Proximal femur fracture: Difference between revisions
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== | ==Background== | ||
* Imaging | * Imaging | ||
** Consider AP pelvis in addition to standard AP and lateral views to compare to contralateral side | ** Consider AP pelvis in addition to standard AP and lateral views to compare to contralateral side | ||
** Consider MRI if strong clinical suspicion but negative | **Consider MRI if strong clinical suspicion but negative x-ray | ||
* Most | *Most fx, including all displaced fx, are treated with ORIF | ||
** Isolated trochanteric fx often does not require surgery | **Isolated trochanteric fx often does not require surgery | ||
* Skeletal traction is not beneficial | *Skeletal traction is not beneficial | ||
* Type and cross/screen for pts at higher risk of hemorrhage | *Type and cross/screen for pts at higher risk of hemorrhage: | ||
** Age > 75 yrs | **Age > 75 yrs | ||
** Initial | **Initial Hb < 12 | ||
** Peritrochanteric fx | **Peritrochanteric fx | ||
==Intracapsular== | ==Intracapsular== | ||
===Femoral Head=== | |||
* Usually occurs along with dislocation | * Usually occurs along with dislocation | ||
** Posterior dislocation - Fracture of inf aspect of femoral head; concomitant sciatic nerve injury | ** Posterior dislocation - Fracture of inf aspect of femoral head; concomitant sciatic nerve injury | ||
** Anterior dislocation - Fracture of anterior femoral head; concomitant vascular injury | ** Anterior dislocation - Fracture of anterior femoral head; concomitant vascular injury | ||
===Femoral neck=== | |||
* Typically minimal bruising (intracapsular) | * Typically minimal bruising (intracapsular) | ||
* If fractured and displaced: | * If fractured and displaced: | ||
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==Extracapsular== | ==Extracapsular== | ||
===Intertrochanteric=== | |||
* Typically pain, swelling, ecchymosis | * Typically pain, swelling, ecchymosis | ||
** May lose 1-2L of blood | ** May lose 1-2L of blood | ||
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** If displaced (> 1cm) refer to orthopedic surgeon for ORIF | ** If displaced (> 1cm) refer to orthopedic surgeon for ORIF | ||
===Subtrochanteric (including mid-shaft)=== | |||
* Occurs with severe trauma or in association with pathological bone | * Occurs with severe trauma or in association with pathological bone | ||
** Blood loss can be substantial (average loss = 1L) | ** Blood loss can be substantial (average loss = 1L) | ||
Revision as of 04:30, 12 February 2012
Background
- Imaging
- Consider AP pelvis in addition to standard AP and lateral views to compare to contralateral side
- Consider MRI if strong clinical suspicion but negative x-ray
- Most fx, including all displaced fx, are treated with ORIF
- Isolated trochanteric fx often does not require surgery
- Skeletal traction is not beneficial
- Type and cross/screen for pts at higher risk of hemorrhage:
- Age > 75 yrs
- Initial Hb < 12
- Peritrochanteric fx
Intracapsular
Femoral Head
- Usually occurs along with dislocation
- Posterior dislocation - Fracture of inf aspect of femoral head; concomitant sciatic nerve injury
- Anterior dislocation - Fracture of anterior femoral head; concomitant vascular injury
Femoral neck
- Typically minimal bruising (intracapsular)
- If fractured and displaced:
- Externally rotated and shortened
- Garden Classification
- Type 1: Impaction Fx
- Type 2: Nondisplaced Fx
- Type 3: Displacement of the femoral head
- Type 4: Complete loss of continuity between fragments
Extracapsular
Intertrochanteric
- Typically pain, swelling, ecchymosis
- May lose 1-2L of blood
- Unable to bear weight
- Shortening and external rotation if fracture is significantly displaced
- Types
- Stable - Lesser trochanter is not displaced, no comminution, medial cortices of prox and dist. fragments are aligned
- Unstable - Displacement occurs, comminution is present, or multiple fracture lines exist
Trochanteric
- Lesser Trochanter
- Pain in groin or may present with knee or posterior thigh pain worse with hip flexion and rotation
- Most common in the young (due to forceful contraction of iliopsoas muscle)
- If occurs in elderly pt with lack of trauma history consider lytic lesion
- Greater Trochanter
- Hip pain that increases with abduction and tenderness over the greater trochanter
- Imaging
- Lessor trochanter - AP view with the leg in supported external rotation
- Greater trochanter - Standard AP view
- Treatment
- NWB for 3-4 weeks for non-displaced fx
- If displaced (> 1cm) refer to orthopedic surgeon for ORIF
Subtrochanteric (including mid-shaft)
- Occurs with severe trauma or in association with pathological bone
- Blood loss can be substantial (average loss = 1L)
- Clinical presentation is similar to intertrochanteric fracture
Source
UpToDate, Harwood-Nuss