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Chapter 273: Hip and Femur Injuries

Chris Courtney

INTRODUCTION AND EPIDEMIOLOGY

Over 350,000 hip fractures occur annually, costing nearly $6 billion. Hip fractures are a life-changing injury. Forty percent of patients fail to regain preinjury ambulation status at 6 months and fail to return to independent living at 1 year, and nearly 25% of those suffering from this injury die within 12 months. Morbidity and mortality result from prolonged immobilization. Compromised preinjury ambulation status and dependent living are predictors of poor functional outcome and long-term mortality.1,2

Hip dislocations are associated with devastating complications. Disruption of vascular supply can result in avascular necrosis and is estimated to occur in up to 25% of hip dislocations. This life-changing complication nearly always mandates total hip arthroplasty (THA).3

Femur fractures are most often associated with trauma and occur across a much broader demographic. These high-energy fractures can result in life-threatening blood loss.4

ANATOMY AND PATHOPHYSIOLOGY

Hip fractures are defined by their anatomic location (Figures 273-1 and 273-2 and Table 273-1) and classified as intracapsular (femoral head and neck) or extracapsular (trochanteric, intertrochanteric, and subtrochanteric). Treatment will vary considerably with fracture type (Table 273-2).

FIGURE 273-1.

Fractures of the proximal femur are traditionally classified as intracapsular and extracapsular.

A diagram depicts the fractures of the proximal femur.
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FIGURE 273-2.

Hip and joint capsule.

Diagrams depict the hip and joint capsule.
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TABLE 273-1Proximal Femur Fractures: Demographics and Clinical Features
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TABLE 273-1 Proximal Femur Fractures: Demographics and Clinical Features
Fracture Incidence/Demographics Mechanism Clinical Findings Concomitant Injuries
Femoral head Isolated fracture rare; seen in 6%–16% of hip dislocations Usually result of high-energy trauma; dashboard to flexed knee most common Limb shortened and externally rotated (anterior dislocation); shortened, flexed, and internally rotated (posterior dislocation) Closed head injury; intrathoracic and/or intra-abdominal injuries; pelvic fracture, knee injuries
Femoral neck Common in older patients with osteoporosis; rarely seen in younger patients Low-impact falls or torsion in elderly; high-energy trauma or stress fractures in young Ranges from pain with weight bearing to inability to ambulate; limb may be shortened and externally rotated Ipsilateral femoral shaft fracture
Greater trochanteric Uncommon; older patients or adolescents Direct trauma (older patients); avulsion due to contraction of gluteus medius (young patients) Ambulatory; pain with palpation or abduction —
Lesser trochanteric Uncommon; adolescents (85%) > adults Avulsion due to forceful contraction of iliopsoas (adolescents); avulsion of pathologic bone (older adults) Usually ambulatory; pain with flexion or rotation —
Intertrochanteric Common in older patients with osteoporosis; rare in younger patients Falls; high-energy trauma Severe pain; swelling; limb shortened and externally rotated Anemia from blood loss into thigh; concomitant traumatic injuries
Subtrochanteric Similar to intertrochanteric; 15% of hip fractures Falls; high-energy trauma; may also be pathologic Severe pain; ecchymosis; limb shortened, abducted, and externally rotated Vascular ...

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