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

Femur Fracture Types

Proximal

• Intracapsular
  • Femoral head fracture
  • Femoral neck fracture
• Extracapsular
  • Intertrochanteric femur fracture
  • Trochanteric femur fracture

Shaft

• Mid-shaft femur fracture (all subtrochanteric)

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

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

See Also

• Fractures (Main)