in only 2.7% of patients.

Table 8:Final Functional Outcome (Harris Hip Score)

Based on the Harris Hip Score, excellent outcomes were observed in 32 patients (42.7%), while good outcomes were seen in 24 patients (32%). Fair and poor outcomes were noted in 16% and 9.3% of patients respectively.

The age distribution of patients in the present study showed that proximal femoral fractures were more common in the older age groups. The highest incidence was observed in patients aged 51–60 years (24.0%), followed by those in the 61–70 years age group (22.6%). Patients aged 41–50 years constituted 18.7% of the study population, indicating a gradual increase in fracture incidence with advancing age. Younger patients aged 31–40 years and 18–30 years accounted for 12.0% and 8.0% respectively, reflecting lower incidence in this group. Patients aged more than 70 years comprised 14.7% of cases, highlighting the vulnerability of the elderly population.

In the present study, a total of 75 patients with proximal femoral fractures were evaluated with respect to gender distribution. Males constituted the majority of the study population with 46 patients, accounting for 61.3% of cases. Female patients comprised 29 cases, representing 38.7% of the total. Kanthimathi B et al ¹² The age distribution was from 24- to 60-years-old with an average age of 46-years-old. Thirty-two were males and eighteen were females.

In the present study, intertrochanteric fractures constituted the majority of proximal femoral fractures, accounting for 62 patients (82.7%). Subtrochanteric fractures were observed in 13 patients (17.3%). The higher incidence of intertrochanteric fractures can be attributed to the anatomical and biomechanical vulnerability of the trochanteric region, especially in elderly individuals with osteoporotic bone. These fractures commonly result from low-energy trauma such as falls. Subtrochanteric fractures, although less frequent, are often associated with higher energy mechanisms and present greater challenges in management due to strong muscular forces acting on the fracture fragments.

The time interval between injury and surgery was analyzed in all patients included in the study. Surgery was performed within 24 hours in 21 patients (28.0%), reflecting early operative intervention in a significant proportion of cases. The majority of patients, 32 (42.7%), underwent surgery within 24–48 hours of injury. A further 14 patients (18.7%) were operated between 48–72 hours. Delayed surgery beyond 72 hours was required in 8 patients (10.6%), mainly due to associated medical comorbidities or delayed presentation.

The duration of hospital stay in the present study varied among patients depending on fracture severity, associated comorbidities, and postoperative recovery. The majority of patients, 31 (41.3%), had a hospital stay of 8–10 days, followed by 28 patients (37.3%) who were discharged within 7 days. A smaller proportion of patients required prolonged hospitalization, with 11 patients (14.7%) staying for 11–14 days. Only 5 patients (6.7%) had a hospital stay exceeding 14 days, which was mainly due to postoperative complications or delayed mobilization.

Postoperative complications were observed in a minority of patients in the present study. Superficial surgical site infection occurred in 4 patients (5.3%), while deep infection was noted in 1 patient (1.3%). Implant-related complications were seen in 5 patients (6.7%), and limb shortening greater than 1 cm was observed in 6 patients (8.0%). Hip stiffness was reported in 8 patients (10.7%), often associated with delayed mobilization. The majority of patients, 51 cases (68%), did not develop any postoperative complications.  The complication rate was low and comparable with reported literature.Sonkaria et al¹³ Complication rates were low, with deep infection and screw migration observed in 4% each.

Radiological assessment of fracture healing showed that a substantial proportion of patients achieved union within an acceptable time frame. Fracture union within 12 weeks was observed in 26 patients (34.7%). The majority of fractures united between 13–16 weeks, accounting for 32 patients (42.7%). Delayed union beyond 16 weeks was noted in 10 patients (13.3%). Only 2 patients (2.7%) progressed to non-union. Overall, these findings indicate a high rate of fracture union in the present study.Jawad MJ et al¹⁴ Radiological assessment showed 29 (90.6%) cases to have smooth union and 3 (9.4%) cases failure of fixation.

Functional outcome assessment using the Harris Hip Score showed that a large proportion of patients achieved favorable results. Excellent outcomes (score >90) were observed in 32 patients (42.7%), indicating near-normal hip function. Good outcomes (score 80–89) were seen in 24 patients (32%), reflecting satisfactory pain relief and mobility. Fair results (score 70–79) were noted in 12 patients (16%), who had mild residual symptoms. Poor outcomes (score <70) were recorded in 7 patients (9.3%), often associated with complications or delayed rehabilitation. Overall, the majority of patients achieved excellent to good functional outcomes, demonstrating effective recovery following treatment.Prakash AK, et al¹⁵ In Group PFN, results were excellent in 56.52% (13 patients), good in 34.78% (eight patients), and fair in 8.70% (two patients).

The findings of this study suggest that appropriate surgical management of proximal femoral fractures leads to favorable radiological and functional outcomes with an acceptable complication profile. Early stabilization, careful perioperative management, and timely rehabilitation play a crucial role in achieving optimal outcomes. The results of the present study are consistent with existing literature and reinforce the importance of structured management protocols in improving the overall prognosis of patients with proximal femoral fractures.

1. Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg 1995;77:1058-64.
2. Sierra RJ, Cabanela ME. Conversion of failed hip hemi- arthroplasties after femoral neck fractures. Clin Orthop Relat Res. 2002;399:129-39.
3. Simpson AH, Varty K, Dodd CA. Sliding hip screws: modes of failure. Injury. 1989;20:227–31.
4. Moein CM, Verhofstad MH, Bleys RL, van der Werken C. Soft tissue injury related to choice of entry point in antegrade femoral nailing: piriform fossa or greater trochanter tip. Injury.2005;36:1337–4.
5. Baumgaertner MR, Curtin SL, Lindskog DM. Intramedullary versus extramedullary fixation for the treatment of intertrochanteric hip fractures. Clin Orthop Relat Res. 1998;348:87–94.
6. Euler E, Huber St, Heining S, Schweiberer L. Spannungsoptische Untersuchung unterschiedlicher Stabilisierungsverfahren bei pertrochanta ren Femurfracturen. Hefte Unfallchir. 1996;262:2.
7. Velasco RU, Comfort TH. Analysis of treatment problems in subtrochantric fractures of the femur. J Trauma. 1978;18(7):513-23.
8. Babst R, Renner N, Bieder MM, Rosso R, Heberer M, Harder F, Regzzoni P. Clinical results using the trochanteric stabilizing plate: the modular extension of the dynamic hip screw for internal fixation of intertrochanteric fractures. J Orthop Trauma. 1998;12(6):392-99.
9. Klinger HM, Baums HM, Eckert M, Neugebauer R. A comparative study of unstable per and intertrochanteric femoral fractures with DHS and PFN and TSP. Zentralbl Chir. 2005;130(4):301-6.
10. Al-yassari G, Langstaff RJ, Jones JW, Al-Lami M. The AO/ASIF proximal femoral nail (PFN) for the treatment of unstable trochanteric femoral fracture. Injury. 2002;33(5):395-9.
11. Pajarinen J, Lindahl J, Michelsson O, Savolainen V, Hirvensalo E. Pertrochanteric femoral fractures treated with a dynamic hip screw or a proximal femoral nail. A randomised study comparing post-operative rehabilitation. J Bone Joint Surg Br.2005;87(1):76-81.
12. Kanthimathi B, Narayanan V. Early Complications in Proximal Femoral Nailing Done for Treatment of Subtrochanteric Fractures. Malays Orthop J. 2012 Mar;6(1):25-9. doi: 10.5704/MOJ.1203.009. PMID: 25279038; PMCID: PMC4093588.
13. Sonkaria, D. R., Singh, D. A. K., Prakash, D. S., & Pawar, D. I. (2025). Evaluation of functional outcomes of unstable intertrochanteric fracture treated with proximal femoral nailing using modified Harris Hip Score. European Journal of Cardiovascular Medicine, 15(2), 142–152. DOI: 10.5083/ejcm/25-02-19.
14. Jawad MJ. Evaluation of using PFN (proximal femoral nailing) in treatment of unstable intertrochanteric fractures in elderly patients. J Pak Med Assoc. 2021 Dec;71(Suppl 8)(12):S179-S184. PMID: 35130245.
15. Prakash AK, S NJ, Shanthappa AH, Venkataraman S, Kamath A. A Comparative Study of Functional Outcome Following Dynamic Hip Screw and Proximal Femoral Nailing for Intertrochanteric Fractures of the Femur. Cureus. 2022 Apr 4;14(4):e23803. doi: 10.7759/cureus.23803. PMID: 35518518; PMCID: PMC9066962.