Hip and femur fractures

Introduction

• Women 2x more likely
• Morbidity and mortality are due to prolonged immobilisation with VTE the most common complication
• 5-8 fold increase in all-cause mortality in first 3 months
• 30% mortality at one year
• Advanced age, male gender and comorbidities increase mortality risk

Introduction

• Intracapsular fractures compromise blood supply to femoral head as the medial and lateral femoral circumflex arteries form an extracapsular ring with branching retinacular arteries in the joint capsule
• Intracapsular = Femoral head and neck
• Extra-capsular = Trochanteric, intertrochanteric and subtrochanteric

Clinical

• If rotation of hip with leg in extension is painful, avoid further hip maoeuvres
• Identification of a hip or pelvic injury in a trauma patient warrants careful searching for associated injuries including intra-abdominal, retro-peritoneal, femoral shaft, knee or urological
• Also assess femoral and sciatic nerves and femoral blood vessels
  • Sciatic – Knee flexion
    • Common fibular: Dorsiflexion of foot and toes – Lateral lower leg, first web space
    • Tibial: Plantarflexion of foot and toes – Posterior lower leg
  • Femoral
    • Anterior branch – Hip flexion – anterior and medial thigh sensation
    • Posterior branch – Knee extension – medial lower leg sensation (saphenous)

Clinical

• Imaging
  • X-ray 90-98% sensitive for hip fracture
  • Pain with weight bearing with normal radiographs should raise suspicion of occult fracture, especially at femoral neck or acetabulum
  • MRI is 100% sensitive and CT is close to this

Femoral head fractures

• Uncommon and typically associated with dislocations
• Seen in 5-15% of posterior dislocations
• Pipkin classification
  • I – Below fovea (Conservative)
  • II – Above fovea (Conservative if non-displaced)
  • III – Associated femoral neck #
  • IV – Associated acetabular fracture

Femoral neck fractures

• Most useful to describe as displaced or non-displaced
• Can be mild groin/inner thigh pain through to severe pain with displacement
• Exam can be subtle if non-displaced
• Evaluate superior surface of neck, Shenton’s line (inferior arc) and neck-shaft angle (normal 120-130 degrees)
  • Look for band of increased or decreased density along neck
  • Compare to contralateral side
• 6-9% will have ipsilateral femoral shaft fracture
• Skeletal traction is CI as may further impede femoral head blood flow
• Higher grade of displacement = worse prognosis for healing and repair

Femoral neck fractures

• Garden classification
  • I – Incomplete
  • II – Complete non-displaced
  • III – Partially displaced
  • IV – Fully displaced
• Predicts AVN risk
• I and II – Head preservation techniques
• III and IV – Hemi- or total arthroplasty

Isolated trochanteric fractures

• Greater trochanter
  • Usually avulsions from gluteus medius
  • In younger patients = true epiphyseal avulsions
  • In adults it is due to direct trauma
  • Type I: No intertrochanteric fracture. Displaced <1cm. NWB with gradual remobilisation
  • Type II: >1cm displacement usually requiring IF
• Lesser trochanter
  • Avulsion from iliopsoas in young people
  • In older patients, if minimal trauma = pathological until proven otherwise
• Treatment is usually crutches with weight bearing as tolerated and ortho f/u within 3-5 days
• ORIF if significant displacement of fracture segment

Intertrochanteric fractures

• Extracapsular and seen mostly in elderly
• Higher mortality than neck fractures
• Typically marked pain and deformity
• Stable or unstable depending on number of fracture lines and amount of displacement
  • Calcar femorale is dense bone from posteromedial shaft to posterior femoral neck and disruption of this = unstable
• Skin traction not recommended
• Blood loss into the leg can be significant
• AVN and non-union are uncommon

Subtrochanteric fractures

• Seen in elderly following fall, younger severe trauma and pathological fractures
• Lesser trochanter to 5cm distal
• Significant blood loss not uncommon
• Traction splinting helpful for analgesia and closed reduction
• ORIF required

Occult hip fractures

• 3-38% of hip fractures are thought to be occult
• Pain with axial loading, restricted mobility prior to injury and risk factors for osteoporosis should all raise suspicion
• MRI is imaging of choice but CT can also be helpful in early phase as easier to obtain

3-in-1 block vs. femoral nerve block vs. fascia iliacus block

• 3-in-1 block perports to block femoral nerve, lateral femoral cutaneous nerve and obturator nerve with large volume of anaesthetic infiltrated around femoral nerve with distal pressure to allow proximal spread of liquid
  • In reality, obturator nerve rarely blocked
• Fascia iliacus block is thought to block the same and maybe slightly more frequently involves the obturator nerve
• Femoral nerve block under USS guidance easy, safe and effective for NOF and femoral shaft fractures

Surgical management

• Grade 1 and 2 femoral neck
  • Internal fixation with dynamic hip screw
• Grade 3 and 4
  • Hemiarthroplasty to prevent AVN
• Young
  • All grades get DHS
• Very old
  • Hemiarthroplasty may prevent further operations
• Total hip replacement
  • Younger patients with long life expectancy

Femoral shaft fractures

• Mostly young patients with severe trauma
• Sciatic nerve injury can occur so full neurovascular assessment is paramount
• IM nailing is preferred (see next slide)
• Traction splinting ideal for analgesia and reduction + limiting blood loss
• Needs treatment within 24 hours ideally to reduce risk of fat embolism

Femoral shaft fracture

• Winquist classification
  • Type I – Minimal comminution with butterfly fragment <25% width of bone
  • Type II – Comminuted. Butterfly fragment <50% width of bone. IM nail.
  • Type III – Butterfly fragment 50-100% of width of bone. Interlocking screws + IM nail
  • Type IV – All cortical contact is lost. Segmental comminution.

Hip dislocation

• Native hips dislocate in high-energy trauma and 95% have associated injuries
• Posterior dislocations of native hips constitute 90% of dislocations
• Prosthetic hips can dislocate with minimal trauma
• Native hip dislocations need immediate reduction, preferably within 6 hours to reduce risk of AVN to femoral head

Posterior hip dislocations

• Frequently dashboard injury with acetabular fractures +- femoral neck/shaft/knee
• Judet views or CT are necessary to assess acetabulum
• Complications include sciatic nerve injury in 10% and AVN of femoral head that increases in direct proportion to delay in anatomic reduction

Posterior hip dislocations

• Allis maneuver
  • Supine, assistant counter-traction on ASIS, in-line traction with simultaneous hip and knee flexion to 90 then rotate femur laterally and medially
• Bigelow maneuver
  • Supine, hip and knee flexed to 90 with flexed elbow under knee. Apply traction, externally rotate and extend the hip
• Captain Morgan 
  • Physicians knee is used as fulcrum pulling down on ankle while lifting knee with ankle plantarflexion and gently rotating the hip

Posterior hip dislocations

• After reduction, take hip through ROM to ensure stability, repeat neurovascular examination and obtain post-reduction imaging
• Place in abduction Charnley pillow/brace and admit for bed rest
• If failed reduction, orthopaedic consult for repeat attempt in ED or OR
• Difficulties can be due to occult intra-articular fracture or incarcerated tendon or capsule
• Post-reduction CT generally recommended to identify occult fractures of acetabulum or femoral head

Anterior hip dislocation

• Can be superior (pelvic) or inferior (obturator)
• MOI: Forced hip abduction with anterior capsular tear
• Present in abduction and external rotation (like NOF)
• Anterior superior reduction
  • Technique is similar but instead of longitudinal traction, the hip is abducted and assistant applies posterior pressure to femoral head
• If inferior (obturator) or central through acetabulum needs reduction in OR

Prosthetic hip dislocation

• Dislocate with minor trauma or movement with hip past 90 degrees of flexion while adducted
• 1-10% of prosthetic hips dislocate, usually in first few months
• Sciatic nerve injury can occur
• Mostly posterior and can be reduced with same techniques
• Discuss treatment plan with orthopaedics prior to reduction techniques as multiple different types of implants may alter technique
• ED vs. ortho equal success rates and shorter LOS if ED reduction performed
• AVN not an issue so timing less of a concern
• If first time, Charnley pillow and admit to Ortho
• If recurrent, can be discharged from ED following recovery from sedation and d/w Ortho

Last Updated on October 6, 2020 by Andrew Crofton