Proximal femur fracture

Background

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 x-ray
Most fx, 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 Hb < 12
- Peritrochanteric fx

Results from high-energy trauma (e.g. dashboard to flexed knee)
Usually occurs along with dislocation:
- Posterior dislocation
  - Fx of inf aspect of femoral head; concomitant sciatic nerve injury
- Anterior dislocation
  - Fx of anterior femoral head; concomitant vascular injury

Common in older pts w/ osteoporosis; rarely seen in younger pts
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

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

Lesser Trochanter
- Via avulsion due to forceful contraction of iliopsoas (adolescents) or pathologic bone
- Pts are usually ambulatory; c/o pain in groin worse w/ flexion
Greater Trochanter
- Via direct trauma (older pts) or avulsion injury (adolescents)
- Hip pain that increases with abduction; tenderness over greater trochanter
Treatment for both types:
- NWB for 3-4 weeks for non-displaced fx
- If displaced (> 1cm) refer to orthopedic surgeon for ORIF

Occurs with severe trauma or in association with pathological bone
- Blood loss can be substantial (average loss = 1L)
Clinical presentation is similar to intertrochanteric fracture

UpToDate, Harwood-Nuss

Authors: