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Epidemiology
occurs in patients more than 50 years 97%
.old. The incidence increases with age
occurs in under 50 years age(20-40) due 3%
to high energy trauma, sports, industrial &
motor vehicle accidents. In 20-40 years most
hip fractures are subtrochanteric or basicervical. Fractures in elderly are serious
injuries, about 250,000 fractures per year in
USA & the number is projected to double by
the year 2050 & the cost exceeds 6 billion $
per year
Anatomy
The femoral side of the hip is made of
the femoral head with its articular
cartilage & the femoral neck which
connects the head to the shaft in the
region of intertrochanteric area. The
synovial membrane incorporates the
entire head &the anterior neck but only
the middle part of the neck posterior
.The neck shaft angle is 130(+_7)
.degree. The Ante version is 10(+_7)
Biomechanics
Falling from standing position leads to direct blow
on the greater trochanter. Osteoporosis is the
.precipitating factor
In young& middle aged high velocity trauma is
.needed to induce fracture
Postmenopausal& senile osteoporosis predisposes
to fracture .By the age of 65 years, 50% of women
show bone mineral content below the threshold for
fracture. By the age of 85 year this will reaches 100%
In elderly it can occur with minor trauma on an
externally rotated thigh or the bone is so weak that
.powerful muscle contraction can lead to fracture
Classifications
:Anatomical classification- 1
:A- Intracapsular
Subcapital (high risk)
Tran cervical (moderate risk)
Basal (less risk) intracapsular anteriorly, extra
.capsular posteriorly
Sometimes, high energy fracture occur in young
which involve the shaft of femur then to the base
of the neck then to the sub capital area. Usually
.these are undisplaced
:B- Extra-capsular
Inter-trochanteric fractures
Per-trochanteric
Notes:Intracapsular fractures carry poor
prognosis because of poor blood supply
which lead to avascular necrosis & nonunion while extracapsular fractures carry
good prognosis due to the good blood
supply
:Gardens classification- 2
They are classified according to the degree of
.displacement of the fracture fragment
Incomplete fracture(abduction& impacted)- 1
.making the neck in valgus
Complete fracture without displacement; the- 2
.neck alignment looks normal
.Complete fractures with partial displacement - 3
.Complete fractures with complete displacement- 4
:Pauwels classification
They are classified according to the
:direction of the fracture
Pauwel s 1: The angle from the
.horizontal line is 30-49 degree
Pauwel s 2: The angle from the
horizontal line is 50-69 degree
.
.Pauwel s 3: The angle is 70& more
Clinical features
Patient is usually old with history of
trauma. The patient is unable to stand
or walk. On examination the limb is
shorter, externally rotated & he is
unable to move it. Movement of the hip
.is tender &limited
Diagnosis
It is achieved by history,Examination, &
X-Ray of the hip, A.P& Lateral views are
.required
:Differential diagnosis
Non-traumatic fractures of the neck of
:-femur
Pathological fractures: Multiple
.myeloma, Secondary bone tumors
.Post-irradiation fractures
Stress fractures: Hair-line
fracture with no
.shortening or deformity
Treatment
According to the treatment required,
the complications likely to occur & the
prognosis; patient are divided into
;three age groups
.Fractures in elderly; over 70 years
.Fractures in young & middle aged
.Fractures in children
Treatment in Children
Some prefer conservative but the best
method of fixation by multiple pins
&immobilization by hip spica for 6
weeks &weight bearing after 8-12
.weeks
Notes: Even undisplaced fractures are
not immune from complications like
.AVN
Complications
:General
DVT& Pulmonary embolism: It is due to prolonged- 1
immoblication, treated by prophylactic early
.mobilization, if happens give Anticoagulants
Bed sores: It is due to prolonged immobilization, - 2
bad nursing &pressure on the skin& bony
prominence leading to necrosis that may be followed
by infection. It is treated by prophylactic frequent
turning of the patient, talk powder& pneumatic
.bedes
.Pneumonia, chronic UTI- 3
..Psychological trauma- 4
Local complications
:Avascular necrosis AVN
Incidence is 10-30% ( 10% in undisplaced
fractures, &30% in displaced fractures). It
may be partial or complete with consequent
collapse of the bone structure leading to
fragmentation. It takes months or even 2-3
years to occur. If involved the fracture site it
may lead to failure to union whereas collapse
at the articular surface leads to O.A & the
patient complains of hip pain & inability to
walk X-Rays reveal increased bone density,
.collapse & later an O.A changes
NON UNION- 2
:-Causes are
.Interference with blood supply- 1
Inadequate immobilization& early- 2
.mobilization
Dissolution of the hematoma by synovial- 3
.fluid
:Pathology of non-union
When there is failure to unite, the fracture
undergoes absorption& if it is associated
.with AVN the head will collapse
Classification
Stable fracture:-The the postero-- 1
medial buttress remains intact or
minimally comminuted& therefore
collapse of the fracture fragment is
.unlikely
Unstable fracture: The large segment- 2
of postero-medial wall is fractured
free& comminuted& therefore tends to
.collapse in varus
KYLE Classification
Non-displaced stable fracture: without- 1
comminution (stable) 21%
Minimal comminution but displaced- 2
fracture: once reduced become (stable) 36%
Large postero-medial comminuted area- 3
.This is a problem fracture (unstable) 28%
Intertrochanteric & subtrochanteric- 4
fracture: It is uncommon (unstable) 15%
Treatment
;Types
.Conservative; Traction for 6-8 weeks- 1
Surgical; Because patients are elderly&- 2
complications of such fractures are high so
.surgery is indicated
:-Principles
Reduction either closed under screen or
.open reduction
Rigid fixation by pin& plate, DHS ,angled
.plate etc
Complications
General; The same as complications of
.fracture neck femur
;Local
Malunion; Varus deformity or external- 1
rotation which is treated by corrective
.osteotomy& fixation
Non-union; rare due to soft tissue- 2
.interposition, treated by ORIF & bone graft
Subtrochanteric fracture
These are fractures in the area between
lesser trochanter & the junction between
proximal and middle 3rd of femur. It occur in
all age groups but there are two peak ages of
;incidence
Late adolescence & early adulthood; here- 1
.high energy trauma is needed
Geriatric; minor trauma to bone lesion like-2
metastatic tumor lung, breast cancer)
causing pathological subtrochanteric
.fracture
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