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