Hip fractures

Contents

Femoral Neck (Subcapital) Fracture

Definition

intracapsular fracture of the femoral neck

Femoral Head Vascular Supply
1.) Extracapsular arterial ring -branches of MFCA and LFCA 2.) Ascending cervical branches (retinacular arteries) 3.) Artery of ligamentum of teres

Mechanism

young = MVA, fall from height; older = simple fall onto hip usually rotational force

Clinical Features

acute onset of hip pain (groin pain)
inability to weightbear
shortened, externally rotated leg
painful ROM

X-ray Features of Subcapital Hip Fractures
Disruption of Shenton’s line Altered neck-shaft angle (normal is 120-130)

Investigations

x-ray: AP hip, pevlis, lateral hip

Classification

Garden classification

Displacement	Extent	Alignment	Trabeculae
None	Incomplete	Valgus	Malaligned
None	Complete	Neutral	Aligned
Some	Complete	Varus	Malaligned
Complete	Complete	Varus	Aligned

Garden Classification

Hip Fracture Risk Factors
Caucasian women Physical inactivity Excessive alcohol intake Use of psyschtropic meds Senile dementia Previous hip #

Treatment

type of treatment depends on displacement and patient age
-undisplaced (Garden 1, 2): internal fixation to prevent displacement
-displaced (Garden 3, 4): depends on patient age and function
-older patient (>60) -> hemiarthroplasty (bipolar hip THA)
-young patient, high function ? reduction with internal fixation within 12 hrs of fracture (to decrease risk of AVN & non-union)

Complications

AVN of femoral head: vascular supply is distal to proximal through the femoral neck so a fracture of the neck will disrupt the blood supply to the head and increase the risk of AVN
non-union
DVT

Intertrochanteric Fractures

Definition

extracapsular fracture including the greater and lesser trochanters and transitional bone between the neck and shaft

Mechanism

direct or indirect force transmitted to the intertrochanteric area

Clinical Features

acute onset hip pain (groin)
unable to weightbear
shortened, externally rotated leg
ecchymosis at back of upper thigh (greater trochanter)

Classification

stable vs. unstable
stable = intact posteromedial cortex
unstable = non-intact posteromedial cortex fractures

Investigations

AP pelvis, AP/lateral hip

Treatment

DVT prophylaxis
obtain a closed reduction under fluoroscopy
after reduction obtained, internal fixation with dynamic hip screw (DHS)

PEARL

the tip apex distance is the sum of the distance from the tip of the lag screw (DHS) to the apex of the femoral head on both AP & lateral view. If > 25mm, screw cut-out is more likely

Complications

few serious complications
varus displacement of the proximal fragment
malrotation deformity
non-union
failure of fixation device

Subtrochanteric Fractures

Definition

fracture that occurs at or below the lesser trochanter to a point 5 cm distal to the lesser trochanter (proximal shaft of femur)

Mechanism

young = high energy trauma
older = osteopenic bone + fall, pathological fracture

Clinical Features

similar to intertrochanteric fractures

Investigations

AP pelvis, AP/lateral hip and femur

Treatment

DVT prophylaxis
obtain a good closed reduction under fluoroscopy
after reduction obtained, interal fixation with intramedullary nail or plating

Complications

malalignment
non-union
wound infection

Plan:

– admit, no indication for Buck’s traction

CBC, LYTES,BUN/CREAT,URINALYSIS + X-MATCH 2 Units.
CXR + ECG
Medical Consult and Anaesthesia Consult pre-op

Types:

Subcapital

Garden types I and II are undisplaced. These require pin and plate fixation.

Garden types III and IV are displaced. These usually require hemiarthroplasty due to the very high incidence of avascular necrosis of the head fragment.