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Fractures of the femur are common and may affect the femoral neck, the femoral shaft or distal (supracondylar) femur, which often also involve the knee joint. Fractures of the femoral neck are far more common in the elderly but fractures of the femoral shaft and supracondylar fractures are usually caused by violent trauma and most often occur in adolescents and young adults. Hip fractures (proximal femoral fractures) occur between the edge of the femoral head and 5 cm below the lesser trochanter:
- Intracapsular fractures (femoral neck fractures): between the edge of the femoral head and insertion of the capsule of the hip joint.
- Extracapsular fractures: between the insertion of the capsule of the hip joint and a line 5 cm below the lesser trochanter.
- Trochanteric fractures: extracapsular fractures that include intertrochanteric or pertrochanteric and reverse oblique fractures.
- Subtrochanteric fractures: extracapsular fractures where the fracture occurs below the lesser trochanter.
Intracapsular fractures of the neck of femur
See also separate article Hip Dislocations.
- These can follow relatively minor trauma in the elderly. Fractures in younger patients are usually caused by a high-energy impact.
- Hip fracture is the most common reason for admission to an orthopaedic trauma ward.
- About a quarter of patients with hip fracture are admitted from institutional care, and about 10-20% of those admitted from home ultimately move to institutional care.
- Intertrochanteric fractures affect the base of the femoral neck. Initial management is the same as for an intracapsular fracture of the neck of femur (see under 'Management' section, below).
- May disrupt the blood supply to the femoral head, leading to avascular necrosis.
- Mortality following hip fractures is high. About 10% of people with a hip fracture die within 1 month and about one third within 12 months. Most of the deaths are due to associated comorbidities and not just to the fracture itself.
- Pain may radiate to the knee. The patient may present with knee pain and no pain on movement of the hip.
- Presentation may be a sudden inability to bear weight. There may be no history of injury, especially in an elderly patient with confusion or dementia.
- The affected leg may be shortened, adducted and externally rotated.
- Pain over the hip may be particularly aggravated by rotation of the leg.
- Anteroposterior (AP) pelvic and lateral hip X-rays: may show disruption of trabeculae, inferior or superior cortices and abnormality of pelvic contours.
- Shenton's line is a radiographic, curved line formed by the top of the obturator foramen and the inner side of the neck of the femur. It is used to determine the relationship of the head of the femur to the acetabulum. This line is broken in fractures.
- Magnetic resonance imaging (MRI) should be performed if a hip fracture is suspected but AP pelvic and lateral hip X-rays don't show a fracture. If MRI is not available within 24 hours or is contra-indicated, then computed tomography (CT) should be requested.
- Intracapsular neck of femur fractures are graded by various classifications, including Garden's classification:
- Garden I: trabeculae angulated, inferior cortex intact. No significant displacement.
- Garden II: trabeculae in line but a fracture line is visible from superior to inferior cortex. No significant displacement.
- Garden III: obvious complete fracture line with slight displacement and/or rotation of the femoral head.
- Garden IV: gross, often complete, displacement of the femoral head.
- Investigations: FBC and cross-match. Initial assessment should also include renal function, glucose, ECG and perhaps a CXR. Other investigations may be required, depending on history and general examination.
- Intravenous access and commence intravenous infusion if indicated.
- Ensure analgesia (including opiates) is adequate for the patient and sufficient to allow the movements necessary for investigations and for nursing care and rehabilitation. Non-steroidal anti-inflammatory drugs (NSAIDs) are not recommended.
- Make an early assessment of any cognitive impairment and any treatable comorbidities, eg anaemia, volume depletion, electrolyte imbalance, uncontrolled diabetes, uncontrolled heart failure, correctable cardiac arrhythmia or ischaemia, acute chest infection or exacerbation of chronic chest conditions.
- Surgery should be performed on the day of, or the day after, admission.
- Internal fixation with screws if undisplaced (arthroplasty should be considered for those patients who are less fit); displaced intracapsular fractures may be treated either by reduction and internal fixation in younger fit patients, or by replacement of the femoral head with an arthroplasty in older less fit patients. Internal fixation is associated with less initial operative trauma but has an increased risk of reoperation on the hip.
- Patients with pre-existing joint disease, medium or high activity levels and a reasonable life expectancy should have a total hip replacement rather than hemiarthroplasty as primary treatment.
- The National Institute for Health and Clinical Excellence (NICE) recommends:
- Replacement arthroplasty (hemiarthroplasty or total hip replacement) for patients with a displaced intracapsular fracture.
- Total hip replacements for patients with a displaced intracapsular fracture who:
- Are able to walk independently out of doors with no more than the use of a stick; and
- Are not cognitively impaired; and
- Are medically fit for anaesthesia and the operation.
- Complications include infection, haemorrhage, nonunion, malunion and avascular necrosis.
- There is a high risk of postoperative complications in the elderly, including pneumonia, myocardial infarction, stroke, deep vein thrombosis, pulmonary embolus and pressure ulcers.
Extracapsular fractures of the neck of femur
- Approximately half of all hip fractures are outside the hip joint capsule (extracapsular proximal femoral fractures).
- Extracapsular hip fractures should all be treated surgically unless there are medical contra-indications.
- These fractures are usually treated by internal fixation but hip arthroplasty may be used (internal fixation may fail, especially for unstable fractures).
- The limited available evidence does not suggest significant differences in outcome between conservative and operative management programmes for extracapsular femoral fractures, but operative treatment is associated with a reduced length of hospital stay and improved rehabilitation.
Isolated trochanteric avulsion fracture
- Sudden violent force may avulse the insertion of gluteus medius from the greater trochanter, or iliopsoas from the lesser trochanter.
- Initial management: adequate analgesia.
- Further management: gradual mobilisation and symptomatic treatment.
- These involve the proximal femoral shaft, at, or just distal to, the trochanters.
- They are usually caused by high-energy trauma in younger patients and are often associated with other serious injuries. They may follow relatively minor trauma in the elderly and patients with osteoporosis or metastatic disease.
- Both intramedullary and extramedullary internal fixation have been advocated for the treatment of subtrochanteric femoral fractures. There is some evidence that operation time and fixation failure are reduced with the use of intramedullary implants.
- NICE recommends extramedullary implants such as a sliding hip screw in preference to an intramedullary nail in patients with trochanteric fractures above and including the lesser trochanter.
Shaft of femur fractures
- These are caused by a high-energy injury, such as road traffic accidents, unless pathological fracture in a patient with osteoporosis or metastatic disease.
- There are often associated injuries to the hip, pelvis, knee and other parts of the body.
- Deformity, shortening, external rotation and abduction at the hip on the affected side.
- Initial management:
- Assess vital functions and any associated chest, head, abdominal or spinal injuries. Resuscitate and treat life-threatening injuries as necessary.
- Splint fractures (Thomas' splint or equivalent traction splint).
- X-rays of the femur.
- Blood tests, including blood for cross-matching.
- Obtain intravenous access and start fluid replacement.
- Peripheral sensation and pulses should be closely monitored.
- Analgesia: adequate intravenous analgesia. Femoral nerve block is usually effective.
- Further management
- Intramedullary nailing is used for treating fractures of the femoral shaft.
- Early immobilisation and treatment reduce the risk of complications. NICE recommends physiotherapy assessment and, unless medically or surgically contra-indicated, mobilisation on the day after surgery. Patients should be offered mobilisation at least once a day and regular physiotherapy review.
- Closed fractures may be associated with a large volume of blood loss before becoming obvious with swelling of the thigh.
- Later complications include fat embolism, deep vein thrombosis, pulmonary embolism, infection, shortening, angulation and nonunion.
- Fractures of the distal third of the femur usually occur as a result of violent direct injury.
- They are often comminuted and often intra-articular with associated damage to the knee joint (see also the separate article Knee Fractures and Dislocations).
- The distal fragment of the femur tends to pulled backwards and the popliteal artery may be damaged.
- Initially, treatment is the same as for fractures of the femoral shaft but a femoral nerve block is not as effective and so additional analgesia is required.
- Treatment for undisplaced fractures: often conservative with skeletal traction with the knee in 30° of flexion.
- Displaced intra-articular fractures require internal fixation.
Further reading & references
- Hip fracture in the elderly person, British Orthopaedic Association (2008)
- Parker MJ, Gillespie WJ, Gillespie LD; Effectiveness of hip protectors for preventing hip fractures in elderly people: systematic review. BMJ. 2006 Mar 11;332(7541):571-4. Epub 2006 Mar 2.
- Davenport M; Hip Fracture, Medscape, Sep 2010
- Hip fracture; NICE Clinical Guideline (June 2011)
- Davidovitch RI, Jordan CJ, Egol KA, et al; Challenges in the treatment of femoral neck fractures in the nonelderly adult. J Trauma. 2010 Jan;68(1):236-42.
- Femoral Shaft Fractures, Wheeless' Textbook of Orthopaedics
- Cho MR, Lee SW, Shin DK, et al; A predictive method for subsequent avascular necrosis of the femoral head (AVNFH) J Orthop Trauma. 2007 Mar;21(3):158-64.
- Management of hip fracture in older people; Scottish Intercollegiate Guidelines Network - SIGN (June 2009)
- Parker MJ, Gurusamy K; Internal fixation versus arthroplasty for intracapsular proximal femoral Cochrane Database Syst Rev. 2006 Oct 18;(4):CD001708.
- Parker MJ, Handoll HH; Intramedullary nails for extracapsular hip fractures in adults. Cochrane Database Syst Rev. 2006 Jul 19;3:CD004961.
- Handoll HH, Parker MJ; Conservative versus operative treatment for hip fractures in adults. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD000337.
- Kuzyk PR, Bhandari M, McKee MD, et al; Intramedullary versus extramedullary fixation for subtrochanteric femur J Orthop Trauma. 2009 Jul;23(6):465-70.
- Ricci WM, Gallagher B, Haidukewych GJ; Intramedullary nailing of femoral shaft fractures: current concepts. J Am Acad Orthop Surg. 2009 May;17(5):296-305.
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Dr Colin Tidy
Dr Colin Tidy
Dr John Cox