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ABSTRACT ObjectivesTo report the results of retrograde intramedullary nailing (RIMN) for the treatment of extremely proximal femur fracturesDesignRetrospective cohortSettingLevel I trauma centerPatients/ParticipantsSixty-three femoral shaft fractures involving the anatomic region within ten centimeters of the inferior border of the lesser trochanter that were treated with RIMNInterventionRetrograde intramedullary femoral nailMain Outcome MeasurementsTime to union, nonunion, malunion, and unplanned reoperationResultsBetween 2009 and 2020, sixty-three fractures were followed to fracture union, reoperation, or a minimum of one year clinically. Mean follow-up was 32 months and 48 (76%) of the patients were followed beyond one year clinically. The mean patient age was 34 years (range 18-84 years) and the mean BMI was 27 (range 14-45). Forty (64%) patients were polytraumatized. Clinical and radiographic union was achieved in 59 (94%) fractures after index operation at a mean time to union of 22 weeks (range 9-51 weeks). Delayed union requiring nail dynamization occurred in one (2%) instance. Malreduction was noted in one (2%) patient with a 12° flexion deformity that resulted in nonunion. In total, there were three (5%) nonunions requiring revision surgery, one treated with retrograde exchange nailing and two revised to cephalomedullary nails; all united after revision.ConclusionsRIMN can be an effective treatment strategy for extremely proximal femur fractures when necessary. Our series demonstrated a high rate of union and a low rate of malalignment and complications.