Proximal femur fracture

Background

• Imaging
  • Consider AP pelvis in addition to AP/lateral views to compare contralateral side
  • Consider MRI if strong clinical suspicion but negative x-ray
• Most fx, including all displaced fx, are treated with ORIF
  • Exception is 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
• Despite good care, 30-day all cause mortality is 22% and grows to 36% at one year

Location of femur fractures

Differential Diagnosis

Hip pain

Acute Trauma

• Femur fracture
  • Proximal
    • Intracapsular
      • Femoral head fracture
      • Femoral neck fracture
    • Extracapsular
      • Intertrochanteric femur fracture
      • Trochanteric femur fracture
  • Shaft
    • Mid-shaft femur fracture (all subtrochanteric)
• Hip dislocation
• Pelvic fractures
  • Acetabular pelvic fractures
  • Open book pelvic fracture
  • Straddle pelvic fracture
  • Pelvic avulsion fracture

Chronic/Atraumatic

• Hip bursitis
• Psoas abscess
• Piriformis syndrome
• Meralgia paresthetica
• Septic arthritis
  • Septic arthritis of the hip (peds)
• Obturator nerve entrapment
• Avascular necrosis of hip

Intracapsular

Femoral Head

• Results from high-energy trauma (e.g. dashboard to flexed knee)
• Usually occurs along with dislocation:
  • Posterior dislocation
    • Fx of inf aspect of femoral head; concomitant sciatic nerve injury
  • Anterior dislocation
    • Fx of anterior femoral head; concomitant vascular injury
• Management
  • Immediate ortho consult; emergent closed reduction of dislocation

Femoral Neck

• Common in older pts w/ osteoporosis; rarely seen in younger pts
• Typically minimal bruising (intracapsular)
• If fractured and displaced: externally rotated and shortened
• If non-displaced: pt may be ambulatory
• 30% of pts w/ symptoms suggestive of fx but negative x-rays have fx on MRI
• Management
  • Ortho consult; admit
  • Skeletal traction is contraindicated (may compromise femoral head blood flow)

Extracapsular

Intertrochanteric

Garden's classification of intertrochanteric fractures

• Occur via fall in elderly or osteoporotic
• 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 (Garden's type I and II)
    • Lesser trochanter non-displaced, no comminution, medial cortices of prox/distal fragments aligned
  • Unstable (Garden's type III and IV)
    • Displacement occurs, comminution is present, or multiple fracture lines exist
• Management
  • Admit for eventual ORIF

Trochanteric

• Greater Trochanter
  • Via direct trauma (older pts) or avulsion injury (adolescents)
  • Hip pain that increases with abduction; tenderness over greater trochanter
• Lesser Trochanter
  • Via avulsion due to forceful contraction of iliopsoas (adolescents) or pathologic bone
  • Pts are usually ambulatory; c/o pain in groin worse w/ flexion
• Treatment for both types:
  • NWB with ortho f/u in 1-2wk

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
• Management
  • Consider traction split though little evidence to support its use
  • Admit for ORIF

See Also

• Fractures (Main)

Source

• UpToDate
• Harwood-Nuss
• Tintinalli