CHAPTER 273| HIP AND FEMUR INJURIES

 Occur most often in the elderly population secondary to falls

 Age, race, and gender are important risk factors for hip injuries
 Incidence is more than two times greater in women than in men

HIP FRACTURES

 Intracapsular - femoral head and neck

 Extracapsular - trochanteric, intertrochanteric, and subtrochanteric

1. FEMORAL HEAD FRACTURE

 Isolated fracture rare; seen in 6%–16% of hip dislocations

 Usually result of high-energy trauma; dashboard to flexed knee most common
 Limb shortened and externally rotated (anterior dislocation); shortened, flexed, and internally
rotated (posterior dislocation)
 Immediate orthopedic consultation; emergent closed reduction of dislocation; ORIF if closed
reduction is unsuccessful

2. FEMORAL NECK FRACTURE

 Common in older patients with osteoporosis; rarely seen in younger patients

 Low-impact falls or torsion in elderly; high-energy trauma or stress fractures in young
 Ranges from pain with weight bearing to inability to ambulate; limb may be shortened and
externally rotated
 Intracapsular, and blood supply to the femoral head may be disrupted
 Disruption of Shenton’s line- a smooth curvilinear line along the superior border of the
obturator foramen and the medial aspect of the femoral metaphysis (AP view)
 Evaluate the neck-shaft angle- measured at the intersection of lines drawn down the axis of the
femoral shaft and the femoral neck ; (normal is 120 to 130 degrees)
 Skeletal traction is contraindicated for femoral neck fractures because it may further
compromise femoral head blood flow.
 Orthopedic consultation; ranges from nonoperative to total hip arthroplasty

3. GREATER TROCHANTERIC FRACTURE

 Uncommon; older patients or adolescents

 Direct trauma (older patients); avulsion due to contraction of gluteus medius (young patients)
 Ambulatory; pain with palpation or abduction
 Analgesics; protected weight bearing

4. LESSER TROCHANTERIC FRACTURE

 Uncommon; adolescents (85%) > adults

 Avulsion due to forceful contraction of iliopsoas (adolescents); avulsion of pathologic bone
(older adults)
 Usually ambulatory; pain with flexion or rotation
  Analgesics; weight bearing as tolerated; evaluate for possible pathologic fracture

5. INTERTROCHANTERIC FRACTURE

 Common in older patients with osteoporosis (MC in women); rare in younger patients
 Falls; high-energy trauma
 Severe pain; swelling; limb shortened and externally rotated
 Classified as stable or unstable based on the number of fracture lines and the amount of
displacement
 Blood loss into the leg can be significant, and some patients will require crystalloid or blood
transfusion
 Skin traction is not recommended for either stabilization or pain control

6. SUBTROCHANTERIC FRACTURE

 Similar to intertrochanteric; 15% of hip fractures

 Falls; high-energy trauma; may also be pathologic
 Severe pain; ecchymosis; limb shortened, abducted, and externally rotated
 Orthopedic consultation; consider Hare® or Sager® splint

7. OCCULT HIP FRACTURE

 Symptoms suggestive of fracture, but with negative plain radiograph

 Pain with axial loading, restricted mobility prior to the injury, and risks for osteoporosis should
all raise suspicion for occult fracture.
 MRI is the imaging of choice because it is both sensitive and specific

FEMORAL SHAFT FRACTURES

 most often occur in younger patients secondary to high-energy trauma

 Severe, direct trauma may result in transverse fractures (most common) with displacement,
oblique or spiral oblique fractures, or comminuted segments.
 Pathologic fractures are uncommon but can occur secondary to metastases or to primary bone
tumors.
 Splint the affected extremity with a traction splint at the time of injury, to minimize pain,
prevent further fracture comminution, and minimize blood loss except in cases of open fracture
or in suspected sciatic nerve, knee, or vascular injury
 Intermedullary nailing is the preferred treatment for most femoral shaft fractures.
 In severely contaminated open fractures, external fixation may be the preferred method of
treatment.

HIP DISLOCATION

 Motor vehicle crash is the most common cause

  Posterior dislocations of native hips account for >90% of dislocations; 10% are anterior and can
be classified as superior or inferior
 are orthopedic emergencies and should be reduced as quickly as possible, preferably within 6
hours of the event, in order to reduce the risk of avascular necrosis to the femoral head.
 Dislocations with neurovascular compromise need reduction as soon as possible

1. POSTERIOR HIP DISLOCATION AND REDUCTION MANEUVERS

 Complications of posterior dislocation include sciatic nerve injury in approximately 10% of

patients and avascular necrosis of the femoral head that increases in direct proportion to the
delay in anatomic reduction

A. Allis maneuver

o is the most commonly performed technique

o In-line traction is performed with simultaneous hip flexion and internal rotation
o Flex the patient’s knee and hip to 90 degrees.
o An assistant should apply downward pressure to the anterior superior iliac spines.
o Grasp the knee with both hands.
o Pull and simultaneously rotate the femur laterally and medially

B. Bigelow maneuver

o the patient should lie supine with the affected hip and knee flexed 90 degrees
o Secure the patient’s knee with your flexed elbow, and grasp the patient’s foot with the
opposite hand.
o Have an assistant apply downward pressure to the anterior superior iliac spines.
o Now, using your flexed elbow, lift upward at the patient’s knee to apply traction to the
femur.
o Externally rotate and extend the hip while applying traction to the femur at the patient’s
knee

C. Captain Morgan technique

o Stabilize the patient’s pelvis by placing the patient on a backboard in the supine position
and strapping the pelvis to the board, or have an assistant stabilize the pelvis on the
stretcher by placing both hands on the patient’s iliac crests and using pressure to keep
the pelvis stable.
o To reduce the dislocation, place your foot on the stretcher or board with your knee
posterior to the patient’s knee.
o With the patient’s knee in flexion, gently pull downward at the patient’s ankle while
applying an upward force to the patient’s hip by lifting your heel by stepping on your
toes and contracting your calf.
 o Gently rotate the patient’s hip while applying the upward traction behind the patient’s
knee

2. ANTERIOR HIP DISLOCATION

 The femoral head rests anteriorly to the coronal plane of the acetabulum.
 Anterior dislocations can be superior (pelvic) or inferior (obturator) depending on the degree of
hip flexion present at the time of injury.
 The mechanism of injury is forced abduction that causes the femoral head to be levered out
through an anterior capsular tear
 An anteroposterior view of the pelvis can easily demonstrate the femoral head to be anterior to
the acetabulum.
 A lateral view illustrates the anterior dislocation more clearly, although it may be difficult to
obtain secondary to patient discomfort.
 Anterior hip dislocations usually require reduction in the operating room.

3. DISLOCATIONS OF PROSTHETIC HIPS

 Prosthetic hips may dislocate relatively easily from minor trauma or movements that place the
hip past 90 degrees of flexion while adducted.
 Approximately 1% to 10% of prosthetic hips dislocate, the majority in the first few months after
surgery
 Most dislocations of prosthetic hips are posterior and can be reduced using procedural sedation
 It is advisable to discuss the treatment plan with the consulting orthopedist prior to attempting
any reduction maneuvers.