Femoral Fractures

Femoral Head Fracture

Neck of Femur Fracture

Epidemiology: female>male (until >60yrs, then male>female); 5% due to metastases from breast; 90% due to falls; 10% have ipsilateral femoral shaft fracture (30% of which are missed initially)X-ray: 95% sensitivity; asymmetry of Shenton’s line (along superior border of obturator foramen and medial aspect of femoral metaphysis); angle to neck of shaft normally 135°; interruption of trabecular pattern, cortical disruption; soft tissue swelling

Epidemiology: rare; usually due to dislocation (superior aspect if anterior dislocation, inferior aspect if posterior; occurs in 6-16% hip dislocations); avascular necrosis in 15-20%, arthritis in 40%, myositis ossificans in 2%Management: number of attempts at reduction in ED should be limited

II

May be able to weight bear if impacted; tender ant-lat, axial compression and abduction; leg shortened and externally rotated if extracapsular (internally rotated in dislocation)MRI: 100% sensitivity Bone scan: 95% sensitivity USS: demonstrates effusion

Assessment

Intra-capsular

III-IV

Subcapital (42%) vs transcervicalHigher risk of complications (poor blood supply, poor bone quality for OT); 1-2 have up to 20% avascular necrosis (due to disruption of trochanteric anastomosis and intracapsular haemarthrosis); 3-4 have worse prognosis than this; 15-35% risk of avascular necrosis overall

Trabeculae disrupted Non-displacedInferior cortex intact Stable

Intra-capsular

Garden’sClassification

Intertrochanteric (43%), trochanteric, subtrochanteric (between trochanter and 5cm down); less risk of avascular necrosis; 4x more common; non-union rare; OT easier

Extra-capsular

Evans Classification

Neck of Femur Fracture (cntd)

I

Fracture complete Non-displacedInferior cortex broken UnstableII

Fracture complete Displaced (femoral head abducted and int rotated)Inferior cortex brokenIII

Fracture complete Fully displaced femoral head (in neutral position)Inferior cortex brokenIV

Single fracture; minimal displacementI

Lesser trochanter fractureII

Greater + lesser trochanter fracture + femoral neck separateIII

Fracture spirals into femoral shaftIV

Seek cause of fall; seek cancer; seek pelvic fracture, SDH; traction contraindicated in intracapsular as may compromise blood flow; no benefit from traction in any of these fracturesGarden I-II / all grades in younger patients / extracapsular = internal fixation with dynamic hip screwGarden III-IV = hemiarthroplastyConsider THJR in younger patient

Manage-ment

Surgical in 15%; medical in 30%; 50-60% return to pre-morbid functionning; mortality 10% @ 1/12, 25% @ 1yr, 50% @ 3yrs; overall mortality 10-30%

Compli-cations

Greater Trochanter

Fracture

Epidemiology: often aged 7-17yrs with indirect trauma or direct blow to hip, or older patientsMOI: direct trauma (older), or avulsion from contraction of gluteus medius (younger)Assessment: more lateral tenderness, less on axial compression; can weight bearClassification: I no intertrochanteric # displaced <1cm II displaced >1cmManagement: I bed rest 3/7 crutches 4/52 NWBing II requires internal fixation

Lesser Trochanter

Fracture

Epidemiology: children and young athletes (85%); due to iliopsoas avulsionAssessment: pain on flexion and internal rotation; Ludloff sign (can’t raise foot off ground when seated)Management: bed rest and slow mobilisation

Slipped Upper Femoral

Epiphysis

Epidemiology: early adolescence (older than Perthes); often overweight, male; may be associated with hypothyroidism, often bilateral; history of injury in <30%Examination: external rotation and shortening (like an extracapsular femoral fracture); especially internal rotation sore +/- flexion and abductionXR: AP: line though greater trochanter epiphysis should cut through femoral head epiphysis; always XR both hips to compare to other side for slip Lateral: Line on lateral should bisect head of NOF; mild <1/3, mod <1/2, severe >1/2Stable if: chronic, can walk, no effusion, evidence of remodellingUnstable if: acute, can’t walk, effusion present, no remodellingManagement: OT

Salter Harris I

Femoral Shaft Fracture Assessment: leg shortened, externally rotated (like SUFE, extracapsular femoral neck fracture), slight

abduction; may be rupture of profunda femorisWinquist classification: I minimal/no comminution II communition of <50% circumference of major # fragments III comminution of >50% circumference of major # fragments IV all cortical contact lost / circumferential comminution of segment of boneManagement: reduction and immobilisation pain and bleeding (use Thomas / Donway splint; splint OK but traction contraindicated if possible sciatic nerve injury); early internal fixation <8hrs in adults (II IM nail; III interlocking screws); may be treated in spica / traction if childComplications: can lose up to 2L blood; high risk of fat embolism if treatment delayed >24hrs; ARDS; malunion and nonunion rare

Epidemiology: usually due to falls, MVA (ie. High force); consider NAI if infant / preschool; transverse most common; pathological are uncommon

Femoral Shaft Fracture

Epidemiology: axial load to flexed knee; high energy needed if young; tend to rotate; may be grossly comminuted

Classification (Muller AO): A extra-articular transverseB intra-articular unicondylar (lateral or medial or coronal) C intra-articular bicondylar shortening and anterior displacement of shaft, posterior angulation of rotation

Management: internal fixation; POP only if extra-articularComplication: vascular injury in 2-3%; knee ligament injury in 20%

Femoral Condyle Fracture

Intercondylar / condylar; possible popliteal artery injury and deep peroneal nerve (1st web space) Complications – DVT, fat embolus, delayed union, malunion, OA