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Skeletal Radiology

, Volume 48, Issue 1, pp 29–45 | Cite as

Fragility fractures of the proximal femur: review and update for radiologists

  • Kimia Khalatbari Kani
  • Jack A. Porrino
  • Hyojeong Mulcahy
  • Felix S. Chew
Review Article
  • 402 Downloads

Abstract

Proximal femoral fragility fractures are common and result in significant morbidity and mortality along with a considerable socioeconomic burden. The goals of this article are to review relevant proximal femoral anatomy together with imaging, classification, and management of proximal femoral fragility fractures, and their most common complications. Imaging plays an integral role in classification, management and follow-up of proximal femoral fragility fractures. Classification of proximal femoral fragility fractures is primarily based on anteroposterior hip radiographs. Pertinent imaging features for each category of proximal femoral fractures that would guide management are: differentiating nondisplaced from displaced femoral neck fractures, distinguishing stable from unstable intertrochanteric fractures, and determining the morphology and comminution of subtrochanteric fractures. Treatment of proximal femoral fragility fractures is primarily surgical with either arthroplasty or internal fixation. Intramedullary nailing is used in the treatment of some types of proximal femoral fragility fractures and may be associated with unique complications that become evident on postoperative follow-up radiographs.

Keywords

Hip fracture Proximal femur fracture Fragility fracture Femoral neck fracture Intertrochanteric fracture Subtrochanteric fracture Sliding hip screw Intramedullary nail Cephalomedullary nail 

Notes

Compliance with ethical standards

Conflicts of interest

The authors declare that they have no conflicts of interest.

References

  1. 1.
    Sozen T, Ozisik L, Basaran NC. An overview and management of osteoporosis. Eur J Rheumatol. 2017;4(1):46–56.CrossRefPubMedGoogle Scholar
  2. 2.
    Kanis JA, Oden A, Johnell O, Jonsson B, de Laet C, Dawson A. The burden of osteoporotic fractures: a method for setting intervention thresholds. Osteoporos Int. 2001;12(5):417–27.CrossRefPubMedGoogle Scholar
  3. 3.
    Ward RJ, Weissman BN, Kransdorf MJ, Adler R, Appel M, Bancroft LW, et al. ACR appropriateness criteria acute hip pain-suspected fracture. J Am Coll Radiol. 2014;11(2):114–20.CrossRefPubMedCentralPubMedGoogle Scholar
  4. 4.
    Sheehan SE, Shyu JY, Weaver MJ, Sodickson AD, Khurana B. Proximal femoral fractures: what the orthopedic surgeon wants to know. Radiographics. 2015;35(5):1563–84.CrossRefPubMedGoogle Scholar
  5. 5.
    Center for Disease Control and Prevention. Hip fractures among older adults. https://www.cdc.gov/homeandrecreationalsafety/falls/adulthipfx.html. Published September 2016. Accessed: April 2018.
  6. 6.
    Kannus P, Parkkari J, Sievanen H, Heinonen A, Vuori I, Jarvinen M. Epidemiology of hip fractures. Bone. 1996;18(1 Suppl):57S–63S.CrossRefPubMedGoogle Scholar
  7. 7.
    Mears SC. Classification and surgical approaches to hip fractures for nonsurgeons. Clin Geriatr Med. 2014;30(2):229–41.CrossRefPubMedGoogle Scholar
  8. 8.
    Wagner FV, Negrao JR, Campos J, Ward SR, Haghighi P, Trudell DJ, et al. Capsular ligaments of the hip: anatomic, histologic, and positional study in cadaveric specimens with MR arthrography. Radiology. 2012;263(1):189–98.CrossRefPubMedGoogle Scholar
  9. 9.
    Kerr R, Resnick D, Pineda C. CT analysis of proximal femoral trabecular pattern simulating skeletal pathology. J Comput Assist Tomogr. 1988;12(2):227–30.CrossRefPubMedGoogle Scholar
  10. 10.
    Tetsunaga T, Fujiwara K, Endo H, Tetsunaga T, Shiota N, Sato T, et al. Calcar femorale in patients with osteoarthritis of the hip secondary to developmental dysplasia. Clin Orthop Surg. 2017;9(4):413–9.CrossRefPubMedCentralPubMedGoogle Scholar
  11. 11.
    Stiehl JB, Jacobson D, Carrera G. Morphological analysis of the proximal femur using quantitative computed tomography. Int Orthop. 2007;31(3):287–92.CrossRefPubMedGoogle Scholar
  12. 12.
    Gnudi S, Sitta E, Pignotti E. Prediction of incident hip fracture by femoral neck bone mineral density and neck-shaft angle: a 5-year longitudinal study in post-menopausal females. Br J Radiol. 2012;85(1016):e467–73.CrossRefPubMedCentralPubMedGoogle Scholar
  13. 13.
    Leslie WD, Lix LM, Morin SN, Johansson H, Oden A, McCloskey EV, et al. Hip axis length is a FRAX- and bone density-independent risk factor for hip fracture in women. J Clin Endocrinol Metab. 2015;100(5):2063–70.CrossRefPubMedGoogle Scholar
  14. 14.
    Alonso CG, Curiel MD, Carranza FH, Cano RP, Perez AD. Femoral bone mineral density, neck-shaft angle and mean femoral neck width as predictors of hip fracture in men and women. multicenter project for research in osteoporosis. Osteoporos Int. 2000;11(8):714–20.CrossRefPubMedGoogle Scholar
  15. 15.
    Court-Brown C, Heckman J, McKee M, McQueen M, Ricci W, Torentta P, editors. Rockwood and Green’s fractures in adults: volume 2. 8th ed. Alphen aan den Rijn: Wolters Kluwer; 2015.Google Scholar
  16. 16.
    Claffey TJ. Avascular necrosis of the femoral head. An anatomical study. J Bone Joint Surg (Br). 1960;42-B:802–9.CrossRefGoogle Scholar
  17. 17.
    Sevitt S, Thompson RG. The distribution and anastomoses of arteries supplying the head and neck of the femur. J Bone Joint Surg (Br). 1965;47:560–73.CrossRefGoogle Scholar
  18. 18.
    Koval KJ, Zuckerman JD. Hip fractures. I. Overview and evaluation and treatment of femoral-neck fractures. J Am Acad Orthop Surg. 1994;2(3):141–9.CrossRefPubMedGoogle Scholar
  19. 19.
    Lubovsky O, Liebergall M, Mattan Y, Weil Y, Mosheiff R. Early diagnosis of occult hip fractures MRI versus CT scan. Injury. 2005;36(6):788–92.CrossRefPubMedGoogle Scholar
  20. 20.
    Sankey RA, Turner J, Lee J, Healy J, Gibbons CE. The use of MRI to detect occult fractures of the proximal femur: a study of 102 consecutive cases over a ten-year period. J Bone Joint Surg (Br). 2009;91(8):1064–8.CrossRefGoogle Scholar
  21. 21.
    Khan SK, Kalra S, Khanna A, Thiruvengada MM, Parker MJ. Timing of surgery for hip fractures: a systematic review of 52 published studies involving 291,413 patients. Injury. 2009;40(7):692–7.CrossRefPubMedGoogle Scholar
  22. 22.
    Van Embden D, Rhemrev SJ, Genelin F, Meylaerts SA, Roukema GR. The reliability of a simplified garden classification for intracapsular hip fractures. Orthop Traumatol Surg Res. 2012;98(4):405–8.CrossRefPubMedGoogle Scholar
  23. 23.
    Thomsen NO, Jensen CM, Skovgaard N, Pedersen MS, Pallesen P, Soe-Nielsen NH, et al. Observer variation in the radiographic classification of fractures of the neck of the femur using garden’s system. Int Orthop. 1996;20(5):326–9.CrossRefPubMedGoogle Scholar
  24. 24.
    Blankenbaker D, Davis K. Diagnostic imaging: musculoskeletal trauma e-book. 2nd ed. Amsterdam: Elsevier Health Sciences; 2016.Google Scholar
  25. 25.
    Verheyen CC, Smulders TC, van Walsum AD. High secondary displacement rate in the conservative treatment of impacted femoral neck fractures in 105 patients. Arch Orthop Trauma Surg. 2005;125(3):166–8.CrossRefPubMedGoogle Scholar
  26. 26.
    Conn KS, Parker MJ. Undisplaced intracapsular hip fractures: results of internal fixation in 375 patients. Clin Orthop Relat Res. 2004;(421):249–54.CrossRefGoogle Scholar
  27. 27.
    Tarasevicius S, Jermolajevas V, Tarasevicius R, Zegunis V, Smailys A, Kalesinskas RJ. Total hip replacement for the treatment of femoral neck fractures. Long-term results. Medicina (Kaunas). 2005;41(6):465–9.Google Scholar
  28. 28.
    Haidukewych GJ, Israel TA, Berry DJ. Long-term survivorship of cemented bipolar hemiarthroplasty for fracture of the femoral neck. Clin Orthop Relat Res. 2002;(403):118–26.CrossRefGoogle Scholar
  29. 29.
    Blair B, Koval KJ, Kummer F, Zuckerman JD. Basicervical fractures of the proximal femur. A biomechanical study of 3 internal fixation techniques. Clin Orthop Relat Res. 1994;(306):256–63.Google Scholar
  30. 30.
    Massoud EI. Fixation of basicervical and related fractures. Int Orthop. 2010;34(4):577–82.CrossRefPubMedGoogle Scholar
  31. 31.
    Fracture and Dislocation Classification Compendium-2018: International Comprehensive Classification of Fractures and Dislocations Committee. https://classification.aoeducation.org/compendium.html.Published January 2018. Accessed April 2018.
  32. 32.
    Russel T. Intertrochanteric fractures of the hip In: Court-Brown C, Heckman J, McQueen M, Ricci W, Tornetta P, editors. Rockwood and Green’s fractures in adults. 8th ed. Philadelphia: Lippincott Williams & Wilkins; 2015.Google Scholar
  33. 33.
    Jensen JS. Classification of trochanteric fractures. Acta Orthop Scand. 1980;51(5):803–10.CrossRefPubMedGoogle Scholar
  34. 34.
    Fung W, Jonsson A, Buhren V, Bhandari M. Classifying intertrochanteric fractures of the proximal femur: does experience matter? Med Princ Pract. 2007;16(3):198–202.CrossRefPubMedGoogle Scholar
  35. 35.
    Kim SJ, Ahn J, Kim HK, Kim JH. Is magnetic resonance imaging necessary in isolated greater trochanter fracture? A systemic review and pooled analysis. BMC Musculoskelet Disord. 2015;16:395.CrossRefPubMedCentralPubMedGoogle Scholar
  36. 36.
    Merlino AF, Nixon JE. Isolated fractures of the greater trochanter. Report of twelve cases. Int Surg. 1969;52(2):117–24.PubMedGoogle Scholar
  37. 37.
    Alam A, Willett K, Ostlere S. The MRI diagnosis and management of incomplete intertrochanteric fractures of the femur. J Bone Joint Surg (Br). 2005;87(9):1253–5.CrossRefGoogle Scholar
  38. 38.
    Herren C, Weber CD, Pishnamaz M, Dienstknecht T, Kobbe P, Hildebrand F, et al. Fracture of the lesser trochanter as a sign of undiagnosed tumor disease in adults. Eur J Med Res. 2015;4:20.Google Scholar
  39. 39.
    Bonshahi AY, Knowles D, Hodgson SP. Isolated lesser trochanter fractures in elderly—a case for prophylactic DHS fixation. A case series. Injury. 2004;35(2):196–8.CrossRefPubMedGoogle Scholar
  40. 40.
    James SL, Davies AM. Atraumatic avulsion of the lesser trochanter as an indicator of tumour infiltration. Eur Radiol. 2006;16(2):512–4.CrossRefPubMedGoogle Scholar
  41. 41.
    Mavrogenis AF, Panagopoulos GN, Megaloikonomos PD, Igoumenou VG, Galanopoulos I, Vottis CT, et al. Complications after hip nailing for fractures. Orthopedics. 2016;39(1):e108–16.CrossRefPubMedGoogle Scholar
  42. 42.
    Mittal R, Banerjee S. Proximal femoral fractures: principles of management and review of literature. J Clin Orthop Trauma. 2012;3(1):15–23.CrossRefPubMedCentralPubMedGoogle Scholar
  43. 43.
    Shane E, Burr D, Abrahamsen B, Adler RA, Brown TD, Cheung AM, et al. Atypical subtrochanteric and diaphyseal femoral fractures: second report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res. 2014;29(1):1–23.CrossRefPubMedGoogle Scholar
  44. 44.
    Tao R, Lu Y, Xu H, Zhou ZY, Wang YH, Liu F. Internal fixation of intertrochanteric hip fractures: a clinical comparison of two implant designs. Sci World J. 2013;2013:834825.CrossRefGoogle Scholar
  45. 45.
    Saleh A, Hegde VV, Potty AG, Lane JM. Bisphosphonate therapy and atypical fractures. Orthop Clin North Am. 2013;44(2):137–51.CrossRefPubMedGoogle Scholar
  46. 46.
    Barbosa de Toledo Lourenco PR, Pires RE. Subtrochanteric fractures of the femur: update. Rev Bras Ortop. 2016;51(3):246–53.CrossRefPubMedCentralPubMedGoogle Scholar
  47. 47.
    Joglekar SB, Lindvall EM, Martirosian A. Contemporary management of subtrochanteric fractures. Orthop Clin North Am. 2015;46(1):21–35.CrossRefPubMedGoogle Scholar
  48. 48.
    Parker M, Johansen A. Hip fracture. BMJ. 2006;333(7557):27–30.CrossRefPubMedCentralPubMedGoogle Scholar
  49. 49.
    Castronuovo E, Pezzotti P, Franzo A, Di Lallo D, Guasticchi G. Early and late mortality in elderly patients after hip fracture: a cohort study using administrative health databases in the Lazio region, Italy. BMC Geriatr. 2011;11:37.CrossRefPubMedCentralPubMedGoogle Scholar
  50. 50.
    Roche JJ, Wenn RT, Sahota O, Moran CG. Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study. BMJ. 2005;331(7529):1374.CrossRefPubMedCentralPubMedGoogle Scholar
  51. 51.
    Carpintero P, Caeiro JR, Carpintero R, Morales A, Silva S, Mesa M. Complications of hip fractures: a review. World J Orthop. 2014;5(4):402–11.CrossRefPubMedCentralPubMedGoogle Scholar
  52. 52.
    Loizou CL, Parker MJ. Avascular necrosis after internal fixation of intracapsular hip fractures; a study of the outcome for 1023 patients. Injury. 2009;40(11):1143–6.CrossRefPubMedGoogle Scholar
  53. 53.
    Tripathy SK, Sen RK, Goyal T. Nonvascularized fibular grafting in nonunion of femoral neck fracture: a systematic review. Indian J Orthop. 2016;50(4):345–51.CrossRefPubMedCentralPubMedGoogle Scholar
  54. 54.
    Varghese VD, Livingston A, Boopalan PR, Jepegnanam TS. Valgus osteotomy for nonunion and neglected neck of femur fractures. World J Orthop. 2016;7(5):301–7.CrossRefPubMedCentralPubMedGoogle Scholar
  55. 55.
    Barnes R, Brown JT, Garden RS, Nicoll EA. Subcapital fractures of the femur. A prospective review. J Bone Joint Surg (Br). 1976;58(1):2–24.CrossRefGoogle Scholar
  56. 56.
    Bojan AJ, Beimel C, Speitling A, Taglang G, Ekholm C, Jonsson A. 3066 consecutive gamma nails. 12 years experience at a single centre. BMC Musculoskelet Disord. 2010;11:133.CrossRefPubMedCentralPubMedGoogle Scholar
  57. 57.
    Bojan AJ, Beimel C, Taglang G, Collin D, Ekholm C, Jonsson A. Critical factors in cut-out complication after gamma nail treatment of proximal femoral fractures. BMC Musculoskelet Disord. 2013;14:1.CrossRefPubMedCentralPubMedGoogle Scholar
  58. 58.
    Pires RE, Santana EO Jr, Santos LE, Giordano V, Balbachevsky D, Dos Reis FB. Failure of fixation of trochanteric femur fractures: clinical recommendations for avoiding Z-effect and reverse Z-effect type complications. Patient Saf Surg. 2011;5:17.CrossRefPubMedCentralPubMedGoogle Scholar

Copyright information

© ISS 2018

Authors and Affiliations

  • Kimia Khalatbari Kani
    • 1
  • Jack A. Porrino
    • 2
  • Hyojeong Mulcahy
    • 3
  • Felix S. Chew
    • 3
  1. 1.Department of RadiologyUniversity of Maryland School of MedicineBaltimoreUSA
  2. 2.Department of RadiologyUniversity of WashingtonSeattleUSA
  3. 3.Radiology and Biomedical ImagingYale School of MedicineNew HavenUSA

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