Femoral Fractures

Fractures of the femur are common and may affect the femoral neck, the femoral shaft or supracondylar, 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.

• Can follow relatively minor trauma in the elderly. Fractures in younger patients imply a violent, high energy injury.
• 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 below).¹
• May disrupt the blood supply to the femoral head leading to avascular necrosis.

Risk factors

• Increased risk in the elderly women because of osteoporosis, osteomalacia and falls.

Presentation

• Pain may radiate down towards the knee. The patient may present with knee pain and no pain on movement of the hip.
• Presentation may be a sudden inability to weight-bear. 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.

X-rays

• AP pelvis 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.
• Fractures of the femoral neck are not always visible on initial x-rays. Repeat x-rays, bone scan or MRI may be required if symptoms continue.
• Intracapsular neck of femur fractures are graded radiologically according to the Garden 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.

Management

• Investigations: full blood count and cross-match. Initial assessment should also include U and E, glucose, ECG and perhaps a chest-xray. Other investigations may be required, depending on history and general examination.
• IV access and commence IV infusion if indicated.
• IV analgesia (plus an antiemetic if required, but studies have shown that routine use of a prophylactic antiemetic in combination with opiate analgesia is unnecessary).²
• Admit to an orthopaedic ward.
• Internal fixation with screws if undisplaced; prosthesis or primary total hip replacement if displaced.
• There is a high risk of non-union and mal-union.
• There is a high risk of post-operative complications in the elderly, including pneumonia, myocardial infarction, stroke, deep vein thrombosis and pulmonary embolus.

• Sudden violent force may 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.

• Involve the proximal femoral shaft, at or just distal to the trochanters.
• Usually caused by high-energy trauma in younger patients. These injuries are often associated with other serious injuries. May follow relatively minor trauma in patients with osteoporosis or metastatic disease.
• Treatment: is essentially the same as for fractures of the femoral shaft; adequate analgesia, splint and orthopaedic referral.

• Caused by a high-energy injury, such as road traffic accidents, unless pathological fracture in patient with osteoporosis or metastatic disease.
• Often associated injury to the hip, pelvis, knee and other parts of the body.

Diagnosis

• Deformity, shortening, external rotation and abduction at the hip on the affected side.
• Closely monitor peripheral sensation and pulses.

Management

• Initial management
  • Assess vital functions and any associated chest, head, abdominal or spinal injuries. Resuscitate and treat life-threatening injuries as necessary.
  • IV access, start fluid replacement and send blood for cross-matching.
  • Adequate intravenous analgesia; splint fractures (Thomas splint or equivalent traction splint).
  • Arrange for a femoral nerve block if available (usually takes 5-10 minutes to become effective).
  • X-rays of the femur and orthopaedic referral.
• Further management
  • Usually by intramedullary nail.
  • Early immobilisation and treatment reduces the risk of complications.

Complications

• 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 non-union.

Supracondylar fractures

• 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.
• The distal fragment of the femur tends to pulled backwards and the popliteal artery may be damaged.
• Treatment: initially the same as 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 degrees of flexion.
• Displaced intra-articular fractures require internal fixation.