Lecture for undergraduate students. Equally useful for postgraduate students.

1. NECK OF FEMUR,
INTERTROCHANTERIC
AND SUBTROCHANTERIC
FRACTURE
DR. SUNDAR KARKI
MBBS, MS(ORTHO), LECTURER
DEPARTMENT OF ORTHOPEDIC AND
TRAUMA
DEVDAHA MEDICAL COLLEGE

2. Relevant Anatomy
• The hip joint is a ball and socket joint with inherent
stability, largely as a result of the adaptation of the
articulating surfaces of the acetabulum and femoral
head to each other.
• The capsule and ligaments of the joint provide
additional stability.
• The acetabulum faces an angle of 30 degree
outwards and anteriorly.
• The normal neck-shaft angle of the femur is 120 to
135 degree in adults, with 15 degree of anteversion.

4. Relevant Anatomy
• The neck is made up of spongy bone with
aggregation of bony trabeculae along the lines of
stress.
• The most important of these is the medial
longitudinal trabecular stream. These run from the
lesser trochanter, along the medial cortex of the neck
to the postero-medial quadrant of the head.
• A thin vertical plate of bone appear from the compact
medial wall of the shaft, and extends into the spongy
bone of the neck. This is called the calcar femorale.

6. FRACTURE OF NECK OF THE
FEMUR
• There are two types of fractures of neck of the femur:
intra-capsular and extra-capsular.
• The term ‘fracture of the neck of the femur’ is used
for intra-capsular fracture of the neck. The extra-
capsular fracture is usually called inter-trochanteric
fracture.
• Women>men.

7. Mechanism of injury
• Low energy (fall from the standing height) in elderly—
associated with the osteoporosis.
• High energy in young patient—associated with the
vertical fracture orientation and femoral shaft
fracture.

8. Pathoanatomy
• Most of these fractures are displaced, with the distal
fragment externally rotated and proximally migrated.
• These displacements also occur in inter-trochanteric
fracture in which these are more marked.

9. Classification (Anatomical
Location)
• On the basis of anatomical location of the fracture, it
can be classified as:
(i) Subcapital – a fracture just below the head;
(ii) Transcervical – a fracture in the middle of the
neck; or
(Iii) Basal – a fracture at the base of the neck.
• The more proximally the fracture is located, the
worse is the prognosis.

11. Pauwel’s classification
• This classification is based on the angle of inclination
of the fracture in relation to the horizontal plane
(pauwel’s
angle.
• The fractures are divided into three types (type i–iii).
• The more the angle, the more unstable is the
fracture, and worse the prognosis.

13. Garden’s classification
 This is based on the degree of displacement of the
fracture
(mainly rotational displacement).
Stage 1: the fracture is incomplete, with head tilted
in posterolateral direction, i.E. Into valgus, therefore
is known as valgus (abduction) impacted fracture.
Stage 2: complete fracture but undisplaced.
Stage 3: complete fracture with partial
displacement.
Stage 4: complete fracture with total displacement.

15. Diagnosis (Clinical
Features)
• Occasionally, a patient with an impacted fracture may
arrive walking; the only complaint being a little pain
in the groin.
• There is pain in the groin and inability to move his
limb or bear weight on the limb following a ‘trivial’
injury like slipping on the floor, missing a step etc.
There is little pain or swelling.
• Often, the injury is trivial, and pain and swelling
almost absent. In such cases, the fracture diagnosis is
missed for days or weeks.

16. Diagnosis
(Examination)
• Careful examinations reveals the following:
• external rotation of the leg, the patella facing
outwards.
• Shortening of the leg, usually slight.
• Tenderness in the groin.
• Attempted hip movements painful, and associated
with severe spasm.
• Active straight leg raising not possible.

17. Diagnosis (Radiological
Features)
• It is useful to ask for x-ray of pelvis with both hips,
rather than that of the affected hip alone. This helps
in comparing
the two sides. The following features should be
noted.
• Break in the medial cortex of the neck.
• External rotation of the femur is evident; the lesser
trochanter appearing more prominent.
• Overriding of greater trochanter, so that it lies at
the level of the head of the femur.
• Break in the trabecular stream.
• Break in shenton’s line

19. Treatment
1. <65 years, < 3- week
o Closed reduction and internal fixation with
multiple screw is the treatment of choice. In
basicervical fracture. Dynamic hip screw can be
done.
o If closed reduction is not possible open reduction
and screw fixation is indicated.
2. <65 years, > 3-week fracture, osteotomy (to
decrease pauwel’s angle)/bone grafting (due to
absence of cambium layer) + fixation.
3. >65 years
o No pre-existing arthritis—hemiarthroplasty
o Pre-existing arthritis—total hip replacement

22. Internal fixation
• Any of the following implants may be used for
internal fixation:
• multiple cancellous screws – most commonly used.
• Dynamic hip screw (DHS) – used sometimes.
• Multiple knowle’s pins/moore’s pins used in
children.

23. The technique of internal
fixation
• The technique being described here is, use of
multiple cancellous
screws.
• The screws used are partially threaded, the threaded
part holds in the head, whereas the smooth part
permits controlled collapse of the fracture, which
helps in union.
• The fracture is reduced by closed manipulation. The
reduction is checked on image intensifier.
• Minimum three screws, preferably parallel, are
necessary.
• The patient is allowed to sit up in bed, and be out of
bed with crutches (non weight bearing) in the early
post-operative period.

25. McMurray’s osteotomy
• This was a popular operation in yesteryears.
• This is an oblique osteotomy at the inter-trochanteric
region.
• The direction of osteotomy is medially upwards,
beginning at the base of the greater trochanter and
ending just above the lesser trochanter.

27. Hemiarthroplasty
• This is a procedure used for elderly patients.
• In this, the head of the femur is excised and replaced
by a prosthesis.
• There are two types of prosthesis commonly in use:
unipolar and bipolar.
• Unipolar prosthesis have a 'head' with an attached
stem. The stem
is introduced inside the medullary canal of the femur,
and the head sits over the neck of the femur.
• In bipolar prosthesis, the head has two parts: a
smaller head, and a mobile plastic cup on top of it.

29. Complications
• Non-union: it occurs in approximately 30 to 40 per
cent of intra-capsular fractures. It is due to
inadequate immobilization of the fracture even with
internal fixation, and its poor blood supply.
• Treatment: the treatment of non-union depends upon
the age of the patient, and on whether or not there is
avascular necrosis of the femoral head. In patients
beyond the age of 60 years, replacement arthroplasty
is performed. In younger individuals, attempt is made
to preserve the head of the femur through neck
reconstruction or pauwel’s osteotomy.

30. Complications
• Avascular necrosis: after a fracture through the neck, all the
medullary blood supply and most of the capsular blood supply
to the head are cut off.
• These changes may not become evident early. It is only after a
few months to as long as 2 years, that one can diagnose
avascular necrosis on x-rays. MRI is the best investigation for
this purpose.
• In young patients treatment options are between arthrodesis of
hip, bipolar arthroplasty (a special type of prosthesis), Meyer’s
procedure or rarely, total hip replacement (THR).
• In elderly patients, a hemi-replacement arthroplasty is
performed. In cases where there is an associated damage to the
hip, a total hip replacement may be preferred.

31. Complications
• Osteoarthritis: it develops a few years following
fracture of the neck of femur. It may be because of: (i)
avascular deformation of the head; or (ii) union in
faulty alignment. The patient presents with pain and
stiffness of the joint.
• Treatment: it depends upon the age and functional
requirement of the patient. Younger patients are
treated by either an inter-trochanteric osteotomy or
arthrodesis of the hip. For an elderly patient, total hip
replacement is the best option.

32. INTER-TROCHANTERIC
FRACTURES
• Fractures in the inter trochanteric region of the
proximal femur, involving either the greater or the
lesser trochanter or both, are grouped in this
category.
• In the elderly, the fracture is normally sustained by a
sideway fall or a blow over the greater trochanter.
• In the young, it occurs following violent trauma, as in
a road traffic accident

33. Pathoanatomy
• The distal fragment rides up so that the femoral
neck-shaft angle is reduced (coxa vara).
• The fracture is generally comminuted and displaced.
Very rarely, it can be an undisplaced fracture.

34. Diagnosis (Clinical
Features)
• There is pain in the region of the groin and an
inability to move the leg.
• There will be swelling in the region of the hip, and
the leg will be short and externally rotated.
• There is tenderness over the greater trochanter. The
physical findings in such a case are more marked
compared to those in a fracture of the neck of the
femur

35. Diagnosis (Radiological
Features)
• Diagnosis is easy on an x-ray.
• Presence of comminution of the medial cortex of the neck,
avulsion of the lesser trochanter and extension of the
fracture to the subtrochanteric region indicate an unstable
fracture, and a poor prognosis.

37. Treatment
• Contrary to fracture of the neck of the femur,
trochanteric fractures unite readily.
• The main objective of treatment is to maintain a normal
femoral neck-shaft angle during the process of union.
• This can be done by conservative means(traction) or by
internal fixation.

38. Conservative
treatment
• There are a number of tractions described for an
inter-trochanteric fracture.
• Those used most frequently are Russell’s traction and
skeletal traction in a Thomas splint.
• With the success of operative methods, whereby,
early mobilization is possible, conservative methods
are used less often.

40. Operative treatment
• The fracture is reduced under x-ray control and fixed
with internal fixation devices. The most commonly
used ones are:
• (i) Dynamic hip screw (DHS)
• (ii) Ender’s nails and
• (iii) Nails such as gamma nail,
• Proximal femoral nail (PFN).
• External fixation is useful for patients with bed sores,
and for those who are unfit for a major operation.

42. Complications
• Malunion: malunion gives rise to coxa vara
(decreased femoral neck-shaft angle), shortening and
the leg in external rotation.
• Treatment: in elderly patients, malunion does not
cause a great deal of disability, except a limp while
walking, and shortening. Compensation for this
shortening, by giving a suitable shoe raise, suffices in
most cases. In young people with severe coxa vara
and shortening, correction may be required. This is
achieved by an inter-trochanteric osteotomy whereby
the neck-shaft angle is corrected and held in the

43. Complications
• Osteoarthritis: due to changes in the hip
biomechanics following trochanteric fractures,
osteoarthritis of the hip develops after a few years.
The patient complains of pain and stiffness in the hip
after a reasonably symptom free period following
union of the fracture. An x-ray confirms changes of
osteoarthritis in the hip joint.
• Treatment: in the early stages, treatment is by
physiotherapy. Later, a trochanteric osteotomy (in
younger patient) or a total hip replacement (in elderly
patient) may be required.

45. SUBTROCHANTERIC
FRACTURE
• Fracture below the lesser trochanter
• Mechanism of injury—higher energy than
intertrochanteric fractures
• Subtrochanteric fractures have several features which
make them interesting (and challenging!) To treat.

47. Classification—Russell-Taylor
Classification
• Based on involvement of lesser trochanter and
piriformis fossa
 Type ia—fracture below lesser trochanter
 Type ib—fracture involves lesser trochanter; greater
trochanter intact
• In type I fracture donot extend to piriformis fossae
 Type iia—greater trochanter involved; lesser
trochanter intact
 Type iib—greater and lesser trochanter involved
• In type II fracture extend to the piriformis fossae.

48. Treatment
 Generally treated with IM fixation
 Standard proximal interlocking (1st generation IM
nail) for fractures with intact lesser trochanter
 Reconstruction interlocking (2nd generation IM nail)
for fractures with involvement of lesser trochanter
 Piriformis entry nail contraindicated for fractures
involving piriformis fossa
 Fixed-angle plate fixation/proximal femoral locking
plates
 Indicated for fractures with proximal comminution
and nonunion
 95-degree devices
 Devices of 135 degrees contraindicated

49. Complications
 Nonunion—minimized with IM nailing and biologic
plating
 Malalignment—varus and apex anterior angulation
with IM nailing. Consider adjunctive reduction aids
and percutaneous reduction.
 Infection—associated with increased soft tissue
dissection