Fractures above the level of the lesser trochanter are termed hip fractures. The femoral head has a tenuous blood supply, and fractures can compromise blood flow, resulting in avascular necrosis. For classification, hip fractures are generally divided into intracapsular (femoral head and neck fractures) and extracapsular (trochanteric, intertrochanteric, and subtrochanteric). Accurate classification is important because intracapsular fractures are more likely to have vascular disruption.
Complaints include groin or buttock pain, tenderness, and an inability to bear weight on the affected side. There can be shortening of the affected leg, as well as abduction and external rotation.
Both the Shenton line (the curved line formed by the top of the obturator foramen and the inner side of the neck of the femur) and the neck shaft angle (normal is 120-130 degrees) should be evaluated, but can be normal in nondisplaced fractures.
Management and Disposition
Fractures of the hip require early orthopedic consultation for admission; in most cases, fractures require surgical reduction and fixation. Femoral head fracture-dislocations are an orthopedic emergency and require immediate reduction. A neurovascular exam should be performed before and after any reduction attempts.
Hip Fractures. This illustration depicts the different types of proximal femoral fractures.
Fracture-dislocation of the femoral head requires a significant amount of force; intra-abdominal and retroperitoneal injuries should be considered.
Hip fractures may be diagnosed by auscultation of differences in bone conduction between the extremities. This is performed by placing the stethoscope’s diaphragm on the anterosuperior iliac spine and giving the patella soft taps.
Any elderly patient with an inability to bear weight has a hip fracture until proven otherwise. Hip fractures can be secondary to osteoporosis, so there does not need to be a history of trauma. Since plain films may not be sensitive enough to identify some hip fractures, other imaging such as CT or MRI should be considered.
Hip Fracture. Patients with hip fractures often present with the affected extremity shortened, externally rotated, and abducted. Note the rotation and shortening in this patient with a right intertrochanteric fracture. (Photo contributor: Cathleen M. Vossler, MD.)
Hip Fractures. Radiographs reveal the different types of hip fractures. Displaced and impacted right femoral head fracture (A). Left femoral neck fracture (B). Displaced left intertrochanteric fracture (C). (Photo contributor: Meghan Breed, MD.)