Anatomy
A good understanding of the femoroacetabular joint is necessary to appreciate hip pathology fully and help guide the physical examination. The hip is a diarthrodial joint consisting of bony and soft tissue constraints making it an inherently stable articulation.
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Bony Anatomy
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Acetabulum, femoral head and neck, greater and lesser trochanter, and femoral shaft
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Deep socket of the acetabulum allows for the large femoral head to be well seated and covered ( Fig. 13-1 )
FIGURE 13-1
Deep socket of the acetabulum allows for the large femoral head to be well seated and covered.
(From Browner BD, Jupiter JB, Levine AM, et al, editors: Skeletal trauma: basic science, management, and reconstruction, ed 3, Philadelphia, 2003, Saunders.)
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This relationship along with a narrow femoral neck affords stability, while permitting a large arc of motion in the sagittal, coronal, and axial planes
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Soft Tissue
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Labrum
Ring of fibrocartilage that deepens the acetabular socket
Increases the femoral head coverage and improves the overall stability of the hip joint
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Ligamentum teres (round ligament of the femur)
Triangular structure consisting of two fibrous bands that attach to the fovea capitis of the femoral head
Traveling within the substance of the bands is the acetabular branch of the obturator artery
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Capsule
Formed by the coalescence of the iliofemoral, pubofemoral, and ischiofemoral ligaments
Fibrocapsular structure significantly increases stability of the hip joint
Adheres anteriorly near the distal femoral neck and intertrochanteric region and posteriorly near the distal half of the femoral neck
Knowledge of neurovascular anatomy of the proximal femur is important when evaluating fractures and dislocations
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Medial Femoral Circumflex Artery
The medial femoral circumflex artery is the main blood supply of the femoral head and most of the neck via the terminal branches. It is a branch of the profunda femoris artery and gives rise to a deep branch. The deep branch initially is extracapsular running deep to the quadratus femoris. As it ascends along the greater trochanter, it pierces the capsule giving rise to multiple terminal branches that supply the femoral head. In adults, there is insignificant contribution from the lateral femoral circumflex artery, medial epiphyseal artery, obturator artery, and superior and inferior gluteal arteries.
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Femoral Nerve
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Derived from the ventral rami of L2-4
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Courses between the iliacus and the psoas muscles and then anteriorly over the iliacus before passing deep to the inguinal ligament
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Innervates the quadriceps muscles, gives sensation to the anteromedial thigh, and terminates as the saphenous nerve
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Sciatic Nerve
The sciatic nerve arises from the lumbosacral plexus (L4-S3). In the most common variation, the nerve exits the pelvis through the greater sciatic foramen and courses anterior to the piriformis muscle. The tibial division arises from the anterior branch and innervates the long head of the biceps femoris, semitendinosus, and posterior compartment muscles. The peroneal division gives rise to the deep and superficial peroneal nerves. They innervate the anterior and lateral compartment muscles of the lower leg and provide sensation for the anterior and lateral aspect of the lower leg and the dorsum of the foot.
History
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A comprehensive history regarding the mechanism of injury, trauma, or any antecedent pain or dysfunction should be obtained.
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Chronicity of symptoms should be determined.
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Location of pain or discomfort, quality, modifying factors, and radiation of the pain help narrow the differential diagnosis.
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The mechanism of injury can be from direct trauma or indirect trauma.
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A fall from a standing height leading to a fracture is typical of a fragility fracture.
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In young patients, significant energy is often required to fracture the femur or to cause a dislocation.
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Axial loading injuries can affect not only the lower limb but also the spine, so back and neck complaints should be sought.
Physical Examination
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When evaluating a patient with hip complaints, it is imperative to be systematic in the musculoskeletal examination.
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Following general principles assists in honing in on the etiology of the symptoms.
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The physical examination comprises inspection, palpation, range of motion, neurologic examination, and vascular examination.
Inspection
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Inspect the patient in a comfortable position either supine or standing.
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Evaluate gait when possible.
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Certain pathologic gaits such as antalgic, spastic, cerebellar ataxic, or Trendelenburg gait can aid in making the correct diagnosis.
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Initially the patient should be disrobed to expose the hip region.
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A thorough evaluation of the spine, pelvis, and hips should be performed.
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Look for any abrasions, lacerations, discolorations, hematomas, or soft tissue swelling.
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Assess for leg-length discrepancies, muscle atrophy, and the position of the extremity.
Palpation
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Palpate to assess for any warmth, fluctuance, or tenderness.
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Start palpating the spinous processes looking for any stepoffs or pain.
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Continue down to the iliac crest, the anterior superior inferior iliac spines, the iliac and pubic tubercles, followed by the greater trochanters bilaterally.
Range of Motion
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Active and passive range of motion should be tested.
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Hip abduction and adduction, flexion and extension, and internal and external rotation should be measured.
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With the patient supine, normal range of motion includes:
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Abduction 45 degrees and adduction 20 degrees
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Hip flexion 120 degrees
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Internal rotation 35 degrees and external rotation 45 degrees
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Test for hip extension in the prone position, which is normally 30 degrees.
Neurologic Examination
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Motor Examination
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Muscle strength is graded with reference to the contralateral side and ranges from 0 to 5 ( Table 13-1 ).
TABLE 13-1
Medical Research Council Grading
Grade
0
No movement
1
Flicker of movement
2
Movement only with gravity eliminated
3
Full range of movement against gravity
4
Full range of movement against some resistance
5
Full power against resistance
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Hip flexors (iliopsoas, rectus femoris) are innervated by the femoral nerve.
- •
Test hip flexors with the patient either supine or sitting and having the patient flex the hip against resistance.
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Hip extensors (gluteus maximus and hamstrings) are innervated by the inferior gluteal nerve and the sciatic nerve.
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Test hip extensors with the patient in prone position by having the patient elevate the thigh off the table against resistance while keeping the knee flexed to relax the hamstrings.
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Abductors (gluteus minimus and medius) are innervated by the superior gluteal nerve.
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To test abductors, the patient is placed in the lateral position and instructed to abduct the leg against resistance.
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Adductors (adductor longus, brevis, magnus, pectineus, and gracilis) are innervated by the obturator nerve (pectineus often is innervated by the femoral nerve).
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Adductors are tested by having the patient lay in the lateral position, making the leg being tested the bottom leg. After abducting the upper leg for the patient and supporting it, the patient is instructed to adduct the leg against resistance.
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Both abductors and adductors can be tested in the supine position by having both legs abducted and instructing the patient to abduct and adduct against resistance. This method allows for direct comparison of both sides.
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Sensation
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Dermatomes of the hip include L1-4, with L1 being the most proximal at the hip and L4 coursing through the knee.
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Vascular Examination
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A thorough vascular evaluation is vital, especially when treating patients with fracture-dislocations of the hip.
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Palpate the popliteal, posterior tibial, and dorsalis pedis pulses.
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If pulses are not palpable, Doppler examination is warranted.
Inspection
- ▪
Inspect the patient in a comfortable position either supine or standing.
- ▪
Evaluate gait when possible.
- ▪
Certain pathologic gaits such as antalgic, spastic, cerebellar ataxic, or Trendelenburg gait can aid in making the correct diagnosis.
- ▪
Initially the patient should be disrobed to expose the hip region.
- ▪
A thorough evaluation of the spine, pelvis, and hips should be performed.
- ▪
Look for any abrasions, lacerations, discolorations, hematomas, or soft tissue swelling.
- ▪
Assess for leg-length discrepancies, muscle atrophy, and the position of the extremity.
Palpation
- ▪
Palpate to assess for any warmth, fluctuance, or tenderness.
- ▪
Start palpating the spinous processes looking for any stepoffs or pain.
- ▪
Continue down to the iliac crest, the anterior superior inferior iliac spines, the iliac and pubic tubercles, followed by the greater trochanters bilaterally.
Range of Motion
- ▪
Active and passive range of motion should be tested.
- ▪
Hip abduction and adduction, flexion and extension, and internal and external rotation should be measured.
- ▪
With the patient supine, normal range of motion includes:
- •
Abduction 45 degrees and adduction 20 degrees
- •
Hip flexion 120 degrees
- •
Internal rotation 35 degrees and external rotation 45 degrees
- •
- ▪
Test for hip extension in the prone position, which is normally 30 degrees.
Neurologic Examination
- ▪
Motor Examination
- •
Muscle strength is graded with reference to the contralateral side and ranges from 0 to 5 ( Table 13-1 ).
TABLE 13-1
Medical Research Council Grading
Grade
0
No movement
1
Flicker of movement
2
Movement only with gravity eliminated
3
Full range of movement against gravity
4
Full range of movement against some resistance
5
Full power against resistance
- •
Hip flexors (iliopsoas, rectus femoris) are innervated by the femoral nerve.
- •
Test hip flexors with the patient either supine or sitting and having the patient flex the hip against resistance.
- •
Hip extensors (gluteus maximus and hamstrings) are innervated by the inferior gluteal nerve and the sciatic nerve.
- •
Test hip extensors with the patient in prone position by having the patient elevate the thigh off the table against resistance while keeping the knee flexed to relax the hamstrings.
- •
Abductors (gluteus minimus and medius) are innervated by the superior gluteal nerve.
- •
To test abductors, the patient is placed in the lateral position and instructed to abduct the leg against resistance.
- •
Adductors (adductor longus, brevis, magnus, pectineus, and gracilis) are innervated by the obturator nerve (pectineus often is innervated by the femoral nerve).
- •
Adductors are tested by having the patient lay in the lateral position, making the leg being tested the bottom leg. After abducting the upper leg for the patient and supporting it, the patient is instructed to adduct the leg against resistance.
- •
Both abductors and adductors can be tested in the supine position by having both legs abducted and instructing the patient to abduct and adduct against resistance. This method allows for direct comparison of both sides.
- •
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Sensation
- •
Dermatomes of the hip include L1-4, with L1 being the most proximal at the hip and L4 coursing through the knee.
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Diagnostic Testing
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Radiography
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Radiographs should be the initial imaging studies.
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Full-length images including the joint above and below are standard.
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Anteroposterior pelvis and anteroposterior and lateral (cross-table) images of the hip should be obtained.
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Anteroposterior and lateral knee radiographs should be obtained.
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Computed Tomography (CT) Scan
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CT scans are reserved for pathologic fractures and for evaluating the congruency of the joint after a hip dislocation.
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Patients who have sustained multiple trauma injuries should have a fine-cut CT scan (2-mm cuts) to evaluate for a nondisplaced femoral neck fracture.
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Magnetic Resonance Imaging (MRI)
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MRI has some indication in the right clinical setting.
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MRI is the preferred diagnostic study to evaluate for an occult femoral neck fracture in an elderly patient who is unable to bear weight after a fall and has negative hip radiographs.
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MRI is useful in evaluating soft tissue injuries around the hip.
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Hip Joint Aspiration
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Hip joint aspiration is rarely indicated in the emergency department.
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In patients in whom there is concern for septic joint, joint fluid aspiration with ultrasound guidance could be attempted.
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Standard joint fluid studies include cell count, Gram stain, culture, glucose, protein, and crystals.
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In the setting of septic joint, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and white blood cell (WBC) count assist in the diagnosis and evaluation of treatment response.
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Proximal Femur Fractures
Femoral Head Fractures
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Although these fractures are uncommon, timely diagnosis is important because delayed treatment can lead to significant morbidity.
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Femoral head fracture should be suspected in polytrauma patients, especially patients with hip dislocations.
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This fracture is estimated to be associated with 5% to 15% of all posterior hip dislocations.
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Diagnosis
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A thorough physical examination should be performed with emphasis on sciatic nerve function especially for posterior hip dislocations.
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Femoral head fractures can be diagnosed with plain films when associated with a hip dislocation or with a CT scan after the hip has been relocated.
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Clinically patients may have a shortened, adducted, and internally rotated extremity with a posterior hip dislocation and a shortened, abducted, and externally rotated extremity with an anterior hip dislocation.
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Classification
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Femoral head fracture is classified by the Brumback or the Pipkin classification scheme.
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The Pipkin classification is the most widely used and reproducible.
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Pipkin classification is based on the location of the femoral head fracture in reference to the fovea capitis femoris and the presence of an associated acetabular or femoral neck fracture ( Fig. 13-2 ).
FIGURE 13-2
Pipkin classification. Notice the location of the femoral head fracture in reference to the fovea centralis and the presence of an associated acetabular or femoral neck fracture.
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Management
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Treatment of these high-energy injuries should be prompt; immediate orthopedic consultation is recommended.
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Rapid restoration of blood perfusion is critical owing to the tenuous vascular supply of the femoral head and concomitant injuries.
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For femoral head fractures associated with a hip dislocation, reduction of the hip within 6 hours from injury has been associated with diminished risk of avascular necrosis (AVN) and osteoarthritis.
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A fine-cut CT scan is recommended after reduction to evaluate for joint congruency and the quality of the fracture reduction.
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Patients with Pipkin I and II fractures can be treated conservatively when the fracture is less than 2 mm displaced, the joint is congruent, and the hip is stable to range of motion examination.
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If these parameters are met, the patient can be made partial weight bearing with crutches.
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Patients with displaced Pipkin I and II fractures, Pipkin III and IV fractures, an incongruent joint, or an unstable hip joint are usually managed surgically.
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Objectives of treatment are anatomic reduction of the femoral head, neck, and acetabular fragments; congruency of the joint; and removal of intra-articular fragments.
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Common Pitfalls
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Delayed closed reduction of the dislocated hip can lead to complications.
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There is evidence that reduction within 6 to 12 hours reduces the risk of developing AVN.
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Overall incidence of AVN is 20%, including both surgical and nonsurgical treatment.
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Every patient with a femoral head fracture should be informed of the risk of developing AVN even with early reduction.
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Risk of developing AVN is higher for Pipkin III and IV fractures.
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There is a 10% to 23% incidence of sciatic nerve injury usually involving the peroneal division; 60% of patients regain partial motor and sensory function.
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Post-traumatic arthrosis is exceedingly common with a reported incidence ranging from 8% to 75%.
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Heterotopic ossification has been documented, especially in fracture-dislocations and in surgically treated injuries.
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Overall incidence of heterotopic ossification is reported to be up to 75%.
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Femoral Head Fractures
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Although these fractures are uncommon, timely diagnosis is important because delayed treatment can lead to significant morbidity.
- ▪
Femoral head fracture should be suspected in polytrauma patients, especially patients with hip dislocations.
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This fracture is estimated to be associated with 5% to 15% of all posterior hip dislocations.
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Diagnosis
- •
A thorough physical examination should be performed with emphasis on sciatic nerve function especially for posterior hip dislocations.
- •
Femoral head fractures can be diagnosed with plain films when associated with a hip dislocation or with a CT scan after the hip has been relocated.
- •
Clinically patients may have a shortened, adducted, and internally rotated extremity with a posterior hip dislocation and a shortened, abducted, and externally rotated extremity with an anterior hip dislocation.
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Classification
- •
Femoral head fracture is classified by the Brumback or the Pipkin classification scheme.
- •
The Pipkin classification is the most widely used and reproducible.
- •
Pipkin classification is based on the location of the femoral head fracture in reference to the fovea capitis femoris and the presence of an associated acetabular or femoral neck fracture ( Fig. 13-2 ).
FIGURE 13-2
Pipkin classification. Notice the location of the femoral head fracture in reference to the fovea centralis and the presence of an associated acetabular or femoral neck fracture.
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Management
- •
Treatment of these high-energy injuries should be prompt; immediate orthopedic consultation is recommended.
- •
Rapid restoration of blood perfusion is critical owing to the tenuous vascular supply of the femoral head and concomitant injuries.
- •
For femoral head fractures associated with a hip dislocation, reduction of the hip within 6 hours from injury has been associated with diminished risk of avascular necrosis (AVN) and osteoarthritis.
- •
A fine-cut CT scan is recommended after reduction to evaluate for joint congruency and the quality of the fracture reduction.
- •
Patients with Pipkin I and II fractures can be treated conservatively when the fracture is less than 2 mm displaced, the joint is congruent, and the hip is stable to range of motion examination.
- •
If these parameters are met, the patient can be made partial weight bearing with crutches.
- •
Patients with displaced Pipkin I and II fractures, Pipkin III and IV fractures, an incongruent joint, or an unstable hip joint are usually managed surgically.
- •
Objectives of treatment are anatomic reduction of the femoral head, neck, and acetabular fragments; congruency of the joint; and removal of intra-articular fragments.
- •
- ▪
Common Pitfalls
- •
Delayed closed reduction of the dislocated hip can lead to complications.
- •
There is evidence that reduction within 6 to 12 hours reduces the risk of developing AVN.
- •
Overall incidence of AVN is 20%, including both surgical and nonsurgical treatment.
- •
Every patient with a femoral head fracture should be informed of the risk of developing AVN even with early reduction.
- •
Risk of developing AVN is higher for Pipkin III and IV fractures.
- •
There is a 10% to 23% incidence of sciatic nerve injury usually involving the peroneal division; 60% of patients regain partial motor and sensory function.
- •
Post-traumatic arthrosis is exceedingly common with a reported incidence ranging from 8% to 75%.
- •
Heterotopic ossification has been documented, especially in fracture-dislocations and in surgically treated injuries.
- •
Overall incidence of heterotopic ossification is reported to be up to 75%.
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Hip Fractures
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The mechanism of injury in elderly patients usually involves a low-energy fall.
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Hip fracture is a fragility fracture by definition.
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Attention should be paid to the ipsilateral upper extremity because concomitant proximal humerus and distal radius fractures can occur as the patient stretches out the hand trying to break the fall.
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Younger patients sustain hip fractures secondary to high-energy trauma.
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Hip fracture in a young patient is usually a result of a motor vehicle or motorcycle accident or a fall from a height.
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There may be life-threatening injuries that take precedence over the limb injuries.
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A hip fracture is managed in an urgent fashion after the patient has been stabilized.
Femoral Neck Fractures
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These are mostly intracapsular fractures that occur below the femoral head and above the trochanters.
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Diagnosis
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Any patient with suspected femoral neck fracture should have anteroposterior and lateral hip radiographs and anteroposterior and lateral knee radiographs.
- •
In situations in which it is unclear whether the patient has a low femoral neck or intertrochanteric hip fracture, internal rotation traction hip radiographs including anteroposterior and lateral views can be helpful.
- •
Distinguishing between the two fracture patterns is important because it may alter the definitive management.
- •
MRI is recommended for patients with acute trauma to the hip who are unable to bear weight and have negative radiographs.
- •
MRI is used to evaluate for occult femoral neck fracture.
- •
A fine-cut (<2 mm) CT scan can be performed in patients with an absolute contraindication for MRI (i.e., metal implants in the eye, brain, or heart) or when MRI is unavailable.
- •
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Classification
- •
The Garden classification is used ( Fig. 13-3 ).
FIGURE 13-3
Garden classification.
- •
Another method is to describe the fracture by its location:
Subcapital: Below or adjacent to the femoral head
Transcervical: Mid–femoral neck region
Basicervical: Distal femoral neck region
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Management
- •
Most femoral neck fractures are treated operatively, and a complete preoperative evaluation is required.
- •
The decision concerning operative versus nonoperative treatment is based on the patient’s age, medical comorbidities, fracture pattern, and concomitant injuries.
- •
At our institution, all patients have complete blood count, electrolytes, blood urea nitrogen and creatinine, prothrombin time/international normalized ratio, and partial thromboplastin time tests.
- •
Patients older than 40 years also have a chest radiograph and electrocardiogram, and a type and crossmatch for 2 units of packed red blood cells is performed.
- •
Femoral neck fracture in a physiologically young patient (≤55 years old), whether displaced or not, is an orthopedic emergency.
- •
Because of the retrograde femoral neck vascularity, timely reduction should be performed to preserve the native anatomy, and urgent orthopedic consultation is recommended.
- •
- ▪
Emergency Department Management
- •
Adequate pain control should be prescribed.
- •
Buck’s skin traction of 10 lb maximum can provide pain relief by limiting motion at the fracture site.
- •
- ▪
Common Pitfalls
- •
Failure to recognize an occult femoral neck fracture
All patients with acute hip pain after a fall who are unable to bear weight should undergo MRI (or CT as discussed) to rule out an occult femoral neck fracture.
- •
Delayed treatment of a displaced femoral neck fracture in a physiologic young patient
Early reduction of femoral neck fractures in physiologic young patients has been associated with reduced risk of osteonecrosis.
Young patients should be informed of the increased risk of osteoarthritis, osteonecrosis, and nonunion when treated with open reduction and internal fixation; this is true for early and delayed treatment.
- •
Inadequate radiographs
Some femoral neck fractures are basicervical or low neck fractures, which can change the treatment plan.
Internal rotation and traction views can help visualize the fracture pattern better and aid in the diagnosis.
Radiographs of the joint above and below the fracture should always be obtained.
- •
Osteoporosis evaluation
All patients sustaining a fragility fracture should be advised to be evaluated for osteoporosis.
More recent literature shows the reduced incidence of fragility fractures with current pharmacologic treatment for osteoporosis.
- •
Intertrochanteric Femur Fractures
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Intertrochanteric femur fractures are fractures located between the greater and lesser trochanter.
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These are among the most common hip fractures in elderly patients and are rare in young patients.
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Diagnosis
- •
Patients with intertrochanteric femur fractures typically complain of acute onset of hip pain after a fall.
- •
Inability to bear weight and restricted range of motion are common findings.
- •
Full-length anteroposterior and lateral radiographs including the knee should be obtained.
- •
In a situation in which it is difficult to delineate between a low femoral neck fracture (basicervical) and an intertrochanteric femur fracture, traction internal rotation radiographs are helpful.
- •
Occasionally a patient with negative radiographs who is unable to bear weight after an acute fall is encountered.
- •
MRI is warranted to rule out an occult hip fracture.
- •
A fine-cut CT scan with 2-mm cuts can be obtained in patients who are unable to undergo MRI.
- •
- ▪
Classification
- •
There have been many proposed classifications for intertrochanteric femur fractures, but no particular classification scheme has been universally accepted.
- •
Assess the number of fracture fragments, the direction of the main fracture, and the integrity of the posterior medial buttress.
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We prefer the Jensen classification because of its reproducibility, while offering guidance for surgical treatment ( Fig. 13-4 ).
FIGURE 13-4
Jensen classification.
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Management
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All patients should have a baseline preinjury functional evaluation
- •
Pain should be controlled with narcotics as appropriate.
- •
Skin traction with Buck’s inline traction can be used to reduce motion at the fracture site and theoretically to improve pain.
- •
Because of the morbidity and mortality associated with untreated or neglected hip fractures, unless medically contraindicated, surgical treatment is nearly universal.
- •
Medical clearance is usually required because these patients are typically older and are likely to have multiple comorbidities.
- •
The goal is to have the patient medically optimized as soon as possible before undergoing surgical management.
- •
Patients with a significant cardiac history should have a cardiology consultation as soon as possible to have adequate time to obtain any necessary studies.
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- ▪
Common Pitfalls
- •
Inadequate radiographs
Full-length films are required to evaluate for any pathologic lesions distal to the fracture and to assist in measuring the proper length of an intramedullary implant if one is used.
- •
Missed occult fracture
Any elderly patient with an acute history of trauma with inability to bear weight should undergo MRI if radiographs are negative.
- •
Incomplete work-up
Hip fractures are usually surgically managed.
Obtaining preoperative laboratory and imaging studies and consultations to optimize the patient medically before surgery is ideal.
- •
Osteoporosis evaluation
All patients with fragility fractures should be referred for an osteoporosis work-up or given information about the future risk of additional fractures secondary to osteoporosis.
- •
Femoral Neck Fractures
- ▪
These are mostly intracapsular fractures that occur below the femoral head and above the trochanters.
- ▪
Diagnosis
- •
Any patient with suspected femoral neck fracture should have anteroposterior and lateral hip radiographs and anteroposterior and lateral knee radiographs.
- •
In situations in which it is unclear whether the patient has a low femoral neck or intertrochanteric hip fracture, internal rotation traction hip radiographs including anteroposterior and lateral views can be helpful.
- •
Distinguishing between the two fracture patterns is important because it may alter the definitive management.
- •
MRI is recommended for patients with acute trauma to the hip who are unable to bear weight and have negative radiographs.
- •
MRI is used to evaluate for occult femoral neck fracture.
- •
A fine-cut (<2 mm) CT scan can be performed in patients with an absolute contraindication for MRI (i.e., metal implants in the eye, brain, or heart) or when MRI is unavailable.
- •
- ▪
Classification
- •
The Garden classification is used ( Fig. 13-3 ).
FIGURE 13-3
Garden classification.
- •
Another method is to describe the fracture by its location:
Subcapital: Below or adjacent to the femoral head
Transcervical: Mid–femoral neck region
Basicervical: Distal femoral neck region
- •
- ▪
Management
- •
Most femoral neck fractures are treated operatively, and a complete preoperative evaluation is required.
- •
The decision concerning operative versus nonoperative treatment is based on the patient’s age, medical comorbidities, fracture pattern, and concomitant injuries.
- •
At our institution, all patients have complete blood count, electrolytes, blood urea nitrogen and creatinine, prothrombin time/international normalized ratio, and partial thromboplastin time tests.
- •
Patients older than 40 years also have a chest radiograph and electrocardiogram, and a type and crossmatch for 2 units of packed red blood cells is performed.
- •
Femoral neck fracture in a physiologically young patient (≤55 years old), whether displaced or not, is an orthopedic emergency.
- •
Because of the retrograde femoral neck vascularity, timely reduction should be performed to preserve the native anatomy, and urgent orthopedic consultation is recommended.
- •
- ▪
Emergency Department Management
- •
Adequate pain control should be prescribed.
- •
Buck’s skin traction of 10 lb maximum can provide pain relief by limiting motion at the fracture site.
- •
- ▪
Common Pitfalls
- •
Failure to recognize an occult femoral neck fracture
All patients with acute hip pain after a fall who are unable to bear weight should undergo MRI (or CT as discussed) to rule out an occult femoral neck fracture.
- •
Delayed treatment of a displaced femoral neck fracture in a physiologic young patient
Early reduction of femoral neck fractures in physiologic young patients has been associated with reduced risk of osteonecrosis.
Young patients should be informed of the increased risk of osteoarthritis, osteonecrosis, and nonunion when treated with open reduction and internal fixation; this is true for early and delayed treatment.
- •
Inadequate radiographs
Some femoral neck fractures are basicervical or low neck fractures, which can change the treatment plan.
Internal rotation and traction views can help visualize the fracture pattern better and aid in the diagnosis.
Radiographs of the joint above and below the fracture should always be obtained.
- •
Osteoporosis evaluation
All patients sustaining a fragility fracture should be advised to be evaluated for osteoporosis.
More recent literature shows the reduced incidence of fragility fractures with current pharmacologic treatment for osteoporosis.
- •
Intertrochanteric Femur Fractures
- ▪
Intertrochanteric femur fractures are fractures located between the greater and lesser trochanter.
- ▪
These are among the most common hip fractures in elderly patients and are rare in young patients.
- ▪
Diagnosis
- •
Patients with intertrochanteric femur fractures typically complain of acute onset of hip pain after a fall.
- •
Inability to bear weight and restricted range of motion are common findings.
- •
Full-length anteroposterior and lateral radiographs including the knee should be obtained.
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In a situation in which it is difficult to delineate between a low femoral neck fracture (basicervical) and an intertrochanteric femur fracture, traction internal rotation radiographs are helpful.
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Occasionally a patient with negative radiographs who is unable to bear weight after an acute fall is encountered.
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MRI is warranted to rule out an occult hip fracture.
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A fine-cut CT scan with 2-mm cuts can be obtained in patients who are unable to undergo MRI.
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Classification
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There have been many proposed classifications for intertrochanteric femur fractures, but no particular classification scheme has been universally accepted.
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Assess the number of fracture fragments, the direction of the main fracture, and the integrity of the posterior medial buttress.
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We prefer the Jensen classification because of its reproducibility, while offering guidance for surgical treatment ( Fig. 13-4 ).
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