Fractures of the

Proximal Femur

Prof. Hesham El Sherif

Proximal Femoral Fractures

• They tend to occur in older patients,

and in those who have osteoporosis.
• Fracture is usually the result of low-
impact trauma.
• In younger patients is due to high-
impact trauma, usually during a car
accident.
Anatomic regions relating to
areas of proximal femoral
fractures
 Types of Hip Fractures
SUBTROCHANTERIC FRACTURES
 Intracapsular fractures
• Intracapsular fractures
can damage the small
intracapsular vessels that
provide the majority of
the blood supply to the
femoral head.
• Femoral neck fractures
are intracapsular .
• Femoral head fractures are rare
intracapsular injuries, but they do not
cause disruption to the vessels that
supply blood to the femoral head.
• They usually occur secondary to
femoral head dislocation.
 Extracapsular Fractures
INTERTROCHANTERIC
SUBTROCHANTERIC FRACTURES
FRACTURES

They are all grouped as Trochanteric fractures of various

types.
FEMORAL NECK
FRACTURES
 Blood supply to the head and
neck of femur
• The profunda femoris
artery arising from the
femoral artery gives
off medial circumflex
femoral artery.
 Incidence

• Is common in the elderly.

• Occasionally in young adults, and
even in children.
• It occurs more frequently in
women.
 Mechanism

• Rotation violence at the hip due to tripping

over something on the floor and falling
or
• A direct violence over the lateral aspect of
the hip by a fall on the side.
 Types of neck of femur
Fractures
• Subcapital: femoral head/neck junction.
• Transcervical: midportion of femoral neck.
• Basicervical :Basal (cervico-trochanteric)
: base of femoral neck. (extracapsular)
 Classification (Garden) of
Femoral Neck Fractures
• According to the appearance of the
hip on the AP radiograph.
• It is used to determine the appropriate
treatment.
stage I : incomplete fracture of
the neck (so-called abducted
or impacted)
stage II : complete without
displacement
stage III: complete with partial displacement:
fragments are still connected by posterior
retinacular attachment; there is mal-alignment
of the femoral trabeculae
stage IV : this is a complete fracture with full
displacement: the proximal fragment is free
and lies in the acetabulum (the trabeculae
appear normally aligned)
 Line of angle fractures
(Pauwels classification).
 Clinical Features
• Elderly person with a history of a fall and
inability to walk.
• On inspection
external rotation, shortening of the leg.
The attachment of the capsule to the distal
fragment prevents excessive external rotation
of the leg.
• On palpation
tenderness over the anterior and lateral aspects
of the hip joint, the greater trochanter is
elevated.
• All movements are extremely painful except in
the rare case of an impacted type of fracture.
Radiological
Features
 • Impacted and stress fractures: No obvious
clinical deformity. The patient has minor
discomfort with active or passive hip range of
motion, muscle spasms at extremes of motion
and pain with percussion over the greater
trochanter.

Sub-capital hip fracture. there is a step-off in the cortex superiorly

(red arrow) while there is abnormal overlapping of the femoral head
and
neck (white arrows) due to impaction.
 Radiography has some limitations

 Spiral fractures are difficult to assess on a

single view.
 Comminution is also not as easily demonstrated
as it is with CT.
 Some stress fractures are simply not visible on
plain images at all.
 CT
• Plays an increasingly important role in
evaluating the hip after a fracture.
 MRI
• MRI is both sensitive and specific in the
detection of femoral neck fractures, because it
can show both the actual fracture line and the
resulting bone marrow edema.
MRI
 Drawbacks of MRI
• Longer imaging time.
• Its relative lack of widespread availability.
• Its higher costs.
• And the exclusion of patients with cardiac
pacemakers and certain metal hardware in their
body.
Nuclear Medicine (Bone scan)

 For suspected femoral neck fractures not confirmed by

means of plain radiography.
 80% of fractures can be visualized 24 hours after
trauma,
 By 3 days after trauma, 95% of fractures are visualized,
 maximal fracture sensitivity is found at 7 days
 Conservative Treatment
Fractures at this level have a poor capacity for union
due to the following factors.
• a) interference with the blood supply to the proximal
fragment.
• b) difficulty in controlling the small proximal fragment.
• c) the lack of organization of the fracture haematoma
due to the presence of the synovial
fluid.
Accordingly, conservative measures are of no value and
recommended only for bed ridden.
Surgical Treatment

• Two essential principles

(a) perfect anatomical reduction.
(b) rigid internal fixation.
In young patients (and Elderly patients
who have Minimally displaced fractures( Garden I or II fractures)

ORIF as soon as
possible to decrease
the risk of avascular
necrosis.
 Closed or open
reduction, with
percutaneous
placement of 3
parallel cannulated
lag screws
Reduction of displaced fractures
 “horizontal” position

• Try to give a more “horizontal” position of the

fracture line, to reduces the risk of
displacement in the postoperative period.
• Special reduction in which the displacement of
fragments give a more “horizontal” position.
• Successful where the blood supply to the
head of the femur is unlikely to have been
damaged by the fracture.
In older patients
In displaced fractures, and
elderly
• The blood vessels on the posterior aspect
of the femoral neck may be torn, and the
blood supply to the head of the femur
may be compromised.
 In older patients above 60
years
• By removing the head of the
femur and replacing it by metal
prosthesis like Austin Moore's or
Thompson’s prosthesis.
• This enables the patient to be
ambulant and start early weight
bearing.
• Total hip replacement may be
preferable in arthritic patients.
 Hemiarthroplasty is the
procedure of choice for
elderly patients with
displaced femoral neck
fractures.
Independent ambulators
benefit from a cemented
hemiarthroplasty, because
pain after surgery and
component loosening are
minimal with this approach.
Fracture neck of femur in Children
The fracture is reduced by manipulation and the
leg immobilized in full plaster spica in abduction
for 8-10 weeks.
When indicated internal fixation could be done
with multiple thin Austin Moore's Pins.
Complications of Fracture Neck
of Femur

The important
complications are:
• a) Non-union
• b) Avascular necrosis
of head of femur.
Non-
union

• Due to improper reduction of imperfect internal fixation

• Pain and instability on walking.
• Treated by intertrochanteric osteotomy (McMurray) in the
younger age group and replacement arthroplasty in the
elderly.
 Avascular Necrosis
• After any type of internal
fixation.
• pain and limping.

• limitation of all movements

with muscle spasm.
• Radiography shows patchy
areas of increased density in
the head of the femur.
• Treatment in the early stages
is by rest, traction and weight
relieving caliper. When
indicated, osteotomy or
replacement arthroplasty is
done.
INTERTROCHANTERIC
FRACTURES
The intertrochanteric line
Classification of intertrochanteric fractures
 TROCHANTERIC FRACTURE
(Extra Capsular Fracture neck of
femur)
• (i) Stable and
• (ii) Unstable fractures.
• the blood supply to the
proximal fragment is not
interfered with
• and there is a greater area of
contact between the two
fragments; hence the fractures
unite easily.
• While union is the rule, it is
common to see these fractures
malunited with a coxa vara
deformity.
• Patients present with more leg external
rotation than subcapital fractures
• X-ray diagnosis is usually straightforward.
• The normal neck shaft
angle is about 115
degrees.
• When the angle is
reduced to nearer
90 degrees, the deformity is
called Coxa Vara.
• These fractures occur in
the elderly and the nature
of the violence is the
same as in the
intracapsular fracture.
 Clinical Features

- Shortening and external rotation (the

degree of external rotation is greater than
in the intra capsular fracture.
Local swelling and echymoses over the
trochanteric area.
Painful limitations of All movements of the
hip (to be differentiated from intracapsular
fracture).
 Intracapsular Extracapsular

Incidence Less common More common

Causative violence Minimal rotation violence Lateral violence

Clinical features

External rotation Minimal Fully externally rotated

Local swelling Nil Marked local swelling

Treatment Difficult Easy

Complications

Non Union Common Does not occur

Malunion Rare Common

 Radiological features

• Stable Type: There is

a single fracture line
and it is a two piece
fracture.
• Unstable Type: This is a comminuated fracture
with multiple fractures at the trochanteric level
 Operative Treatment (DHS)

• The advantage
compared with a static
screw, is that it allows for
impaction of the
fragments; this impaction
increases the bone-on-
bone contact, promoting
osseous healing while
decreasing implant stress.
The disadvantage

• Shortening and rotation at the fracture site.

• Internal fixation of intertrochanteric
fractures with the ‘dynamic hip screw’
(DHS) is the preferred treatment method
• It allows controlled collapse of the fracture
when the patient is weight bearing to
encourage union of the fracture.
• As the fracture heals, some shortening may
occur.
 Complications
• The main complication is malunion with coxa
vara and shortening.
• If the coxa vara is gross, it can be corrected
by osteotomy.
 SUBTROCHANTERIC FRACTURES

 Subtrochanteric is
typically defined as
the area from
lesser trochanter
to 5 cm distal.
 Are less common than
femoral neck and
intertrochanteric
fractures.
• Usually in younger patients with a high-
energy trauma and may occur in elderly
patients from a low-energy trauma.
 Russell-Taylor classification
• Type I does not extend into the
piriformis fossa, and thus,
intramedullary nailing can be
beneficial.
• Type II fracture extends proximally
into the greater trochanter and
involve the piriformis fossa.
• Symptoms
Hip and thigh pain and inability to bear weight.
• Physical exam
Pain with motion, typically is associated with
obvious deformity (shortening and varus
alignment).
Flexion of proximal fragment may threaten
overlying skin.
 Radiographs
• AP and lateral radiographs of the hip shows
the proximal fragment flexed and abducted
while the distal fragment is adducted and
externally rotated.
• Subtrochanteric fractures generally
have a good prognosis due to the
good supply of blood and adequate
collateral circulation.
Treatment
• One option
Intramedullary nail with
interlocking hardware
that extends into the
femoral neck.
is the method of
choice.
 intramedullary fixation of
subtrochanteric fracture.
• Another option
Fixed angle plate
extramedullary device,
such as a 95-degree lag
screw and side plate or
blade plate
. indicated in associated
femoral neck fracture,
narrow medullary canal
and pre-existing femoral
shaft deformity.
Thank You