Proximal Femur Fractures by Kenneth A. Egol & Philipp Leucht

Author:Kenneth A. Egol & Philipp Leucht
Language: eng
Format: epub
Publisher: Springer International Publishing, Cham

Initial Evaluation, Work-Up, and Management

Subtrochanteric fractures, especially in the young patient, typically involve high-energy mechanisms and must be evaluated for other associated injuries. A primary survey under the ATLS guidelines is essential [28, 29]. Life-threatening injuries must be identified and resuscitative measures initiated. The secondary survey should be performed later as part of a more detailed head to toe examination. Critically ill, multiply injured patients should be evaluated and temporarily stabilized and resuscitated.

In the older individual with a lower mechanism of injury, a detailed history of how the accident occurred should be performed to uncover any possible comorbidities leading to injury. If the patient had a syncopal episode resulting in a fall, then an appropriate work-up must be conducted before the patient can be cleared for any surgical intervention. The patient’s medication history must be evaluated for the use of bisphosphonates. Recent studies have shown that chronic bisphosphonate therapy for more than 3–5 years may increase the risk of atypical femoral fractures [6–8]. In regard to bisphosphonates, prodromal thigh pain as well as contralateral imaging should be performed. Concern for insufficiency fracture can be diagnosed further with advanced imaging such as magnetic resonance imaging, CT, or bone scan [30–34].

On physical examination when the fracture is displaced, the injured extremity is most often shortened and externally rotated. The thigh may be swollen and can at times have a bony prominence from the deforming forces acting on the proximal fragment. Patients are unable to actively flex their hip or tolerate any range of hip motion. The patient is usually neurologically intact without vascular deficit. Penetrating injuries, on the other hand, can cause neurovascular injury to the surrounding structures and must be carefully evaluated. Initial diagnostic studies should include plain radiographs consisting of anteroposterior (AP) and cross-table views of the hip along with full-length femur views. An AP pelvis view (typically obtained during the trauma work-up) can be helpful in assessing femoral neck/shaft morphology of the uninjured side.

The characteristics of an atypical fracture due to long-term bisphosphonate use on radiographic evaluation include lateral cortical thickening, transverse fracture orientation, lack of comminution, and medial cortical spike [7]. Diagnostic studies on the contralateral side are indicated if the patient has any history of thigh pain on the contralateral side of the injury. A recent retrospective study by Saleh et al. suggested that if a symptomatic patient taking long-term bisphosphonate therapy presents with lateral cortical thickening and no radiolucent line, then discontinuation of bisphosphonate treatment and conservative treatment with teriparatide can resolve the fracture [35]. When a radiolucent line is visible along with lateral cortical thickening, then surgical prophylaxis is recommended to prevent propagation to a complete fracture [7, 8, 35]. Identification of an occult fracture will change the clinical course of the patient providing a definitive medical management and a shorter hospital stay [36].

Initial management includes proper evaluation and hemodynamic resuscitation, if needed. Skeletal traction via a distal femoral or proximal tibial traction pin not only restores length but also can provide considerable pain relief. Skin traction (i.

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