Proximal femur fracture: Difference between revisions

Revision as of 05:28, 12 February 2012

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
- 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
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

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
  - Lesser trochanter non-displaced, no comminution, medial cortices of prox/distal fragments aligned
- Unstable
  - 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
- Admit for ORIF

Source

UpToDate
Harwood-Nuss
Tintinalli

Authors:

@@ Line 1: / Line 1: @@
 ==Background==
 * Imaging
-** Consider AP pelvis in addition to standard AP and lateral views to compare to contralateral side
+**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
@@ Line 19: / Line 19: @@
 **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:
+*If fractured and displaced: externally rotated and shortened
-**Externally rotated and shortened
+*If non-displaced: pt may be ambulatory
-*Garden Classification
+*30% of pts w/ symptoms suggestive of fx but negative x-rays have fx on MRI
-**Type 1: Impaction Fx
+*Management
-**Type 2: Nondisplaced Fx
+**Ortho consult; admit
-**Type 3: Displacement of the femoral head
+**Skeletal traction is contraindicated (may compromise femoral head blood flow)
-**Type 4: Complete loss of continuity between fragments
 ==Extracapsular==
 ===Intertrochanteric===
-* Typically pain, swelling, ecchymosis
+*Occur via fall in elderly or osteoporotic
-** May lose 1-2L of blood
+*Typically pain, swelling, ecchymosis
-* Unable to bear weight
+**May lose 1-2L of blood
-* Shortening and external rotation if fracture is significantly displaced
+*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
+***Lesser trochanter non-displaced, no comminution, medial cortices of prox/distal fragments aligned
 **Unstable
 ***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
-*'''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
+**NWB with ortho f/u in 1-2wk
-**If displaced (> 1cm) refer to orthopedic surgeon for ORIF
-===Subtrochanteric (including mid-shaft)===
+===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)
-* Clinical presentation is similar to intertrochanteric fracture
+*Clinical presentation is similar to intertrochanteric fracture
+*Management
+**Admit for ORIF
 ==Source==
-UpToDate, Harwood-Nuss
+*UpToDate
+*Harwood-Nuss
+*Tintinalli
 [[Category:Ortho]]