1.2.1 Definition and basic concepts
In the Anglo-American literature and in the colloquial language the fractures of the proximal femur are known as "hip fractures" on account of their frequency and their medical and socioeconomic impact. This term is imprecise and has therefore not been accepted in other languages. In the pertinent literature one finds terms such as proximal femur fractures, fractures of the upper third of the femur and femoral fractures close to the hip.
Two major groups of hip fractures have been recognized in the pertinent literature and in trauma surgery. We distinguish between intracapsular (medial neck-) and extracapsular (lateral neck-also known as basal, as well as trochanteric and subtrochanteric) fractures (Figs. 1 and 2).
An increasing number of researchers insist that in respect to mean age, degree of osteoporosis and
Fig. 1. Recommendations of classification of hip fractures according to Parker and Pryor (1993).
I. Limit between neck and trochanter region. II. Most frequent localization of recess of joint capsule. Medial neck fracture (1.). Extracapsular fractures (2., 3. and 4.). Lateral and base of neck fracture (2.). Per- and intertrochanteric fracture (3.). Subtrochanteric fracture (4.)
general condition a distinction must be made between the two fracture types in respect to the patient collective (Lawton et al, 1981; Hedlund et al, 1987; Karagas et al, 1996; Mautalen et al, 1996; Fox et al, 1999; Michaelsson et al, 1999; Huang et al, 2000). Moreover, the principle differences in the causes of the disease and the treatment (surgical techniques) justify a distinction between both groups as also accepted by the International Classification of Diseases (ICD).
Moreover, an essential difference lies in the fact that the blood loss of the intracapsular fractures is minimal, that the fracture line in general lies inside the joint capsule, that the injured person tolerates the fracture better, that the patient can be operated immediately and that the incidence of early mortality is lower (Jakobssen and Stenstrom, 1984; Koval et al, 1996). On the other hand, the blood loss of extracapsular fracture, particu larly for comminuted fractures, can be considerable given the great surface of exposed cancellous bone and the concomitant injury to surrounding blood vessels. These facts must be considered during treatment; they may play a role in the increased incidence of mortality.
Further on, another definite difference is found in the fact that the blood supply to the femoral neck is at greater risk in intracapsular fractures (Manninger, 1963). The retinacular arteries and veins supplying the femoral head may tear or become incarcerated between the fragments. If these vessels are severely injured or if the decompression is not done in a timely fashion due to a delayed reduction, a partial or complete necrosis of the femoral head may result. The consequence is a nonunion or after consolidation a progressive deformity and later a collapse of the head resulting in a severe osteoarthritis.
t basal extracapsular fr- trochanteric undisplaced displaced undisplaced displaced
, undisplaced , displaced 2 fragments femoral neck
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