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Fractures of the Proximal Femur

 

         Hip fractures are associated with a substantial mortality, as many as 15-20% dying within one year of the fracture

         Conditions that predispose to hip fractures include aging, osteoporosis and osteomalacia

o       Most hip fractures in the elderly (90%) occur as a result of a fall, frequently a minor fall such as from the standing position

         In younger individuals, hip fractures are often the result of high velocity, high impact trauma

         Most hip fractures occur in Caucasian women

         Imaging

o       Conventional radiography is the study of first choice

o       When further imaging is required, MRI or nuclear medicine scans are used most often utilized

o       The femoral neck will be seen in profile when the leg is held in internal rotation

         Hip fractures can be classified as to their geographic position as: subcapital, transcervical, basicervical, intertrochanteric and subtrochanteric

o       Subcapital, transcervical and  basicervical are intracapsular

o       Intertrochanteric and subtrochanteric are extracapsular

         Intracapsular fractures have a higher incidence of nonunion and avascular necrosis  of the femoral head (up to 35%) than extracapsular fractures

o       The more displaced the fragments are, the higher the rate of complications

         Subcapital fractures

o       Most common intracapsular fracture of the hip

o       Subtle, frequently impacted

o       White line of increased density of impacted bone may be seen at base of femoral head

o       There may be a discontinuity in the normal smooth curve of the superior aspect of the femoral neck as it joins the head

o       Pitfall: a rim of osteophytes may form around the femoral head and project over the neck mimicking the sclerotic line of a subcapital fracture

         Look for cortical discontinuity

         May require additional imaging such as MRI for confirmation of fracture

         Transcervical fractures

o       Occur across the neck of the femur

o       Usually easy to see on views of the hip obtained in internal rotation

o       Frequently associated with varus deformity

         Basicervical fractures

o       Base of the femoral neck

o       May be difficult to differentiate a basicervical fracture from a non-displaced and non-comminuted intertrochanteric fracture

         Intertrochanteric fractures

o       Most common of the extracapsular hip fractures

o       Comminuted fractures may also manifest separate fragments of either or both of the lesser and greater trochanters

o       Intertrochanteric fractures associated with a separate fragment of lesser trochanter may also include a portion of the posterior cortex of femoral neck and are considered unstable

o       Many intertrochanteric fracture are associated with a varus deformity

 

 

Comminuted intertrochanteric fracture. There is a fracture from the greater to the
lesser trochanter (blue arrow). There are separate fragments of the greater trochanter
(white arrow) and lesser trochanter (red arrow). There is varus deformity
(white line) of the femoral shaft.

For a larger photo of the same image without arrows, click on this link

 

         Isolated fractures of the greater trochanter

o       Occur in osteoporotic females and are the result of a fall on the greater trochanter or may occur as an avulsion-type fracture from pull of the gluteus medius insertion

o       These fractures may be difficult to see as the greater trochanter may be overexposed on routine views of the hip

o       Important to exclude an intertrochanteric fracture which requires operative reduction and internal fixation, while the isolated fracture of the greater trochanter does not

o       MRI may be needed to exclude intertrochanteric extension

         Classification - Garden Classification

o       The most commonly used classification system for femoral neck fractures is some variation of the Garden classification

o       As its basis, the classification separates non-displaced fractures from displaced fractures because of the better healing rate of the former
 

Stage

Description

Remarks

Stage I

Incomplete fracture of the neck

May be impacted and in valgus

Stage II

Complete without displacement

Stage III

Complete with partial displacement

Fragments are still connected by posterior retinacular attachment

Stage IV

Complete femoral neck fracture with full displacement

Allows the femoral head to rotate back into anatomical position

 

         Treatment

o       Intracapsular fractures of the femoral neck are most often treated with a prosthetic or replacement device for the femoral head and/or neck

o       Intertrochanteric fractures are frequently treated using a compression-type screw, pin or nail and laterally-placed side-plate

         Intramedullary nails are also used for fixation


 

 

 
Harris and Harris, The Radiology of Emergency Medicine
eMedicine, Hieu T Truong and Amilcare Gentili