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