Traumatic Proximal Femur

Fractures
Molly E. Collins, Harvard Medical School
Gillian Lieberman, MD
 Overview of Presentation
• Discuss the importance of fractures
affecting the hip joint
• Review anatomy and types of fractures
• Introduce a classic patient presentation
• Discuss the radiologic evaluation
• Address complications and treatment
principles
 Falls and Fractures
• More than one-third of those over age 65
fall each year.
• 90% of fractures involving the hip joint
occur in those over age 50.
• 90% of falls in the elderly are the result of
a simple fall.
• We may think of the scope of this topic
as…

Tinetti, NEJM 2003

 Scope of Topic
Prevention Mediating Factors

Risk Factors • Bone strength

• Force vector of fall
• Medical issues
• Baseline function

Falls Complications
• Fractures affecting
hip joint
Predisposing Medical Conditions
• Other MSK trauma
• Subdural hematoma
• Dehydration
• Immobility, disability

Tinetti, NEJM 2003

 Background
• Epidemiology:
– 250,000 fractures affecting the hip joint in the U.S. each year.
– Affects one-third of American women who survive past 80
years old.
– Risk factors include: maternal history of fracture, excessive
consumption of alcohol and caffeine, physical inactivity, low body
weight, tall stature, previous fracture, use of certain psychotropic
medications, residence in an institution, visual impairment, and
dementia.
• The bones of the hip joint are among the most
common sites of fracture in those with osteoporosis.
• Downward spiral: Mortality rate is 14-36% in the first
year following a fracture involving the hip joint.

Eustace, Radiol Clin North Am 1997; Zuckerman, NEJM 1996

Anatomy of Proximal Femur
Anterior View

Netter, http://www2.ma.psu.edu/~pt/384fem1a.gif
Types of Proximal Femur
Fractures
• Fractures may be
classified
anatomically as
intracapsular or
extracapsular.
• ~45% of proximal
femur fractures
Intracapsular occur at the
femoral neck
(intracapsular), and
~45% are
intertrochanteric
(extracapsular).
Extracapsular • Subtrochanteric
fractures (also
(extracapsular)
account for 5-10%.

Tintinalli, Kelen, Stapczynski, Tintinalli’s Emergency Medicine, 6th Ed.

 Describing Fractures
• Although there are many different classification
systems for proximal femur fractures, it is usually
most helpful to identify the fracture anatomically
and describe it accurately.
• With proximal femur fractures, it is especially
important to note whether there is displacement,
as this reflects stability of the fracture and the
likelihood of complications.
 Our Patient: History and Physical
• 84 year-old female presenting with pain
status-post mechanical fall onto left hip.
• HPI: No head trauma, loss of
consciousness. No preceding vertigo,
lightheadedness.
• PMH: Osteoporosis, atrial fibrillation,
hypertension.
• Exam: Left lower extremity shortening and
external rotation, peripheral pulses intact.
 Our Patient: Left Femoral Fracture on Pelvis Radiograph
Film Findings
• Comminuted
intertrochanteric
fracture
• Asymmetric
lesser
trochanters
• Degenerative
changes:
sclerosis and
joint space
narrowing along
pubic symphysis,
SI joints, and
lower lumbar
spine

PACS, BIDMC
 Our Patient: Fracture on Proximal Femur Radiograph
Film Findings
• Comminuted
intertrochanteric
fracture lines
appearing as
lucencies, with
communicating
fracture planes
• Extension of
fracture into the
femoral shaft

PACS, BIDMC
Our Patient: Fracture on Cross-Table Lateral Radiograph
Anterior

Film Findings
• Film is underexposed and this is, therefore, a limited evaluation of the femoral head
and neck for displacement.
PACS, BIDMC
• Cortex discontinuity, comminuted fracture.
 Our Patient: Fracture Description

• In summary, our patient’s fracture is described

as a comminuted left intertrochanteric fracture
extending into the proximal femoral shaft with
mild varus angulation of the femoral shaft.
• The most common complications of
intertrochanteric fractures are malunion and
shortening.
• Avascular necrosis and nonunion are rare here
given the rich blood supply to the
intertrochanteric region from cancellous bone.
 Radiologic Evaluation of Suspected
Proximal Femur Fractures
• First obtain plain radiographs in
anteroposterior and lateral views.
– Obtain AP view with 15-20 degrees of internal rotation at the hip
joint to lengthen the femoral neck for the best view.
• Beware of occult fractures, which can be difficult
to see, especially when nondisplaced and in
osteopenic bone.
– In one study of 70 patients with negative plain films, 37% had
proximal femur fractures discovered with MRI.
– Delayed diagnosis can lead to complications. In one study of 38
patients with delayed diagnosis, 7 of 9 who had displaced
fractures developed avascular necrosis or nonunion.

Bogost, Lizerbram, Crues, Radiololgy 1995; Eustace, Radiol Clin North Am 1997; Ohashi, Brandser, El-
Khoury, Radiol Clin North Am 1997
 Radiologic Evaluation, Continued
• If plain film is nondiagnostic and there is continued clinical suspicion
of a proximal femur fracture, this must be pursued.
• Next obtain:
– MRI
• Test of choice given high sensitivity and specificity,
approaching 100% within the first 24 hours following a fracture.
• Detects marrow edema and hemorrhage.
• May distinguish other injuries that mimic fractures clinically,
such as muscle injury.
– Bone scan
• 80% detection rate in the first 24 hours, may take up to 72 hours
to show radiotracer uptake.
– CT
• Less sensitive than MRI, so consider if there is contraindication
to MRI.
• Will show fracture lines better than plain film, and can identify
cortical abnormalities.

Conway, Totty, McEnery, Radiology 1996; Eustace, Radiol Clin North Am 1997; Ohashi, Brandser, El-
Khoury, Radiol Clin North Am 1997
 Occult Fractures
• A demonstration of these concepts…
 Companion Patient 2: Normal Proximal Femur on
Radiograph
• Plain film
obtained for
suspected
femoral
fracture.

Film Findings
• Film read as
normal by
radiologist.
• Patient
positioned well,
with good
visualization of
femoral neck.

Courtesy Dr. Shetty

Companion Patient 2: Proximal Femur Fracture on MRI
Film Findings
• Low signal fracture line
• Fluid in soft tissue, likely blood
• Significant bone marrow edema

MRI
• Fractures are seen as low signal in all
sequences.
• American College of Radiology
appropriateness criteria guidelines
recommend coronal T1-weighted
sequence to evaluate suspected occult
fracture.
• MRI can facilitate appropriate early
intervention or discharge and can also
aid in surgical planning by showing the
axis of fracture and the extent of injury.
T2 Fat Saturation, Coronal View
Courtesy Dr. Shetty
 Complications of Femoral Neck
Fractures
• Common complications of femoral neck
fractures include avascular necrosis and
nonunion.
• Incidence varies by fracture location,
degree of fracture displacement, and is
decreased with appropriate treatment.
Companion Patient 3: Right Femoral Neck
Fracture on Pelvis Radiograph
• 88 year-old
woman s/p
mechanical
fall.

Film Findings
• Minimally
displaced
femoral neck
fracture

PACS, BIDMC
Companion Patient 3: Femoral Neck Fracture on
Femur Radiograph
Film Findings
• Minimally
displaced
femoral neck
fracture

Courtesy Dr. Wu
 Companion Patient 3: Fracture on Cross-Table
Lateral Radiograph
Anterior
Film Findings
• Femoral neck fracture
• Femoral head with
slight posterior
rotation/displacement
• Ischial tuberosity
• Pubic symphysis

• Even minor
displacement may be
associated with
avascular necrosis
(AVN) due to the
anatomy of the
vascular supply of the
femoral neck.
PACS, BIDMC
 Vascular Anatomy

• The femoral head and neck are supplied by the medial and lateral femoral
circumflex arteries, with a minor contribution from a branch of the obturator
artery.
Jones, http://home.pacific.net.au/~rossjones/Avn.htm
 Vascular Anatomy, Continued

• Vessels may be kinked, torn, or compressed by a displaced fracture, leading

to AVN.
Wheeless, http://www.wheelessonline.com/ortho/medial_femoral_circumflex_artery
 Treatment Principles
• Stabilize the patient:
– Correct fluid and electrolyte abnormalities if present.
– Prevent weight-bearing on injured hip until work-up is
complete.
• Early surgery followed by early mobilization:
– If indicated, surgery should be performed within 24-48
hours, as longer intervals increase post-operative
complications and mortality at one year.
• Return patient to prior level of function:
– 50-65% regain prior level of ambulation.
• Address osteoporosis:
– In a recent study only 13% of women >65 with a
recent fracture received adequate treatment.
Morrison, Siu, UpToDate 2008; Zuckerman, NEJM 1996
 Our Patient: Hospital Course
• Taken to the OR for open reduction
internal fixation.
• Our patient was able to ambulate with a
walker upon discharge.
 Our Patient: Post-Op Fixation on Pelvis Radiograph
Film Findings
• Intramedullary
nail in femoral
shaft
• Gamma nail in
femoral head

PACS, BIDMC
 Our Patient: Post-Op Fixation on Femur Radiograph
Film Findings
• Intramedullary
nail in femoral
shaft
• Gamma nail in
femoral head
• Screw fixing
intramedullary
nail

• Screws prevent
migration of the
intermedullary nail.

PACS, BIDMC
 Summary
• Proximal femur fractures are common, and can
be life-changing events with significant
associated morbidity and mortality.
• Early radiological identification of fractures with
radiograph and follow-up studies is critical.
• Detection rate of subtle or occult fractures has
been improved with MRI.
• Accurate description of fractures allows
appropriate and timely treatment to avoid long-
term complications and improve outcomes.
 References
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Jones, R. Arthritis and other joint problems - AVN, 2001. http://home.pacific.net.au/~rossjones/Avn.htm
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Radiologic Clinics of North America 35: 591-613, 1997.
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Tintinalli JE, Kelen GD, Stapczynski JS. Classification of proximal femur fractures. Tintinalli’s Emergency Medicine: A
Comprehensive Study Guide, 6th Ed. http://accessemergencymedicine.com
Wheeless CR. Medial femoral circumflex artery. Wheeless’ Textbook of Orthopaedics.
http://www.wheelessonline.com/ortho/medial_femoral_circumflex_artery
Zuckerman JD. Hip fracture. New England Journal of Medicine 334: 1519-1525, 1996.
 Acknowledgments
I would like to sincerely thank:
Dr. Ferris Hall
Dr. Gillian Lieberman
Dr. Sanjay Shetty
Dr. Jim Wu