Isolated femoral head fractures are uncommon and are typically associated with dislocations of the hip (Table 273-1). The signs and symptoms are often from the dislocation rather than from the fracture itself. They are usually best seen on radiographs obtained after reduction of a hip dislocation.
The standard anteroposterior and lateral views usually demonstrate the fragment adequately. Judet views or thin-cut CT scans are often recommended for further evaluation of the acetabulum and fracture fragmentation.
Treatment is to reduce the associated dislocation and then attain anatomic reduction of the fracture fragment (Table 273-3). See subsequent section on dislocations for further discussion. Management of concomitant life-threatening injuries due to high-energy trauma must take priority.
TABLE 273-3Proximal Femur Fractures: Treatment Issues ||Download (.pdf) TABLE 273-3 Proximal Femur Fractures: Treatment Issues
|Fracture ||ED Management ||Disposition and Follow-Up ||Complications |
|Femoral head ||Immediate orthopedic consultation; emergent closed reduction of dislocation; ORIF if closed reduction is unsuccessful ||Admission to orthopedic or trauma service ||AVN; posttraumatic arthritis; sciatic nerve injury; heterotopic ossification |
|Femoral neck ||Orthopedic consultation; ranges from nonoperative to total hip arthroplasty ||Admission to orthopedic service ||AVN; infection; DVT and/or pulmonary embolus |
|Greater trochanteric ||Analgesics; protected weight bearing ||Orthopedic follow-up 1–2 wk; possible ORIF if displacement >1 cm ||Nonunion rare |
|Lesser trochanteric ||Analgesics; weight bearing as tolerated; evaluate for possible pathologic fracture ||Orthopedic or PCP follow-up in 1–2 wk; admit or urgent follow-up for pathologic fracture ||Nonunion rare |
|Intertrochanteric ||Orthopedic consultation ||Admit for eventual ORIF; may need preoperative testing and clearance by PCP or hospitalist ||DVT and/or pulmonary embolism; infection |
|Subtrochanteric ||Orthopedic consultation; consider Hare® or Sager® splint ||Admit for ORIF ||DVT and/or pulmonary embolism; infection; malunion (shortened limb); nonunion |
Prognosis is related to the severity of the initial trauma resulting in the dislocation and associated injuries, delay to reduction, and repetitive unsuccessful reduction attempts.8
Femoral neck fractures are most commonly seen among older adults with osteoporosis and occur more frequently in women than in men. Falls are the most common cause (90%), but stress or traumatic femoral neck fractures may be seen in younger patients (Table 273-1).9 There are multiple classification systems for femoral neck fractures, but it is most useful to describe them as displaced or nondisplaced. Femoral neck fractures are intracapsular, and blood supply to the femoral head may be disrupted.
The symptoms seen with femoral neck fractures range from complaints of mild pain in the groin or inner thigh in patients with an incomplete fracture, to moderate to severe pain in patients with displaced fractures. Patients with nondisplaced fractures may be somewhat ambulatory, whereas those with displaced fractures are typically unable to bear weight at all. Examination findings can be subtle in nondisplaced fractures, while displaced fractures are quite evident with the leg held in external rotation, abduction, and shortened (Figure 273-3).
Shortened, abducted, externally rotated limb (arrow) seen in femoral neck fracture. [Image used with permission of Dr. Allan Mishra, http://www.emedx.com.]
Radiographic evaluation is essential in any patient suspected of having a femoral neck fracture. Ideally, the standard anteroposterior view should have the patient internally rotated as much as patient condition allows to best demonstrate the femoral neck. Nondisplaced fractures may be subtle. The anteroposterior view should be inspected for a fracture line starting on the superior surface of the neck (Figure 273-4). Disruption of Shenton's line, a smooth curvilinear line along the superior border of the obturator foramen and the medial aspect of the femoral metaphysis, may be appreciated on the anteroposterior view in some instances (Figure 273-5). Evaluate the neck-shaft angle in suspected fractures; normal is 120 to 130 degrees (Figure 273-6). The neck-shaft angle is measured at the intersection of lines drawn down the axis of the femoral shaft and the femoral neck.10 Displaced fractures are obvious on the anteroposterior view, but a lateral view should also be obtained to ascertain the exact fracture position. Approximately 6% to 9% of patients with a femoral neck fracture will have an ipsilateral femoral shaft fracture.11
Radiograph of femoral neck fracture. The disruption of the bone is most visible when following the superior surface of the femoral neck. Also notice the shortening and impaction of the femoral neck.
Treat pain, immobilize the extremity in a position of comfort, and obtain orthopedic consultation in the ED. Skeletal traction is contraindicated for femoral neck fractures because it may further compromise femoral head blood flow.
For both displaced and nondisplaced fractures, outcomes are generally best with surgical fixation because this leads to earlier mobilization and less morbidity and mortality than with conservative management.12,13 Decisions regarding the timing and type of operative intervention depend on the patient's physiologic age, activity level, and fracture severity.14 Conservative treatment may be considered in those whose operative risk outweighs potential benefit or in patients who are not ambulatory.
The complications of femoral neck fractures are significant (Table 273-3). Prognosis is related to the number and severity of complications. A higher grade of fracture displacement also implies a worse prognosis for healing and repair.
ISOLATED TROCHANTERIC FRACTURES
Greater trochanteric fractures are usually caused by avulsions at the insertion of the gluteus medius. In the younger population (7 to 17 years of age), this is a true epiphyseal separation, in contrast to the adult population, in whom the cause is direct trauma (Table 273-1).
Lesser trochanteric fractures caused by an avulsion secondary to forceful contraction of the iliopsoas are commonly seen in children and young athletic adults, particularly gymnasts and dancers. Lesser trochanter fractures in older patients with minimal trauma should be considered pathologic until proven otherwise.15
Standard anteroposterior and lateral views reveal the displacement. CT of the pelvis may be helpful if a fracture is strongly suspected but difficult to visualize.
In most instances, the treatment is crutches with weight bearing as tolerated until orthopedic follow-up is obtained within 3 to 5 days, and then gradually increasing to full activity. Full recovery generally occurs in patients with healthy bone. Operative fixation may be indicated in cases where there is significant displacement of the fracture fragment (Table 273-3).
Intertrochanteric fractures are defined as extracapsular fractures occurring in a line between the greater and lesser trochanters. They generally occur in the elderly and are more common in women, again due to the high incidence of osteoporosis. The mechanism of injury is usually a fall (Table 273-1).
Patients typically have marked pain and deformity on examination, and fractures are usually easily visualized on standard anteroposterior and lateral views. Intertrochanteric fractures should be classified as sTable or unsTable based on the number of fracture lines and the amount of displacement.16
After life-threatening injuries have been excluded, the consulting orthopedic physician can then admit the patient to the hospital and perform surgical fixation as soon as possible (Table 273-3). Skin traction is not recommended for either stabilization or pain control.17,18
The complications and prognosis are related to associated injuries and prior disease. Blood loss into the leg can be significant, and some patients will require crystalloid or blood transfusion.19 Infection and pulmonary embolism are the main complications. Avascular necrosis and nonunion are uncommon complications.
Subtrochanteric fractures may be seen in three different populations: older patients with osteoporosis who fall (Table 273-1), younger patients as a result of major trauma, or patients with bony metastases.
The symptoms and signs are similar to those of intertrochanteric or femoral shaft fractures: localized pain, deformity, swelling, and crepitance. Significant blood loss may develop. Evaluate for concomitant life-threatening injuries.
Standard anteroposterior and lateral views of the hip are typically sufficient to evaluate these fractures. Consider radiographic studies of the pelvis, femur, and knee to exclude associated fractures.
ED treatment consists of pain control, immobilization, and orthopedic consultation. Hare® (Dynamed, Westbury, Tasmania) or Sager® (Minto Research and Development, Inc., Redding, CA) splints (Figures 2-7 and 2-8, respectively) are commonly employed in the prehospital setting and infrequently in the ED (also see chapter 2, Prehospital Equipment and Adjuncts). Traction splinting may ease pain and provide some fracture reduction.18 Do not apply a traction splint if there is open fracture, suspected pelvic fracture, hip dislocation, suspicion for neurovascular injury to the extremity, or injury about the knee, as a traction splint may exacerbate neurovascular or knee injury. Operative reduction/internal fixation is generally indicated for complicated fracture management.
Symptoms suggestive of fracture, but with negative plain radiographs, are called occult hip fractures.4 Anywhere from 3% to 38% of hip fractures are initially "occult."6 Stress, incomplete, or nondisplaced fractures may not become evident on plain radiographs for days or weeks after injury. Pain with axial loading, restricted mobility prior to the injury, and risks for osteoporosis should all raise suspicion for occult fracture.20 MRI is the imaging of choice because it is both sensitive and specific.4 If clinical suspicion is high, obtain an MRI in the ED, or if that is not possible, obtain an MRI within the next 24 to 48 hours—with the patient non–weight bearing until diagnosis is confirmed and orthopedic follow-up is obtained.