15 Bony Trauma 2: Proximal Femur
Jeffrey J. Peterson and Thomas H. Berquist
J. J. Peterson, MD; T. H. Berquist, MD
Department of Radiology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224-3899, USA
sustain a hip fracture. These figures double to 20%
and 10% respectively by age 90 (Manister et al.
2002).
Proximal femoral fractures are best categorized by their location, either intracapsular or extracap- sular. Intracapsular fractures can be further sub- divided into capital, subcapital, transcervical, or basocervical fractures. Extracapsular fractures can be subdivided into intertrochanteric or subtrochan- teric.
15.2
Intracapsular
15.2.1 Classification
Intracapsular fractures can be subdivided into capi- tal, subcapital, transcervical, or basocervical frac- tures. Subcapital fractures are most common, while capital and basocervical fractures are less frequent.
Transcervical fractures are rare. As a generalization the more proximal the fracture line the greater sever- ity of the fracture and the greater risk of nonunion and avascular necrosis (Manister et al. 2002).
Several classification schemes have been pro- posed for intracapsular proximal femoral fractures;
however, two classifications have proven clinically relevant. Both account for factors which determine stability of the fracture and are therefore applicable to both management and prognosis.
The first classification was described by Pau- wels in 1935 (Table 15.1). Pauwels classified sub- capital femoral fractures based on the obliquity of the fracture line in relation to the horizontal (Fig. 15.1). Type I fractures formed an angle of 30 ° or less; type II fractures formed an angle between 30 ° and 70°, and type III fractures formed an angle of greater than 70 °. According to Pauwels’ classifica- tion, the angle of the fracture determined the ulti- mate prognosis of the fracture with more vertical 15.1
Introduction
Fractures of the hip are significant injuries occur- ring in both young and old patients. Proximal femo- ral fractures have a significant effect on lifestyle and morbidity as well as a tremendous effect on the health care system. The worldwide incidence of proximal femoral fractures continues to rise paral- lel to the average increase in the age of the popula- tion (Maniscalo et al. 2002). Frandsen and Kruse (1983) predict the number of proximal femoral frac- tures will triple by the year 2050.
Fractures most commonly occur after falls and are more common in elderly women (Frandsen and Kruse 1983). The propensity for femoral fractures to occur in the elderly is multifactorial including osteoporosis, decreased physical activity, malnu- trition, decreased visual acuity, neurologic defects, altered reflexes, and equilibrium problems (Manis- calo et al. 2002). It is estimated that by age 80, 10%
of Caucasian women and 5% of Caucasian men will
CONTENTS
15.1 Introduction 237 15.2 Intracapsular 237 15.2.1 Classification 237 15.2.2 Treatment 239 15.2.3 Complications 240 15.3 Extracapsular 241 15.3.1 Classification 241
15.3.2 Intertrochanteric Fractures 241 15.3.3 Subtrochanteric Fractures 243 15.3.4 Avulsion Fractures 244 15.3.5 Treatment 244 15.3.5 Complications 245 References 245
fractures being inherently less stable and therefore more prone to nonunion. More horizontal fractures (type I) tend to impact and impart some degree of stability increasing the ability of the fracture to heal.
With more vertical fractures (type III) axial load- ing with weight bearing creates varus shearing and instability hindering the fractures ability to heal.
Pauwels’ classification was based on obliquity and alignment on post-reduction radiographs.
The more commonly utilized classification scheme was elaborated by Garden (1964) (Table 15.1). Gar- den’s classification is based on alignment on prer-
eduction radiographs and relates to displacement of the fracture and the ability to obtain stability on post-reduction radiographs. A four-stage clas- sification scheme was described by Garden with instability and nonunion seen more frequently in stages III and IV. Stage I fractures consisted of incomplete fractures with valgus positioning of the femoral neck. Stage II fractures in contrast are non- displaced complete fractures with varus angulation (Fig. 15.2). Stage III fractures represent complete fractures with varus angulation of the femoral head and displacement of the fracture (Fig. 15.3). Stage IV fractures are complete displaced fractures in which the femoral head fragment returns to normal posi- tion (Berquist 1992). Assessment of the position of the femoral head with subcapital fractures is helpful as valgus position indicates a stage I fracture, while varus position indicates stage II or III. Anatomic position of the femoral head is typically seen with stage IV fractures (Manister et al. 2002).
Incomplete fractures (stage I) or subtle nondis- placed fractures (stage II) require careful exami- nation of the radiographic studies and may require additional cross sectional imaging for full charac- terization. Occasionally degenerative changes about the proximal femur with linear osteophyte forma- tion may be seen mimicking fracture. Cross sectional imaging is of great value in such cases. MR imag- ing is preferable to CT for evaluation of equivocal proximal femoral fractures as MR will detect associ- ated marrow edema and subtle trabecular fractures which may not be appreciable with radiographs or CT. CT is very helpful, however, in complete frac- tures and can be useful in assessing alignment and preoperative planning.
Table 15.1. Classifi cation of intracapsular proximal femoral fractures
Pauwels’ classifi cation
Type I Femoral neck fracture with an angle of 30° or less
Type II Femoral neck fracture with an angle of between 30° and 70°
Type III Femoral neck fracture with an angle greater than 70°
Garden’s classifi cation
Stage I Incomplete or impacted fracture of the femo- ral neck with no displacement of the medial trabeculae
Stage II Complete fracture of the femoral neck with no displacement of the medial trabeculae Stage III Complete fracture of the femoral neck with
varus angulation and displacement of the medial trabeculae
Stage IV Complete fracture with the femoral neck with total displacement of the fragments
Fig. 15.1a–c. Pauwels’ classifi cation of femoral neck fractures. a Class I, fracture line 30° or less from vertical. b Class II, fracture line 30°–70°. c Class III, fracture line greater than 70°
b
a c
15.2.2 Treatment
Choice of treatment options for femoral neck frac- tures varies depending on several factors, the most important of which being stability of the fractures.
Unstable fractures include Garden III and IV frac- tures while stable fractures consist of Garden type I and II fractures. Adequate reduction is the first and most important step in the treatment of displaced intracapsular proximal femoral fractures. No inter- nal fixation device can compensate for malreduc- tion (Bosch et al. 2002).
The primary aim of treatment of intracapsular fractures of the femur is to restore function of the hip to preinjury levels with a little comorbidity as pos- sible (Bosch et al. 2002). Conservative nonoperative treatment of femoral fractures as commonly utilized in the early 19th century are quite debilitating and disabling. In 1931, Smith-Petersen reported open reduction and internal fixation of femoral neck fractures, while Leadbetter in 1933 described a closed reduction technique with a guide wire and cannulated implants. In 1943 Moore and Bohlman first reported the use of endoprosthesis replacement of the femoral head and an alternative to internal fixation. In the latter half of the last century hemi- arthroplasty and total hip replacement has proven to be an additional alternative. Today the options for treatment of intracapsular fractures are many and continue to evolve. Currently the most common method for internal fixation are with cannulated screws placed in parallel. Cannulated screws allow axial compression across the fracture line aiding stability.
A major factor in dictating treatment of proximal femoral fractures is the age of the patient. In older patients proximal femoral fractures are common most frequently related to osteoporosis and falls.
In contrast in the younger age population proximal femoral fractures are more commonly the result of high-energy trauma. In younger patients (< 50 years) preservation of the femoral head is ideal. The out- come of their treatment may have long-term effect on the function of their hip and may have a large impact on work and disability (Verattas et al.
2002). Femoral head-preserving procedures are the method of choice in compliant young active individ- uals who are able to perform the demands of post- operative rehabilitation (Krischak et al. 2003). Use of cannulated cancellous screws are most commonly utilized. Patients who do not achieve adequate func- tion following internal fixation may have a satisfac- tory result with subsequent conversion of a total hip arthroplasty. In older patients (> 50 years) hemiar- throplasty and total hip replacement is becoming an increasingly popular treatment option.
Timing of surgery is another factor in treatment options. Urgent reduction of proximal femoral frac- tures has been suggested to minimize the risk of complications (Iorio et al. 2001; Jeanneret and Jacob 1985). After 48 h following a fracture, there is a progressive risk of healing complications with intracapsular femoral fractures (Bosch et al. 2002).
Evidence from experimental studies indicate that
Fig. 15.2. An 85-year-old female status post fall with impacted Garden type II fracture of the left femoral neck
Fig. 15.3. Garden stage III fracture of the femoral neck with displacement of the fracture and varus angulation with malalignment of the medial trabeculae (black lines)
early reduction relieves compression of the sur- rounding vascular structures and restores blood flow to the femoral head (Bosch et al. 2002). Man- ninger et al. (1985) also reported a significantly lower incidence of articular collapse of the femoral head with prompt (< 6 h) reduction and internal fixation of intracapsular femoral fractures.
15.2.3
Complications
Although reduction in anatomic orientation is achieved in less than 30% of cases of intracapsu- lar femoral fractures fixed with cancellous screws (Weinrobe et al. 1998), clinical studies show that uneventful fracture healing occurs in 62%–72%
of cases (Chiu et al. 1994; Cobb and Gibson 1986;
Gerber et al. 1993).
It has been reported that in patients with dis- placed hip fractures, an average rate of nonunion of 33% is expected (Kyle et al. 1994) and a 28%
re-operation rate should be expected for failures of internal fixation of proximal femoral fractures (Lu- Yao et al. 1994).
It is generally agreed that the optimal reduction of proximal femoral fractures should be as anatomic as possible (Krischak et al. 2003). Although some authors prefer slight valgus orientation secondary to both impaction of the fragments during weight bear- ing, and the increased bony stability at the fracture site (Krischak et al. 2003). Slight valgus angulation may also decrease the risk of developing a less favor- able varus angulation. Stability of internal fixation depends upon both the accuracy of reduction, the technique utilized, and the density of the cancellous bone in the femoral head (Jackson and Learmonth 2002). Nonunion may develop where stability of the fixation has been compromised by poor surgical technique or by the inability to achieve compres- sion because of severe osteoporosis. The exact rate of nonunion is difficult to estimate and is related to numerous factors including patient demographics, severity of injury, degree of mineralization of the bone, and surgical technique (Jackson and Lear- month 2002).
Because of the morphologic features of proximal femoral fractures there is significant risk of vascu- lar injury to the femoral head with the potential risk of avascular necrosis (Jackson and Learmonth 2002). The primary circulation to the femoral head is through the retinacular artery, which ends as the lateral epiphyseal artery (Berquist 1992) (Fig. 15.4).
Additional blood supply to the femoral head included the medial retinacular artery which is a branch of the inferior retinacular artery, and the foveal artery.
Poor contact, unstable reduction, and disruption of the retinacular arteries are the most prominent fac- tors leading to avascular necrosis (Berquist 1992), which typically presents 9–12 months following the fracture, but can present as early as 3 months or as late as 3 years following the fracture (Fig. 15.5). In younger populations, there is a higher incidence of avascular necrosis and nonunion with Took and Favero (1985) reporting an incidence of 33% and 5.5% nonunion of nondisplaced intracapsular frac- tures (Verattas et al. 2002). Swiontkowski et al. (1984), in a series of 27 displaced intracapsular femoral fractures, also reported a 20% incidence of avascular necrosis with no nonunions. Prompt reduction appears to have an effect as all cases in Swiontkowski et al.’s 1984 study were reduced within 12 h. Gautam et al. (1998) also reported that emergent open reduction and screw fixation in 25 patients revealed only one nonunion at 32 months.
Treatment variables play a key role in achieving good outcome with proximal femoral fractures.
Accurate reduction and stable fixation are prereq- uisites for satisfactory union. Tissue variables also play a role in the success of treatment of intracapsu- lar hip fractures. Many fractures are associated with osteoporosis. Adequate reduction is often difficult with significant deficiencies in bone mineralization contributing to nonunion. It has also been found that patients with abnormal bone such as Paget’s disease have up to a 75% risk of nonunion (Dove 1980) prompting treatment with prosthetic replace- ment in these patients. This has also been reported to be a concern in patients with fibrous dysplasia and
Fig. 15.4. Vascular supply to the femoral head
osteopetrosis (Steinwalter et al. 1995; Tsuchiya et al. 1995).
Imaging can be helpful in evaluating for non- union. With conventional radiographs, a change in fracture or screw position, backing out of screws, or penetration of the femoral head by a screw suggest unstable internal reduction and nonunion. Recent advances in CT allow precise visualization of the hardware and surrounding bone with very little metallic artifact and can be quite helpful in equivo- cal cases or in preoperative planning when revision is needed.
In cases of nonunion several options are avail- able for achieving union and the decision must be tailored to the individual patient. Prosthetic replacement is the most obvious option but in cases in which prosthesis replacement is deemed unsuit- able there are many femoral head sparing options for achieving union of the fracture (Jackson and Learmonth 2002). Several procedures includ- ing vascularized fibular grafting, additional com- pression fixation, and femoral neck osteotomy augmented by muscle pedicle grafting are options (Jackson and Learmonth 2002). Simple removal of the cancellous screws with larger screws may be successful in uncomplicated cases with no signifi- cant malalignment of foreshortening. Dynamic hip screws may also be considered especially in cases of foreshortening (Wu et al. 1999). Bone grafting with
free vascularized or nonvascularized fibular grafts may also utilized (Hou et al. 1993; Nagi et al. 1998).
Treatment of nonunion with total hip arthroplasty typically represents the best option in older patients with low functional demands and in complicated cases, although studies have shown a slightly higher failure rate with arthroplasty following nonunion for hip fracture as opposed to those for osteoarthri- tis (Franzen et al. 1990; Skeide et al. 1996). It is generally accepted that hip arthroplasty should be reserved for older patients, noncompliant patients, and for patients with significant preexisting acetab- ular disease (Rodriguez-Marchan 2003).
15.3
Extracapsular
15.3.1 Classification
Extracapsular fractures are those fractures occur- ring below the hip joint involving the trochanters and the subtrochanteric femur and fittingly can be divided into intertrochanteric fractures and subtro- chanteric fractures. Avulsion fractures of the greater and lesser trochanters can also occur and represent a third category of extracapsular proximal femoral fractures.
15.3.2
Intertrochanteric Fractures
Fracture lines occur with variable obliquities but typically extend between the greater and lesser trochanters. Comminution with detachment of the greater and lesser trochanters are common (Manis- calo et al. 2002). Intertrochanteric fractures are most commonly the result of a fall. The musculature about the hip plays a role in the fracture morphol- ogy. The external rotators of the hip tend to remain with the proximal fragment while the internal rota- tors tend to remain attached to the distal fracture fragment (Berquist 1992).
Various classification schemes have been sug- gested based on location, angulation, fracture plane, and degree of displacement. Delee (1984) classified fractures as stable or unstable with fractures consid- ered stable if, when reduced, there was adequate cor- tical contact medially and posteriorly at the fracture site, the medial cortex of the femur was not commi-
Fig. 15.5. A 49-year-old patient status post fall with closed reduction and internal fi xation of a left femoral neck fracture 2 years previously with subsequent development of vascular necrosis and collapse of the articular surface of the femoral head
nuted, and the lesser trochanter was intact. Verti- cally oriented fractures, or fractures with comminu- tion of the medial cortex were considered unstable.
Ender (1978) proposed a classification scheme (Table 15.2) for intertrochanteric fractures based on mechanism of injury, either eversion fracture (type 1), impaction fracture (type 2), or ditrochan- teric fracture (type 3). Probably the most widely used classification scheme today is the Evans system, modified by Jensen and Michaelson in 1975 (Table 15.2). This classification scheme is based on the prognosis for anatomic reduction and the likeli- hood of post-reduction instability. The scheme clas- sified fractures by the degree of comminution of the calcar region and the greater trochanter (Fig. 15.6).
Involvement of these structures increases the risk of instability following reduction. Fracture obliq- uity is also important. Stable fractures follow the intertrochanteric line which fracture orientation perpendicular to this leads to greater instability.
Type 1 fractures are nondisplaced two part fractures which follow the intertrochanteric line while type 2 fracture are similarly oriented fractures with dis- placement. Type 1 and type 2 fractures can be suc- cessfully reduced in 94% of cases (Jensen 1980) and are considered stable. Type 3 fractures are three part fractures with displacement of the greater trochan- ter. These fractures are unstable and can be success- fully reduced in 33% of cases. Type 4 is a three part fracture with displacement of the lesser trochanter or involvement of the trochanter and can be reduced in only 21% of cases. Type 5 fractures are four part fractures and represent a combination of type 3 and 4 fractures with both medial and lateral commi- nution and involvement of both of the trochanters (Fig. 15.7).
Table 15.2. Classifi cation of extracapsular intertrochanteric proximal femoral fractures
Ender classifi cation
Type I Eversion fracture Type II Impaction fracture Type III Ditrochanteric fracture Evans classifi cation
Type I Undisplaced two-part fracture Type II Displaced two-part fracture
Type III Three-part fracture with greater trochanteric fragment
Type IV Three-part fracture with lesser trochanteric or calcar fragment
Type V Four-part fracture with greater and lesser trochanteric fragments
Fig. 15.6. Evans classifi cation of trochanteric fractures modi- fi ed by Jansen and Michaelson. Type 1, nondisplaced two-part fracture. Type 2, displaced two-part fracture. Type 3, three-part fracture with greater trochanteric fragment. Type 4, three-part fracture with lesser trochanteric or calcar fragment. Type 5, four-part fracture with lesser and greater trochanteric frag- ments
Fig. 15.7. Evans classifi cation type 5 fracture with varus angu- lation (black lines) and both lesser and greater trochanteric fracture fragments (white arrows)
15.3.3
Subtrochanteric Fractures
Subtrochanteric fractures occur below the level of the trochanters; however, extension distally into the femoral shaft and proximally into the intertro- chanteric region is not uncommon. Subtrochanteric fractures tend to occur in younger patients with significant trauma or in patients with underlying pathologic bone.
There are three major classification schemes for subtrochanteric fractures. Fielding proposed a simple classification of subtrochanteric fractures based on location (Table 15.3). Zone 1 includes the lesser trochanter, zone 2, 1–2 in. distal to the lesser trochanter, and zone 3, 2–3 in. below the lesser tro- chanter (Fig. 15.8). With zone 2 and zone 3 there is progressive involvement of cortical bone which heals slower and occurs in higher stress regions which makes treatment more difficult (Berquist 1992).
Seinsheimer further classified subtrochanteric fractures utilizing anatomical considerations such as the number of fracture lines, the location and shape of the fracture lines and the degree of com- minution (Table 15.3). There are eight different cat- egories. Three part spiral fractures which compose group III have the highest rate of failure following internal fixation (Weissman and Sledge 1986).
Boyd and Griffin’s classification is based on clini- cal information rather than anatomic considerations (Table 15.3). Their classification scheme is based on prognosis of obtaining and maintaining reduction of the extracapsular fracture (Fig 15.9). Zone 1 frac- tures are linear intertrochanteric in which reduction
Table 15.3. Classifi cations of extracapsular subtrochanteric proximal femoral fractures
Fielding classifi cation
Zone 1 Fracture includes the lesser trochanteric region Zone 2 Fracture 1–2 in. distal to the lesser trochanter Zone 3 Fracture 2–3 in. distal to the lesser trochanter Boyd and Griffen classifi cation
Type I Linear intertrochanteric fracture
Type II Comminuted fracture with main fracture line along the intertrochanteric line
Type III Subtrochanteric fracture with at least one fracture line passing through or just below the lesser trochanter
Type IV Comminuted trochanteric fracture extending into the shaft with fracture lines in at least two planes
Seinsheimer classifi cation
Group I Undisplaced fracture (less than 2 mm) Group II Two-part fracture:
A. Transverse fracture B. Spiral fracture
C. Spiral fracture with lesser trochanteric involvement
Group III Three-part fracture:
A. Spiral fracture with lesser trochanteric involvement
B. Spiral fracture with butterfl y fragment Group IV Four-part fracture
Group V Subtrochanteric fractures with extension into the intertrochanteric region and involvement of the greater trochanter
Fig. 15.8. The Fielding classifi cation of subtrochanteric frac- tures
Fig. 15.9. The Boyd and Griffen classifi cation
is less difficult. Type 2 is a subtrochanteric fracture with multiple fracture lines with the main fracture occurring along the intertrochanteric line. Type 2 fractures are more difficult to achieve lasting reduc- tion than type 1 fractures. Type 3 consist of subtro- chanteric fracture lines that coexist with fractures of type 1 and 2. Type 4 fractures are comminuted with trochanteric extension of the fracture lines and extension into the shaft (Fig. 15.10). Type 4 fractures have fracture lines extending in at least two planes.
Type 3 and 4 fractures are more difficult to treat and loss of reduction is not uncommon.
15.3.4
Avulsion Fractures
Abrupt muscular contraction can lead to greater or lesser trochanteric fractures which compose the third category of extracapsular proximal femoral fractures. Greater trochanteric avulsion fractures are not uncommon and are typically seen in elderly populations, while lesser trochanteric fractures are uncommon and mostly seen in younger athletic individuals (Delee 1984; Epstein 1973). Pathologic fractures of the lesser trochanter are actually more common than traumatic avulsions (Rogers 1982).
Several muscle groups attach to the greater trochan- ter and can result in avulsions, while the iliopsoas tendon attaches to the lesser trochanter. Treatment of trochanteric fractures as with intracapsular femo- ral fractures depends on stability (Berquist 1992).
15.3.5 Treatment
A successful reduction will align the fracture frag- ments, obtain bone-to-bone contact of the calcar and medial cortex, and avoid varus angulation Reduc- tion and fixation are fluoroscopically monitored.
The variety of implants available for the treatment of extracapsular proximal femoral fractures contin- ues to evolve. Sliding hip screws are most commonly utilized and allow impaction at the fracture site favor- ing healing (Boldin et al. 2003) (Fig. 15.11). The slid- ing nail also decreases the probability of cut-out or acetabular protrusion (Maniscalo et al. 2002). Fixed nail plates should not be used as stresses at the angle of the nail plate have been found to be significant which can lead to failure (Berquist 1992). From the biome- chanical perspective, there are two main options, the
Fig. 15.10. Boyd and Griffen classifi cation type IV fracture with comminuted proximal femoral fracture with fracture lines in at least two planes and extension into the proximal femoral shaft
Fig. 15.11a,b. A 63- year-old female status post motor vehicle accident with type 1 trochanteric fracture (a). Internal fi xation was performed with a sliding-screw and plate (b)
a b
sliding neck screw or bolt connected to a plate on the lateral femoral cortex or a sliding neck screw or bolt stabilized by an intramedullary nail (Boldin et al.
2003). The choice remains controversial. The use of intramedullary fixation minimizes soft tissue dissec- tion and surgical trauma, blood loss, infection, and wound complications; however, the Gamma nail, the most commonly utilized intramedullary device, has a high learning curve and has been reported to have technical and mechanical failure rates of about 10%
(Boldin et al. 2003). The most widely used method is currently the dynamic hip screw (DHS) (Boldin et al.
2003), which utilizes a sliding screw and a lateral side plate. There are reportedly lower complications rates with extramedullary implants compared to intra- medullary devices (Boldin et al. 2003). Often in the final analysis it is the experience of the surgeon that becomes the determining factor in the choice of treat- ment of trochanteric fractures (Davis et al. 1990). For markedly comminuted intertrochanteric fractures in older populations, treatment with an endoprosthesis may be the proper choice (Lord et al. 1977).
15.3.5
Complications
Common complications are typically easily seen with routine conventional radiographs and include fracture of the fixation devices, loss of reduction, and migration of the devices (Fig. 15.12). Loss of reduction with cutting out of the fixation is the most
common complication especially in those patients with osteopenia. Unlike intracapsular fractures, extracapsular proximal femoral fractures rarely injure the vascular supply to the femoral head and therefore avascular necrosis is less common (Ber- quist 1992). Trochanteric fractures have a low inci- dence of nonunion with approximately 1%–2% for intertrochanteric fractures and 5% for subtrochan- teric fractures (Verattas et al. 2002).
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