FIG. 265-16. Fractures of the proximal femur are traditionally classified as intracapsular and extracapsular. (From Greenspan A. Orthopedic Radiology. Philadelphia: JB Lippincott, 1988, p 5.17. Used with permission.)
In intracapsular fractures with displacement, the femoral neck vessels are compromised due to a tear or compression secondary to an intracapsular hemarthrosis. The blood supply through the ligamentum teres may not be sufficient to nourish the entire femoral head. Therefore, avascular necrosis inevitably results (15 to 35 percent overall) unless some of the capsular vessels remain intact. Basilar neck and intertrochanteric fractures below the capsule rarely sever important arteries. Morbidity and mortality associated with hip fractures is primarily due to patient immobilization and the development of deep venous thrombosis and pulmonary embolus. Even with modern treatment modalities, mortality following hip fracture ranges from 15 to 35 percent within one year of surgery and 25 to 50 percent of the survivors will not regain their ability to ambulate.29 Factors predictive of increased mortality include male sex, increased age, dementia, institutionalization, poorly controlled systemic disease, and the development of postoperative complications. There is some evidence that early (<72 h) hip fracture fixation of low impact hip fractures in the elderly reduces morbidity and mortality.303! and32
FEMORAL HEAD FRACTURES Isolated femoral head fractures occur infrequently. They are usually associated with dislocations of the hip. Shear fractures of the superior aspect of the femoral head are associated with anterior dislocations, and shear fractures of the inferior femoral head are associated with posterior dislocations.
In most instances, the symptoms and signs are those of the associated dislocation rather than of the fracture itself. The standard AP and lateral x-ray views usually demonstrate the fragment adequately. When there is an associated dislocation, the postreduction films offer a better view of the fracture fragment.
Orthopedic consultation should be obtained in the ED for these fractures. Treatment is to reduce the associated dislocation and then attain anatomic reduction of the fracture fragment. Complications are associated with the high-energy trauma that produces the fracture-dislocation, that is, the more comminuted the fracture, the more severe the dislocation and the greater the severity of trauma to the patient. Life-threatening injuries must then be ruled out.
The prognosis is related to the severity of the initial trauma resulting in the dislocation. Poor prognostic indicators include delay between hip dislocation and reduction, repetitive unsuccessful relocation attempts and associated injuries. Posttraumatic arthritis occurs in one-third to two-thirds of patients, avascular necrosis in 10 to 20 percent and myositis ossificans in approximately 1 to 2 percent. 33
FEMORAL NECK FRACTURES Femoral neck fractures are commonly seen among older adults, due to osteoporosis, and occur more frequently in women than in men. These fractures are rare among the younger population. The cause of such fractures is usually minor trauma secondary to falls (90 percent) or torsion in the patient with osteoporosis or osteomalacia. In younger patients, the high kinetic energy sustained in the major trauma causes a fracture through normal bone with marked soft tissue disruption and comminution.
The classification of femoral neck fractures is by fragment displacement. The symptoms seen with femoral neck fractures range from complaints of mild pain in the groin or inner thigh in patients with an incomplete fracture to moderate to severe pain in patients with displaced fractures.
Patients who have sustained a fracture without displacement may walk with some limping rather than being completely unable to bear weight. Their only physical findings are minor pain with movement and minimal muscle spasm limiting range of motion. In contrast, displaced fractures cause severe pain, inability to ambulate, limited range of motion, and no palpable movement of the extracapsular head. The patient lies with the extremity in slight external rotation, abduction, and shortening.
Radiographic evaluation is essential in any patient suspected of having a femoral neck fracture. Stress fractures, however, may not show up on x-ray for days or weeks, so repeat films or bone scans in symptomatic patients are necessary. The standard AP view should have the patient maximally internally rotated to best demonstrate the femoral neck. The AP view should be inspected for a fracture line starting on the superior surface of the neck. These fracture lines routinely become complete within 10 to 14 days. Also, disruption of Shenton's line may be appreciated on the AP view in some instances. If there is any concern that the patient has sustained a fracture that is not visible on the initial x-ray examination, the patient should be conservatively treated and x-ray films should be made again in 10 to 14 days; or the physician may order a CT or MRI, which demonstrates the fracture in most instances. In contrast, displaced fractures are obvious on the AP film, but a lateral view should also be done to ascertain the exact position.
Orthopedic consultation should be obtained in the emergency department for these fractures. The orthopedic surgeon's goal of treatment for femoral neck fractures is anatomic reduction and stability. Treatment for nondisplaced or impacted fractures is somewhat controversial but usually involves a form of internal fixation. This is due in part because up to 15 percent of impacted fractures can develop secondary displacement without surgery. Conservative treatment is generally only considered if the patient is medically unfit for surgery or the fracture is several weeks old and the patient is walking without pain. 22 Displaced fractures definitely require emergency surgery for fixation. Prosthetic hip replacements may be required in certain instances, particularly in those patients over age 70. 27 The timing of surgery remains controversial. Early surgery (<72 h) is indicated in fit patients, whereas surgery should be delayed if correctable comorbidities are present. Special note should be made of stress fractures because some are treated in a conservative manner and others are treated with internal fixation, depending on the type of fracture and the patient's cooperation. Skeletal traction is contraindicated with femoral neck fractures because it may further compromise femoral head blood flow.
The complications of femoral neck fractures are significant. They include infections, emboli, and avascular necrosis, which is the most feared early complication. Avascular necrosis has an incidence of 15 percent in nondisplaced fractures and rises to near 90 percent with untreated, completely displaced fractures. A higher incidence is also associated with more severe fractures or fractures that are not surgically reduced to anatomic position within 48 h. Nonunion in nondisplaced fractures is rare but occurs in approximately 20 to 30 percent of patients with displaced fractures. 22
TROCHANTERIC FRACTURES Greater trochanteric fractures are usually due to avulsions at the insertion of the gluteus medius. In the younger population (7 to 17 years of age), this is a true epiphyseal separation, in contrast to the adult population, in which this is due to direct trauma. 22 The patient presents with pain, especially with abduction and extension, and a limp. Also, there is tenderness to palpation over the greater trochanter.
Standard AP and lateral x-ray views reveal displacement in the superior-posterior area, or comminution. The treatment is generally conservative with protected weight-bearing recommended until the patient is asymptomatic. Outpatient orthopedic referral is indicated. Orthopedic consultation for possible surgical fixation may be indicated for fracture displacement of greater than 1 cm.22
Lesser trochanteric fractures due to an avulsion secondary to a forceful contraction of the iliopsoas are commonly seen in children and young athletic adults, particularly gymnasts and dancers. These patients present with pain during flexion and internal rotation maneuvers. In most instances, the treatment is bedrest and then gradual weight-bearing to regain full activity. Outpatient followup by primary care or orthopedics is advised. Full recovery generally occurs within three weeks.
If greater than 2-cm displacement is seen on the standard AP and lateral views, then screw fixation by the consulting orthopedic surgeon may be indicated.
INTERTROCHANTERIC FRACTURES These fractures are defined as extracapsular fractures occurring in a line between the greater and lesser trochanters. Intertrochanteric fractures generally occur in the elderly and are more common in women, again due to the high incidence of osteoporosis. The mechanism of injury is usually a fall or occasionally an automobile accident. It is postulated that a rotational component along with the direct trauma is involved in some instances as well.
Symptoms and signs include pain, swelling of the hip, local ecchymosis, and pain with any hip movement or weight-bearing. Moreover, the extremity is markedly externally rotated and shortened, in contrast to the minimal deformities associated with femoral neck fractures. These fractures are classified as stable or unstable. Stable fractures are defined as ones in which the medial cortices of the neck and femoral fragments abut. X-ray evaluation should include AP and lateral views, with the AP view having as much internal rotation as possible to adequately visualize the neck.
Severe life-threatening injuries must be excluded. The consulting orthopedic physician can then admit the patient to the hospital and perform surgical fixation to attain a stable reduction as soon as possible, although this is not an emergency. Buck's traction ( Fig, 2.6.5.-1.7.) may temporarily help reduce pain.
The complications and prognosis are related to other associated injuries and prior disease. The overall mortality is approximately 10 to 30 percent. Infection can be a major problem, with an incidence of up to 17 percent.34 Thromboembolic disease is especially a problem if postoperative mobilization does not occur quickly. Avascular necrosis is rare in these patients, and nonunion is also uncommon. Morbidity is due to the patient's inability to return to prefracture activity.
SUBTROCHANTERIC FRACTURES Subtrochanteric fractures may be seen in two different populations. They usually occur secondary to falling in the 40- to 60-year-old patient with osteoporotic or weakened bone. The second population is young persons who have suffered major trauma with significant kinetic energies directed into the femur. These fractures may be an extension of an intertrochanteric or other isolated fracture and are usually classified as stable or unstable, with stable defined as bony contact of the medial and posterior femoral cortices.
The symptoms and signs are similar to those of trochanteric or femoral fractures, with local pain, deformity, swelling, crepitance, etc. These patients can lose a large amount of blood into the thigh area and may present in hypovolemic shock. Because this injury is due to significant trauma, other, more life-threatening injuries must be excluded prior to treatment of this specific fracture.
Treatment consists of immobilization with a traction apparatus. Hare (Dyna-Med, Carlsbad, CA) or Sager (Minto Research & Development, Redding, CA) splints ( Fig.
265-18 and Fig 265-19) may be employed in the prehospital setting. Proper evaluation of the entire patient to rule out associated severe injuries should be conducted. After the patient has stabilized and secondary evaluation has occurred, orthopedics should be consulted. Open reduction and internal fixation is generally indicated for fracture management.34
The complications are similar to those of intertrochanteric fractures, except that there is a higher incidence of nonunion. Malunion and delayed union occur as well in this population. Prognosis is better for proximal fractures that are not comminuted.
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