Proximal femur fracture: Difference between revisions

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==Intracapsular==
==Intracapsular==
===Femoral Head===
===Femoral Head===
* Usually occurs along with dislocation
*Results from high-energy trauma (e.g. dashboard to flexed knee)
** Posterior dislocation - Fracture of inf aspect of femoral head; concomitant sciatic nerve injury
*Usually occurs along with dislocation:
** Anterior dislocation - Fracture of anterior femoral head; concomitant vascular injury
**Posterior dislocation
===Femoral neck===
***Fx of inf aspect of femoral head; concomitant sciatic nerve injury
* Typically minimal bruising (intracapsular)
**Anterior dislocation
* If fractured and displaced:
***Fx of anterior femoral head; concomitant vascular injury
** Externally rotated and shortened
 
* Garden Classification
===Femoral Neck===
** Type 1: Impaction Fx
*Common in older pts w/ osteoporosis; rarely seen in younger pts
** Type 2: Nondisplaced Fx
*Typically minimal bruising (intracapsular)
** Type 3: Displacement of the femoral head
*If fractured and displaced:
** Type 4: Complete loss of continuity between fragments
**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==
==Extracapsular==
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* Unable to bear weight
* Unable to bear weight
* Shortening and external rotation if fracture is significantly displaced
* Shortening and external rotation if fracture is significantly displaced
* Types
*Types:
** Stable - Lesser trochanter is not displaced, no comminution, medial cortices of prox and dist. fragments are aligned
**Stable
** Unstable - Displacement occurs, comminution is present, or multiple fracture lines exist
***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===
===Trochanteric===
* '''Lesser Trochanter'''
*'''Lesser Trochanter'''
** Pain in groin or may present with knee or posterior thigh pain worse with hip flexion and rotation
**Via avulsion due to forceful contraction of iliopsoas (adolescents) or pathologic bone
** Most common in the young (due to forceful contraction of iliopsoas muscle)
**Pts are usually ambulatory; c/o pain in groin worse w/ flexion
*** If occurs in elderly pt with lack of trauma history consider lytic lesion
*'''Greater Trochanter'''
* '''Greater Trochanter'''
**Via direct trauma (older pts) or avulsion injury (adolescents)
** Hip pain that increases with abduction and tenderness over the greater trochanter
** Hip pain that increases with abduction; tenderness over greater trochanter
* Imaging
*Treatment for both types:
** Lessor trochanter - AP view with the leg in supported external rotation
**NWB for 3-4 weeks for non-displaced fx
** Greater trochanter - Standard AP view
**If displaced (> 1cm) refer to orthopedic surgeon for ORIF
* Treatment
** NWB for 3-4 weeks for non-displaced fx
** If displaced (> 1cm) refer to orthopedic surgeon for ORIF


===Subtrochanteric (including mid-shaft)===
===Subtrochanteric (including mid-shaft)===

Revision as of 04:53, 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

  • 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

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

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