Proximal femur fracture

Overview

• 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 xray
• Most fractures, 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 hemoglobin < 12
  • Peritrochanteric fx�
• Adolescent + knee or hip pain = rule-out SCFE�

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)====
  • Occur 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