Download Femoral Fractures

Femoral Fractures
Epidemiology: rare; usually due to dislocation (superior aspect if anterior
dislocation, inferior aspect if posterior; occurs in 6-16% hip dislocations);
avascular necrosis in 15-20%, arthritis in 40%, myositis ossificans in 2%
Management: number of attempts at reduction in ED should be limited
Femoral Head
Fracture
Epidemiology: female>male (until >60yrs, then male>female); 5% due to metastases from breast; 90%
due to falls; 10% have ipsilateral femoral shaft fracture (30% of which are missed initially)
X-ray: 95% sensitivity; asymmetry of Shenton’s line (along superior border of obturator foramen and
medial aspect of femoral metaphysis); angle to neck of shaft normally 135°; interruption of trabecular
pattern, cortical disruption; soft tissue swelling
Neck of Femur
Fracture
Assessment
May be able to weight bear if impacted; tender ant-lat, axial compression and
abduction; leg shortened and externally rotated if extracapsular (internally rotated
in dislocation)
MRI: 100% sensitivity Bone scan: 95% sensitivity USS: demonstrates effusion
Subcapital (42%) vs transcervical
Higher risk of complications (poor blood supply, poor bone quality for OT); 1-2 have
up to 20% avascular necrosis (due to disruption of trochanteric anastomosis and
intracapsular haemarthrosis); 3-4 have worse prognosis than this; 15-35% risk of
avascular necrosis overall
II
Intracapsular
III-IV
I
Trabeculae disrupted
Inferior cortex intact
Non-displaced
Stable
Intracapsular
II
Fracture complete
Inferior cortex broken
Non-displaced
Unstable
Garden’s
Classification
III
Fracture complete
Inferior cortex broken
Displaced (femoral head abducted and int rotated)
IV
Fracture complete
Inferior cortex broken
Fully displaced femoral head (in neutral position)
Intertrochanteric (43%), trochanteric, subtrochanteric (between trochanter and
5cm down); less risk of avascular necrosis; 4x more common; non-union rare; OT
easier
Neck of Femur
Fracture (cntd)
Extracapsular
Evans
Classification
Greater
Trochanter
Fracture
I
Single fracture; minimal displacement
II
Lesser trochanter fracture
III
Greater + lesser trochanter fracture + femoral neck separate
IV
Fracture spirals into femoral shaft
Management
Seek cause of fall; seek cancer; seek pelvic fracture, SDH; traction contraindicated
in intracapsular as may compromise blood flow; no benefit from traction in any
of these fractures
Garden I-II / all grades in younger patients / extracapsular = internal fixation with
dynamic hip screw
Garden III-IV = hemiarthroplasty
Consider THJR in younger patient
Complications
Surgical in 15%; medical in 30%; 50-60% return to pre-morbid functionning;
mortality 10% @ 1/12, 25% @ 1yr, 50% @ 3yrs; overall mortality 10-30%
Epidemiology: often aged 7-17yrs with indirect trauma or direct blow to
hip, or older patients
MOI: direct trauma (older), or avulsion from contraction of gluteus
medius (younger)
Assessment: more lateral tenderness, less on axial compression; can
weight bear
Classification: I no intertrochanteric # displaced <1cm
II
displaced >1cm
Management: I bed rest 3/7  crutches 4/52 NWBing
II requires internal fixation
Lesser
Trochanter
Fracture
Slipped Upper
Femoral
Epiphysis
Epidemiology: children and young athletes (85%); due to iliopsoas
avulsion
Assessment: pain on flexion and internal rotation; Ludloff sign (can’t
raise foot off ground when seated)
Management: bed rest and slow mobilisation
Salter Harris I
Epidemiology: early adolescence (older than Perthes); often overweight, male; may be associated with
hypothyroidism, often bilateral; history of injury in <30%
Examination: external rotation and shortening (like an extracapsular femoral fracture); especially
internal rotation sore +/- flexion and abduction
XR: AP: line though greater trochanter epiphysis should cut through femoral head epiphysis; always XR
both hips to compare to other side for slip
Lateral: Line on lateral should bisect head of NOF; mild <1/3, mod <1/2, severe >1/2
Stable if: chronic, can walk, no effusion, evidence of remodelling
Unstable if: acute, can’t walk, effusion present, no remodelling
Management: OT
Epidemiology: usually due to
falls, MVA (ie. High force);
consider NAI if infant /
preschool; transverse most
common; pathological are
uncommon
Femoral Shaft
Fracture
Assessment: leg shortened, externally rotated (like SUFE, extracapsular femoral neck fracture), slight
abduction; may be rupture of profunda femoris
Winquist classification: I minimal/no comminution
II communition of <50% circumference of major # fragments
III comminution of >50% circumference of major # fragments
IV all cortical contact lost / circumferential comminution of segment of bone
Management: reduction and immobilisation  pain and bleeding (use Thomas / Donway splint; splint
OK but traction contraindicated if possible sciatic nerve injury); early internal fixation <8hrs in adults (II
 IM nail; III  interlocking screws); may be treated in spica / traction if child
Complications: can lose up to 2L blood; high risk of fat embolism if treatment delayed >24hrs; ARDS;
malunion and nonunion rare
Epidemiology: axial load to flexed knee;
high energy needed if young; tend to
rotate; may be grossly comminuted
Femoral Shaft
Fracture
Classification (Muller AO):
A extra-articular transverse
B intra-articular unicondylar (lateral or
medial or coronal)
C intra-articular bicondylar
shortening and anterior displacement
of shaft, posterior angulation of
rotation
Management: internal fixation; POP only
if extra-articular
Complication: vascular injury in 2-3%;
knee ligament injury in 20%
Femoral Condyle
Fracture
Intercondylar / condylar; possible popliteal artery
injury and deep peroneal nerve (1st web space)
Complications – DVT, fat embolus, delayed union,
malunion, OA