1. Proximal femur fractures are divided into femoral head, femoral neck, and extracapsular fractures based on location. Accurately classifying the fracture type guides surgical management. 2. Femoral neck fractures occur through the intra-capsular part of the femoral neck. They are classified using the Garden or Pauwel's classifications which determine stability and treatment approach. 3. Intertrochanteric fractures occur between the greater and lesser trochanters. Younger patients often experience high-energy injuries while the elderly commonly sustain them from falls. Treatment depends on the Evans classification and stability.

1. Proximal Femur Fractures
(Hip fractures)
Khaled ALNAHHAL
5th year medical student @ Al-Azhar university – Gaza

2. Outline
• Organization Tree
• Anatomy
• Head fracture
• Neck fracture
• Trochanteric fracture
• Intertrochanteric
• Sub trochanteric fracture

3. Organization Tree
Proximal femur fractures may be divided into femoral head,
intracapsular femoral neck, and extracapsular fractures.
Accurately categorizing the anatomic location and subtype of the
fracture has significant implications for surgical management

4. * Basicervical fractures, although intracapsular, are managed like intertrochanteric fractures.

6. The hip is a synovial joint with wide range of rotational motion and stability
Stability is conferred by its ball and deep socket configuration, acetabular
labrum, a strong joint capsule, articular cartilage, and surrounding muscle

9. Anatomy: Arterial Supply
1. Extracapsular arterial ring located at the base of the femoral neck
(Medial & lateral femoral circumflex artery)
2. Ascending cervical branches of the extracapsular arterial ring on the
surface of the femoral neck (known as retinacular arteries)
3. The arteries of the ligamentum teres
4. Nutritional artery

10. Anatomy: Arterial Supply
• Medial femoral circumflex artery
• Largest, most important contributor
• Posterior portion of extracapsular arterial ring
• Lateral femoral circumflex artery
• Anterior portion of extracapsular arterial ring
• Ascending cervical arteries (Retinacular arteries)
• Feeder vessels arising from extracapsular ring
• Penetrate capsule
• Run parallel to femoral neck towards the head
• Lateral vessels provide greatest supply
• Fovealar artery from obdurator artery
• Via ligamentum teres
• Little supply to femoral head, inadequate in
setting of displaced head/heck fractures

11. Extracapsular
arterial ring
Retinacular arteries:
Divided into four groups
(anterior, medial,
posterior, and lateral)
based on
their relationship to the
femoral neck.

12. • At the subsynovial intra-articular ring,
epiphyseal arterial branches arise that
enter the femoral head.
• Epiphyseal artery forms 2 groups of
vessels
1. lateral epiphyseal arteries
2. Inferior metaphyseal arteries
• Most important is, lateral epiphyseal
arterial group supplying the
lateral weight bearing portion of
the femoral head

13. Traumatic Femoral Head (Osteochondral)
Fractures
• Traumatic femoral head fractures typically result from high energy
impact(such as motor-vehicle accident or fall from a significant
height), and are often associated with hip dislocations.
• Posterior dislocations 9x more common than anterior.
• Partial flexion, internal rotation typically leads to a posterior fracture-
dislocation pattern
• Pipkin Classification

14. Pipkin Classification

16. Presentation
• History
• frontal impact MVA with knee striking dashboard
• fall from height
• Symptoms
• localized hip pain
• unable to bear weight
• other symptoms associated with impact
• Physical exam
• inspection
• shortened lower limb
• with large acetabular wall fractures, little to no rotational asymmetry is seen
• posterior dislocation
• limb is flexed, adducted, internally rotated
• anterior dislocation
• limb is flexed, abducted, externally rotated
• neurovascular
• may have signs of sciatic nerve injury

17. Imaging
• Radiographs
• recommended views
• AP pelvis, lateral hip and Judet views
• both pre-reduction and post-reduction
• inlet and outlet views
• if acetabular or pelvic ring injury suspected
• CT scan
• indications
• after reduction
• to evaluate:
• concentric reduction
• loose bodies in the joint
• acetabular fracture
• femoral head or neck fracture
• findings
• femoral head fracture
• intra-articular fragments
• posterior pelvic ring injury
• impaction
• acetabular fracture

19. Management Strategies
• Conservative management: Pipkin I
• ORIF: Pipkin II, Pipkin III, IV, irreducible fracture-dislocation

20. Femoral Neck Fracture
• A fracture through the intra capsular part of the femoral neck is
usually referred to by the term femoral neck fracture.
• Another term is intracapsular proximal femoral fracture. About 80%
of these fractures are displaced.

21. Risk Factors
• Epidemiology increasingly common due to aging population
• women > men
• whites > blacks
• United states has highest incidence of hip fx rates worldwide
• most expensive fracture to treat on per-person basis

23. • Neck connects head with shaft and is about 3.7 cm long
• It makes angle with the shaft 130+/- 7 degree( less in female due to
their wider pelvis).
• It is strengthened by calcar femorale (bony thickening along
its concavity)

24. Mechanism of injury
• Low energy falls in older patients
• Direct: A fall onto the greater trochanter (valgus
impaction) or forced external rotation of the lower
extremity impinges an osteoporotic neck onto the
posterior lip of the acetabulum (resulting in posterior
comminution).
• Indirect: Muscle forces overwhelm the strength of the
femoral neck
• High energy in younger patients
• such as motor-vehicle accident or fall from a significant
height

25. Associated injuries
• Femoral shaft fractures
• 6-9% associated with femoral neck fractures
• Treat femoral neck first followed by shaft
Prognosis
• Mortality
• ~25-30% at one year (higher than vertebral compression fractures)

26. Classification
• Garden Classification
• Pauwels Classification

27. Garden Classification

29. Simplified Garden Classification
Nondisplaced Includes Garden I and II
Displaced
Includes Garden IIII and
IV

30. Pauwel Classification
• This is based on the angle of fracture from the horizontal

31. • Type 1 (More stable)
• Type 2 (Most common)
• Type 3 (Most unstable with highest risk of nonunion and AVN)
• Better categorizes stability than the Garden Classification
• Type III fractures complicated by nonunion may require
intertrochanteric osteotomy to reorient the fracture
line to a more Type 1 (stable) angle

32. Presentation
• Symptoms
• impacted and stress fractures
• slight pain in the groin or pain referred along the medial side of the thigh and knee
• displaced fractures
• pain in the entire hip region
• Physical exam
• impacted and stress fractures
• no obvious clinical deformity
• minor discomfort with active or passive hip range of motion, muscle spasms at extremes of
motion
• pain with percussion over greater trochanter
• displaced fractures
• leg in external rotation and abduction, with shortening

33. Imaging
• Radiographs
• recommended views
• obtain AP pelvis and cross-table lateral, and full length femur film of ipsilateral side
• traction-internal rotation AP hip is best for defining fracture type
• Garden classification is based on AP pelvis
• CT
• helpful in determining displacement and degree of comminution in some patients
• MRI
• helpful to rule out occult fracture
• not helpful in reliably assessing viability of femoral head after fracture
• Bone scan
• helpful to rule out occult fracture
• not helpful in reliably assessing viability of femoral head after fracture
• Duplex Scanning
• indication
• rule out DVT if delayed presentation to hospital after hip fracture

34. TREATMENT

36. Dynamic Hip Screw
• Most commonly used
device for both stable
and unstable fracture
patterns.
• Plate angle is variable
130 to 150 degrees.
• Has to be positioned
centrally in the femoral
head.
• Use of radiological
views to know the exact
position.

38. Complications
• Thromboembolism:- leading cause of death within first 7 days (40%)
• Nonunion
• Avascular necrosis

42. Intertrochanteric Fracture
• An intertrochanteric hip fracture occurs between the greater trochanter, where the gluteus
medius and minimus muscles (hip extensors and
abductors) attach, and the lesser trochanter, where the iliopsoas muscle (hip flexor) attaches
• Common in elderly osteoporotic patient
• Usually woman in eighth decade
• Unite easily and rarely cause avascular necrosis
• Anatomy
• Intertrochanteric line: anterior ridge between greater and lesser trochanters
• Extracapsular, transition between femoral neck and shaft
• Mechanism
• Resulting from fall

44. Mechanism
• In younger individuals are usually the result of a high-energy injury,
such as a motor vehicle accident (MVA) or fall from a height
• In the elderly, it results from a simple fall.

45. Evans Classification
• Useful for
deciding stability
and treatment of
intertrochanteric
fractures. Also,
reverse obliquity
fractures are
unstable and
treated like
subtrochanteric
fractures

47. Signs & Symptoms
• Pain
• Marked shortening of lower limb
• Patient cannot lift his/her leg
• Complete External Rotation Deformity
• Swelling, ecchymoses and Tenderness over the Greater Trochanter
• Displaced fractures are clearly symptomatic, such patients usually cannot
stand, much less ambulate
• Nondisplaced fractures may be ambulatory and experience minimal pain
• The amount of clinical deformity in patients with an intertrochanteric
fracture reflects the degree of fracture displacement

48. Imaging
When a hip fracture is suspected but
not apparent on standard x-rays, a
technetium bone scan or a magnetic
resonance imaging (MRI) scan should
be obtained. MRI has been shown to be
at least as accurate as bone scanning in
identification of occult fractures of the
hip, and it will reveal a fracture within
24 hours of injury

49. Management
• Management depends on completeness and stability
• Risk of AVN and nonunion less than in femoral neck fractures
• basicervical fractures treated like intertrochanteric fractures

50. cont
• Complete:
• Stable: Dynamic plate and screw
• Unstable or reverse obliquity: Intramedullary device
• Incomplete
• Obtain MRI to ensure fracture not complete
• If incomplete and <50% fracture width, potentially can treat
conservatively
• Risk of fracture completion

51. Greater Trochanter Fracture
• Anatomy
Greater trochanter is the insertion site for hip abductors (gluteus medius
and minimus) and external rotators (piriformis, gemelli, obdurators)
• Mechanism
Isolated greater trochanter fracture may be related to impaction from fall,
versus avulsion
• Imaging
If incomplete, obtain MRI to assess extent of fracture
• Management
- Most heal well with nonoperative management
- If significant displacement, then ORIF

53. Lesser Trochanter Fracture
• Anatomy
Lesser trochanter is attachment site for iliopsoas
• Mechanism
Fracture may be due to avulsion
In the absence of injury, isolated lesser
trochanter fracture is highly suspicious for an
underlying malignancy
• Imaging
Obtain MRI to assess extent of fracture
Evaluate for underlying malignancy
• Management
- Nondisplaced fractures heal well with nonoperative management
- If significantly displaced, then ORIF

54. • Thank You