neck of femur, intertrochanteric,subtrochanteric fractures

1. Proximal femoral fractures
Presenter : DR. SOUVIK PAUL

2. ANATOMY OF PROXIMAL FEMUR
• Physeal closure age 16
• Neck-shaft angle : 130° ± 7°
• Anteversion : 10° ± 7°
• Minimal periosteum about the femoral neck
• Calcar Femorale (cantilever of femur): dense vertical plate of bone
extending from postero-medial portion of femoral shaft and radiating
lateral to the greater trochanter , thicker medially

3. BLOOD SUPPLY OF PROXIMAL FEMUR

4. TRABECULAR PATTERN OF PROXIMAL FEMUR

5. AO PROXIMAL FEMUR # CLASSIFICATION

6. Classification
1. Femoral head fracture
2. Femoral neck fracture
3. Intertrochanteric fracture
4. Subtrochanteric fracture

7. FEMORAL HEAD FRACTURE
• Almost all a/w hip dislocations.
• A/w 10% of posterior hip dislocations.
• Impaction fractures a/w anterior hip dislocations (25% to 75%).

8. Pipkin Classification
• Type I : Posterior dislocation with femoral head # caudad to the fovea
• Type II : Posterior dislocation with
femoral head # cephalad to the fovea
• Type III : Femoral head # with
associated femoral neck #
• Type IV : Type I, II, or III a/w
acetabular fracture

9. TREATMENT
• Pipkin Type I :CRIF if fails ORIF with small subarticular screws
• Pipkin Type II : ORIF
• Pipkin Type III :
■ Younger age : emergency ORIF
■ Older age : prosthetic replacement
• Pipkin Type IV : Treated in tandem with associated acetabular fracture.

10. Femoral neck fracture
• 80 % in women. (Women: male 2.5: 1)
• Incidence doubles every 5 to 6 years in women age >30 years.
• RISK FACTORS:
1. female sex,
2. white race,
3. increasing age,
4. tobacco and alcohol use,
5. previous fracture,
6. low estrogen level.

11. Garden Classification
I Valgus impacted or
incomplete
II Complete
Non-displaced
III Complete
Partial displacement
IV Complete
Full displacement

12. Anatomical classification

13. Pauwels Classification
Less
stable Less stable unstable

14. Ao classification

15. Mechanism of injury
1. Low-energy trauma: older patients.
■ Direct: fall onto the greater trochanter (valgus impaction) or
forced ER of LL impinges neck onto post lip of acetabulum ( posterior
comminution)
■ Indirect: By muscle forces
2. High-energy trauma: younger and older patients
3. Cyclical loading : athletes, military recruits and ballet dancers

16. DIAGNOSIS
• Accurate history
• Pain in the groin or referred pain along the medial side of the knee
may be able to walk with a limp
• Displaced fractures are non-ambulatory with shortening and external
rotation of the LL
• Impacted or stress fractures lack deformity and may bear weight.
• Tenderness to palpation of ant. hip joint line or deep tenderness over GT
• X RAY (Break in shenton line ,proximal migration of femur) CT , MRI

17. Treatment Goals: Young Patients
• Spare femoral head
• Avoid deformity
– Improves union rate
– Optimal functional outcome
• Minimize vascular injury
– Avoid AVN

18. Treatment Goals: Geriatric Patients
• Mobilize
– Weight bearing as tolerated
– Minimize period of bed rest
• Minimize surgical morbidity
– Safest operation
– Decrease chance of reoperation

19. TREATMENT OF IMPACTED AND NONDISPLACED FRACTURES
(GARDEN I AND II)
• Internal fixation with multiple cancellous lag screws.

20. DISPLACED FEMORAL NECK FRACTURES
• Parallel cancellous lag screws
• Austin-Moore hemiarthroplasty
• Bipolar or unipolar modular hemiarthroplasty
• Total hip replacement.

21. Closed Reduction
• Whitman technique: applying traction to the
abducted, extended, externally rotated hip with
subsequent internal rotation.
• Leadbetter technique:when Whitman
technique is unsuccessful.
• flexed at the hip to 90 degrees, and the thigh is
slightly internally rotated; traction is applied in
line with femur. limb is circumducted into
abduction, maintaining the internal rotation,
brought down to table level in extension
• evaluated the reduction with a “heel-palm” test

22. Open approach
• Smith-Peterson
 Direct access to fracture
 Between TFL and sartorius
• Watson-Jones
 anterolateral
 Between TFL&gluteus medius
 Best for basicevical

23. Fixation Concepts
• Reduction makes it stable
– Avoid ANY varus
– Avoid inferior offset
• Malreduction likely to fail
• Tip to apex distance measured
on both AP and lateral views
should total < 2.5 cm
• Screws parallel to each other

24. Fixation Concepts
• Screw position
– Inferior : within 3 mm of
cortex
– Posterior: within 3 mm of
cortex
– Avoid posterior/superior
• To avoid iatrogenic
vascular damage
• To avoid screw cutout Good Bad

25. Garden’s index
Assessing reduction in
subcapital fractures on AP view.
Medial femoral shaft and axis of trabecular
markings over the medial aspect of the
femoral neck lie at 160° to 180° in acceptable
reduction
In lateral view
trabecular markings in line acceptable
reduction is
within 20° of this ideal.

26. COMPLICATIONS
 Nonunion (In ORIF ): 5% of nondisplaced # , 25% of displaced #
t/t: Proximal femoral osteotomy.
Cancellous bone grafting
Muscle pedicle grafting
 Osteonecrosis (ORIF):
10% of nondisplaced # , 30% of displaced #
t/t: Early without x-ray changes: protected weight bearing
core decompression.
Late with x-ray changes : arthroplasty
 Fixation failure (ORIF)
 DVT/PE
 Dislocation (replacement): THR > hemiarthroplasty. Overall 1% to 2%.

27. Internal Screw Fixation Compared with Bipolar Hemiarthroplasty for Treatment of
Displaced Femoral Neck Fractures in Elderly Patients
J.-E. Gjertsen, T Vinje, L.B. Engesæter et al.
J Bone Joint Surg Am. 2010;92:619-628.
• Prospective study
• Level of Evidence: Therapeutic Level III.
• n =4335 patients >70 yr age
• IF:1823 patients
• Hemiarthroplasty : 2512 patients
• Follow-up 12 months.

28. • 1 year mortality, no of reoperations, and patient self-assessment of pain,
satisfaction, and quality of life at 4 & 12 months were analyzed
• mortality : 27% - osteosynthesis group
25% -arthroplasty group; (p = 0.76).
• reoperations : 412 - osteosynthesis group
72 -arthroplasty group (p =0.02)
• pain : mean score: 29.9 - osteosynthesis group (p < 0.001 )
19.2 -arthroplasty group
• higher dissatisfaction : mean score 38.9 - osteosynthesis group
25.7 -arthroplasty group (p < 0.001 )
• lower quality of life :mean score, 0.51 :osteosynthesis group
0.60: arthroplasty group (p < 0.001 )
Scored By :EuroQol visual analog scale
Reseachers found Bipolar HA better than screw fixation in elderly

29. Intertrochanteric Fractures
• 50% of all fractures of the proximal femur.
• Women: men ranges from 2:1 to 8:1
• Risk factors: same as femoral neck fractures

30. Anatomy & biomechanics
• Extracapsular # cancellous bone with an abundant blood supply .
• Deforming muscle forces produce shortening, external rotation, and varus at #
site
• Fracture stability : Integrity of posteromedial corte ,lateral cortex
• Reverse fracture is more unstable

31. Diagnosis
• H/o High-energy injury or rarely simple fall in old age
• Usually Non ambulatory ,shortened and externally rotated LL.
• Tenderness to palpation in GT
• Ecchymosis
• ROM testing of the hip :very painful and avoided

32. AO classification trochanteric #
• Group A1, simple two-part fracture; group A2, fracture extends over two or more levels of medial
cortex; group A3, fracture extends through lateral cortex of femur.

33. Boyd & Griffin Classification
Stable fractures
• Type I: Nondisplaced fracture
• Type II: Displaced fracture
Unstable fractures
• Type III: Reverse,subtrochanteric,or
posteromedial comminution fracture
• Type IV: Intertrochanteric fracture with
subtrochanteric fracture

34. Nonoperative Treatment
• Prolonged bedrest in traction (usually 10 to 12 weeks), f/b program of
ambulation training
• indicated for the most infirm, moribund patients where surgical
intervention is impossible
• A/W high complication rates :
1. Decubitus ulcer,
2. UTI
3. Joint contractures
4. Pneumonia
5. DVT & PE
6. Varus deformity and shortening

35. Operative Treatment
 Sling Hip Screw
 Intramedullary Devices:
1. Proximal femoral nail (PFN)
2. Gamma 2
3. Gamma 3
Rehabilitation
■ Early patient mobilization with weight bearing as tolerated is indicated.

36. COMPLICATIONS
• Malunion
• Implant failure
• Nonunion: <2% mainly in unstable fracture
• Osteonecrosis of the femoral head :rare
• Neurovascular injury

37. .
Proximal femoral nail vs. dynamic hip screw in treatment of
intertrochanteric fractures: a meta-analysis.
Zhang K, Zhang S, Yang J,
Med Sci Monit. 2014 Sep 12;20:1628-33
• Meta-analysis
• RCT comparing the effects of PFN and DHS were searched for following
the requirements of the Cochrane Library Handbook.
• Six eligible studies involving 669 unstable fractures

38. PFN :less operative time (WMD: -21.15, 95% CI: -34.91 - -7.39, P=0.003)
intraoperative blood loss (WMD: -139.81, 95% CI: -210.39 - -69.22,
P=0.0001)
length of incision (WMD: -6.97, 95% CI: -9.19 - -4.74, P<0.00001) than the
DHS group.
No significant differences regarding postoperative infection rate, lag screw
cut-out rate, or reoperation rate.
Researchers recommend PFN as the first option in treating IT# .

39. Subtrochanteric fractures
10% to 30% of all hip fractures
Bimodal distribution in individuals 20 to 40 years of age and >60
years of age

40. Anatomy and biomechanics
• # between lesser trochanter and a point 5 cm distal
• Medial and posteromedial cortices :
high compressive forces
• Lateral cortex : high tensile forces
• Kochs diagram on stress over femur

41. Symptoms and Signs
• Swelling
• Shortening
• ER of LL
• Hypovolemic shock in high velocity trauma

42. Fielding classification
• Anatomical classification
describing the position of the
major fracture line with respect
to the lesser trochanter

43. Russell-Taylor classification
• Type I: Fractures do not extend into
the piriformis fossa.
IA: Lesser trochanter is intact.
IB: Lesser trochanter is not intact.
• Type II: Fractures extend into the
piriformis fossa.
IIA: Lesser trochanter is intact.
IIB: Lesser trochanter is not intact

44. AO classification

45. Nonoperative treatment
Skeletal traction f/b hip spica or cast
•Only for those elderly individuals with severe co morbidities & children.
•Complication:
1. :Nonunion
2. Delayed union
3. Malunion with varus angulation,
4. Rotational deformity
5. Shortening.

46. Operative
• Implants :
1.Intramedullary Nail:
• ■ First-generation (centromedullary) nails: both
trochanters intact.
• ■ Second-generation( cephalomedullary )nails :
( Use: loss of the posteromedial cortex ,
#extending into the piriformis fossae)
2.Ninety-Five Degree Fixed Angle Device :# involving both trochanters
3.Sliding Hip Screw

47. COMPLICATION
1. Non union
2. Malunion
3. Implant failure

48. Paediatric proximal femur #
 Cause:
Severe high-energy trauma ( fall from height, motor vehicle accident, or fall
from bicycle)
Trivial trauma with preexisting conditions like
Unicameral bone cyst,
Osteogenesis imperfecta,
Fibrous dysplasia,
Myelomeningocele, and
Osteopenia from previous polio
Child abuse

49. Classification
• 4 types on anatomic location of # by Delbet
• Type I: Transepiphyseal : acute traumatic separation of a previously normal
physis
• Type II: Transcervical—fracture through mid-portion of the femoral neck.
Usually from severe trauma & displaced
Most common complication is AVN
• Type III: Cervicotrochanteric—fracture through the base of the femoral
neck
• Type IV: Pertrochanteric or intertrochanteric—fracture between the
greater and lesser trochanters

50. Clinical features
• severe pain
• unable to actively move the limb
• If dislocation is present: LL in flexion, adduction, and internal rotation

51. Treatment
Type I: Transepiphyseal- anatomic reduction with rigid IF f/b cast immobilization
Type II: Transcervical Fractures –
CRIF to avoid loss of
reduction and subsequent malunion,
delayed union, or nonunion .
Type III: Cervicotrochanteric : CRIF
Type IV: Pertrochanteric :
nonoperatively in <6 years
CRIF :displaced fracture in any age group
nondisplaced fracture in an older child >6 yr

52. Conclusion
• Goal of proximal femur # management:
maintaining neck shaft angle & whole
abductor mechanism .
• Achieve union
• Posteromedial cortex ,lateral cortex , Calcar
femorale play a crucial role