LL: PROXIMAL FEMUR FRACTURES

Question 1

FEMORAL NECK FRACTURES

Answer 1

CAUSE
Falls, particularly in the elderly

DEFORMITY
Unable to weightbear on the affected side
May or may not complain of pain in the hip
The leg is usually held in external rotation and may be shortened

COMPLICATIONS
Avascular necrosis
Non-union

Question 2

TREATMENT OF FEMORAL NECK FRACTURES

Answer 2

The patient is usually put on skin traction to relieve pain and minimise further displacement
Early mobilisation is a priority for elderly patients Internal fixation, hemiarthroplasty or THR depending on classification

Type 1 and Type 2
Position maintained by pins, screws or screw and plate
Sometimes Types 1 and 2 are treated conservatively. The patient will be put onto skin traction until the pain settles (not more than 1/52) and will then be mobilised PWB for up to 8 weeks. X-ray monitoring is important.

Type 3
If the fracture can be reduced, the reduction is maintained by a dynamic hip screw. If it cannot be reduced it is treated as a grade 4.

Type 4
A fit young patient may have a dynamic hip screw inserted as they can undergo THR later if necessary. An older patient will probably have a THR. An elderly patient who is not fit and healthy will have a hemiarthroplasty.

Question 3

CONTRA-INDICATIONS AND PRECAUTIONS OF FEMORAL NECK FRACTURES

Answer 3

Skin Traction
General contra-indications
No SLR
Dynamic hip screw (or other plates and screws)
No SLR
No abduction in side lying
TWB/PWB (usually FWB by 3/52)
Hip flexion initially limited to 90
No forced passive movements
Avoid excessive hip rotation
Hemiarthroplasty/ Total Hip Replacement
Posterior approach- 6/52
Do not cross legs (i.e. no hip abduction)
Do not remove abduction pillow
Avoid combined hip flexion, adduction and internal rotation at least for 
6/52
Hip internal/external rotation <45,
No hip flexion > 90
No SLR 
No side lying
PWB initially
Avoid sitting in low chairs and low toilet seats

Anterolateral approach- 4/52
Do not cross legs (i.e. no hip abduction)
Do not remove abduction pillow
No hip flexion > 90
Hip internal/external rotation <45
No SLR
PWB initially
Additional Restrictions:
Abduction pillow postoperative, elevated toilet seats, elevated chairs,
prevented from sleeping on their side, prevented from driving
intertrochanteric fracture- fracture line runs along the base of the
femoral neck between the trochanters
pertrochanteric fracture- the line involves both trochanters, one or
both of which, may be fractured or separated

Question 4

CLASSIFICATION OF FEMORAL NECK FRACTURES

Answer 4

Garden Type 1
Incomplete fracture of the neck- cortex is not completely disrupted
Trabeculae are angulated
No obvious displacement of fragments
Maybe impacted and in valgus

Garden Type 2
Complete without displacement
Fracture line is complete
Trabecular lines interrupted, but not angulated
No obvious displacement of fragments

Garden Type 3
Complete with partial displacement
Fracture line is complete
Rotation of the femoral head in the acetabulum
Fracture is only slightly displaced
Disturbance of trabecular pattern

Garden Type 4
Complete femoral fracture with full displacement
Fracture is fully displaced
Femoral head usually lies in neutral in acetabulum- rotates back into its
anatomical position

Question 5

INTERTROCHANTERIC FRACTURES PATHOPHYSIOLOGY & MANAGEMENT

Answer 5

CAUSE
Associated with falls in the elderly
TYPES
Stable if fracture only has two parts
Unstable if more comminuted and medial femoral cortex is disrupted
COMPLICATIONS
Malunion
Prolonged immobilisation in elderly patients
TREATMENT
Dynamic hip screw is usually the treatment of choice

Question 6

SUBTROCHANTERIC FRACTURES

Answer 6

CAUSE
Major trauma
Pathological fracture

DEFORMITY
Proximal fragment pulled into flexion and abduction

A) AP view showing varus deformity caused by strong abductors acting on the proximal segment
B) Lateral view showing flexion caused by iliopsoas
(Hak et al. 2015)

COMPLICATIONS
Malunion
Often associated with knee injury

TREATMENT
Conservative
Skeletal traction with the hip and knee both flexed to 90
Surgical treatment
ORIF with a variety if options for fixation (intra-medullary nails, dynamic
screws, plates etc)

CONTRA-INDICATIONS AND PRECAUTIONS
Skeletal traction
General contra-indications
No further hip flexion
No sitting > elbow support for 3-4/52

ORIF
As for ORIF discussed for other fractures

Question 7

TROCHANTERIC FRACTURES

Answer 7

Isolated fractures of the greater or lesser trochanter may occur due to sudden
muscle contraction. Fracture of the greater trochanter may also result from direct
violence.
Large fragments may be reattached with screws. These fractures are usually
treated symptomatically.
Non-union may occur causing marked weakness.