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Fracture of the femur: causes, symptoms, diagnosis, treatment
Last reviewed: 07.07.2025
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[ Proximal femur fractures
ICD-10 code
- S72.0. Fracture of femoral neck.
- S72.1. Pertrochanteric fracture.
- S72.2. Subtrochanteric fracture.
Classification
A distinction is made between medial (intra-articular) and lateral (extra-articular) fractures. The former include fractures of the head and neck of the femur, the latter include intertrochanteric, transtrochanteric, and isolated fractures of the greater and lesser trochanters.
Medial femoral fractures
Epidemiology
Fractures of the femoral head are rare. Violations of the integrity of its neck account for 25% of all femoral fractures.
Classification
Depending on the course of the fracture line, there are subcapital, transcervical, and base of the neck (basal) fractures.
Depending on the position of the limb at the time of injury, femoral neck fractures are divided into abduction and adduction.
Reasons
Abduction fractures occur when falling on a leg abducted at the hip joint. In this case, the neck-diaphyseal angle, which is normally 125-127°, increases, which is why such fractures are also called valgus.
When falling on the adducted leg, the neck-diaphyseal angle decreases (adduction or varus fractures). Varus fractures are 4-5 times more common.
Symptoms
Medial femoral neck fractures are more common in older people when they fall on an adducted or abducted leg. After the injury, pain appears in the hip joint and the ability to support the limb is lost.
Diagnostics
Anamnesis
The anamnesis shows a characteristic injury.
Inspection and physical examination
The injured limb is rotated outward, moderately shortened. The hip joint area is unchanged. Palpation reveals increased pulsation of the femoral vessels under the inguinal ligament (S.S. Girgolava symptom) and pain. Positive symptoms of axial load and "stuck heel": patients cannot lift a leg extended at the knee joint. The limb is shortened due to its functional length.
Laboratory and instrumental studies
The location of the fracture and the size of the neck-diaphyseal angle are determined from the radiograph.
Treatment
Patients with femoral neck fractures are treated surgically, with the exception of impacted valgus fractures and injuries against the background of general contraindications to surgical intervention.
Conservative treatment
Conservative treatment in young people consists of applying a large Whitman hip plaster cast with 30° abduction and inward rotation for 3 months. Then walking on crutches without putting weight on the injured limb is allowed. Weight bearing is allowed no earlier than 6 months after the injury. Working capacity is restored after 7-8 months.
In older people, a large hip bandage causes various complications, so it is more appropriate to apply skeletal traction for the femoral condyles for 8-10 weeks with a load weighing 3-6 kg. The limb is abducted by 20-30 ° and moderately rotated inward. Early therapeutic gymnastics is prescribed. From the 7-10th day, patients are allowed to rise on their elbows, gradually teaching them to sit in bed, and after 2 months - to stand on crutches without load on the limb. Further tactics are the same as after removing the plaster.
Surgical treatment
The bone callus, as has been said earlier, develops from the endosteum, periosteum, intermediary, paraosseous from adjacent muscles and the primary blood clot, and for full reparative regeneration, a good blood supply is necessary. In case of a fracture of the femoral neck, the central fragment is almost completely deprived of nutrition, since the blood supply comes from the metaphysis from the place of attachment of the capsule. The artery of the round ligament of the femur is obliterated at the age of 5-6 years. The femoral neck is not covered with periosteum, it is fenced off from the nearest muscles by the joint capsule, and the primary blood clot is washed away by synovial fluid, thus, only the endosteum remains the source of regeneration. All this becomes the main cause of post-traumatic aseptic necrosis of the head and neck of the femur in 25% of victims and more.
Thus, in order for consolidation of a femoral neck fracture to occur in such unfavorable conditions, good alignment and rigid fixation of the fragments are necessary, which can only be achieved surgically.
In surgical treatment, there are two types of osteosynthesis of the femoral neck: open and closed.
With the open method, an arthrotomy of the hip joint is performed, the fragments are exposed and repositioned. Then a pin is punched from the subtrochanteric region, which is used to fasten the fragments under visual control. The wound is sutured. The open, or intra-articular, method is rarely used, since it often leads to severe coxarthrosis. The method is traumatic.
The closed or extra-articular method of osteosynthesis of the femoral neck has become widespread. The patient is placed on an orthopedic table. Under local or general anesthesia, the fragments are repositioned by abducting the limb by 15-25°, traction along the axis and internal rotation by 30-40° compared to the normal position of the foot. The achieved reposition is confirmed by an X-ray.
The soft tissues in the subtrochanteric region are cut to the bone, from this point a pin is driven through, which should fasten the fragments without deviating from the axis of the femoral neck. This is not an easy task, since the surgeon does not see the fragments. In order not to miss, various guides are used. Many surgeons do not use guides, but proceed as follows. Parallel to the inguinal ligament, a metal strip with holes is sewn onto the skin of the patient's abdomen. Two spokes are passed from the subtrochanteric region, focusing on the expected projection of the femoral neck. X-ray control is carried out. If the spokes are in good position, a three-bladed nail is driven through them. If not, the position of the nail is corrected, focusing on the spokes and the plate with holes. After the fragments are fastened, the traction along the limb axis is eliminated, the fragments are hammered together with a special tool (impactor), and a diaphyseal plate is screwed to the three-bladed nail, which is then secured to the femur with screws. The wound is sutured. A posterior plaster splint is applied from the angle of the scapula to the tips of the fingers for 7-10 days. Respiratory gymnastics is started from the first day after the operation. After the immobilization of the limb is eliminated, a derotational position is given. The patient is allowed to rise on the elbows, and then sit on the bed. After 4 weeks, the victim can walk on crutches without putting weight on the operated limb. Weight-bearing is allowed no earlier than 6 months after the operation. Working capacity is restored after 8-12 months.
Teleradiological control optimally simplifies the technique of closed osteosynthesis of the femoral neck. It helps to significantly reduce the time of intervention, which is extremely necessary in operations on elderly patients burdened with concomitant diseases. After repositioning, an incision is made to the bone in the area of the subtrochanteric fossa, 2-3 cm long. The fragments are fastened with two or three long cancellous screws. Sutures are applied to the skin.
A more reliable and durable type of osteosynthesis of cervical and trochanteric fractures is fixation with a dynamic cervical screw DHS, which will be discussed in the section “Lateral fractures”.
If the patient refuses surgery or concomitant diseases are considered a contraindication to surgical intervention, treatment should be aimed at activating the patient. Refusal of surgery does not mean refusal of treatment. It begins with the prevention of thromboembolic complications (bandaging of limbs, anticoagulants). The patient should sit in bed, starting from the 2nd day after the injury, on the 3rd day - sit with his legs hanging off the bed. The patient should learn to stand and move on crutches with the limb suspended on his own neck with a cloth strap as early as possible.
Currently, in the treatment of medial subcapital fractures in elderly people with a high degree of prospects for the development of aseptic necrosis, joint endoprosthetics is increasingly recognized. It can be unipolar (with replacement of only the head of the femur) or bipolar (with replacement of the head and acetabulum). For this purpose, Sivash, Sherscher, Moore and other prostheses are used. Preference is given to total endoprosthetics.
Lateral femur fractures
Epidemiology
Lateral fractures account for 20% of all hip fractures.
Intertrochanteric and pertrochanteric fractures of the femur
Clinical picture and diagnostics. Pain in the area of injury, dysfunction of the limb. During examination, swelling is detected in the area of the greater trochanter, its palpation is painful. Positive symptom of axial load. The X-ray reveals a fracture, the line of which is extra-articular - lateral to the attachment of the joint capsule.
Legion. The large fracture area, and accordingly the area of contact of the fragments, as well as good blood supply allow successful treatment of trochanteric fractures conservatively.
Skeletal traction is applied to the femoral epicondyles, with a load weight of 4-6 kg. The limb is placed on a functional splint and abducted by 20-30°. The traction lasts 6 weeks, then the leg is fixed with a plaster hip bandage for another 4-6 weeks. The total immobilization period is at least 12 weeks. Work is permitted after 4-5 months.
In elderly people, treatment with skeletal traction can be continued for up to 8 weeks. Then, for 4 weeks, cuff traction is used with a load of 1-2 kg or a derotational position of the limb is given using a derotational boot. Rotation of the limb can be eliminated using sandbags or a derotational boot, A.P. Chernov's cuff.
Surgical treatment of trochanteric fractures is performed with the aim of activating the victim, reducing the time spent in bed, and quickly learning to walk on crutches and self-care.
The operation involves inserting a two- or three-bladed nail into the femoral neck, which fastens the fragments together, and a large diaphyseal pad is used to give rigidity to the structure. An L-shaped plate can be used instead of nails. The treatment and recovery periods are the same as with conservative treatment.
In weakened patients, the operation is simplified by replacing the three-bladed nail with three long spongy screws.
One of the optimal fixators for trochanteric fractures is the dynamic DHS screw. Some stages of its application technique are shown in Fig. 8-6.
After the intervention, external immobilization is not required. The patient walks on crutches with a measured load on the limb, starting from the 3rd-4th week.
In case of simultaneous fractures of the femoral neck and trochanters, a gamma nail with locking screws (GN) is used. The gamma nail is distinguished by its robust construction and is qualitatively superior to the DHS nail. It is also good because in case of a subtrochanteric fracture of the femur, its elongated version (LGN) can be used. The main advantage of the nail is that the patient is allowed a measured load on crutches already on the 6th day after the operation.
Isolated fractures of the trochanters
A fracture of the greater trochanter most often occurs as a result of a direct mechanism of injury and is characterized by local pain, swelling, and limitation of limb function. Crepitus and a mobile bone fragment can be detected by palpation. X-rays are then taken.
20 ml of 1% procaine solution is injected into the fracture site. The limb is placed on a functional splint with 20° abduction and moderate external rotation.
A fracture of the lesser trochanter is the result of a sharp contraction of the iliopsoas muscle. In this case, swelling and pain are found on the inner surface of the thigh, a violation of hip flexion - the "symptom of a stuck heel". The reliability of the diagnosis is confirmed by an X-ray.
After anesthesia of the fracture site, the limb is placed on a splint in a position of flexion in the knee and hip joints to an angle of 90° and moderate internal rotation. In both cases, disciplinary cuff traction is applied with a load weighing up to 2 kg.
The period of immobilization for isolated trochanteric fractures is 3-4 weeks.
Restoration of working capacity occurs within 4-5 weeks.
Diaphyseal fractures of the femur
ICD-10 code
S72.3. Fracture of shaft [diaphysis] of femur.
Epidemiology
They account for about 40% of all femur fractures.
Reasons
They arise from direct and indirect mechanisms of injury.
Symptoms and diagnosis
The diagnosis of a typical diaphyseal fracture is characterized by all its inherent signs. The peculiarity of the injury is the frequent development of shock and bleeding into soft tissues, reaching a loss of 0.5-1.5 liters.
Depending on the level of damage, fractures of the upper, middle and lower thirds are distinguished, and the displacement of fragments, and accordingly the tactics for violating the integrity of each segment, will be different.
- In fractures in the upper third, under the action of muscle traction, the central fragment is displaced forward, outward, and rotated outward. The peripheral fragment is adducted and pulled upward.
- In a fracture in the middle third, the central fragment is slightly deflected forward and outward, the peripheral fragment is displaced upward and slightly adducted. Deformation of the limb occurs due to predominant displacement along the length and moderate angular curvature.
- A fracture in the lower third of the femur is characterized by the displacement of the central fragment forward and inward due to the pull of the flexors and powerful adductor muscles. The short peripheral fragment is deflected backward as a result of contraction of the gastrocnemius muscles. Damage to the neurovascular bundle by a bone fragment is possible.
Where does it hurt?
Complications of hip fracture
After hip fractures, especially those treated with old methods, persistent extension contractures of the knee joint often develop. They are caused by prolonged immobilization, joint damage, or myofasciotendosis. The latter involves the fusion of the heads of the quadriceps muscle of the thigh with the bone, as well as different layers of soft tissues with each other, which leads to the shutdown of the knee joint functions. Sometimes myofasciotendosis is combined with patellodesis - the fusion of the patella to the femoral condyles.
Myofasciotenodesis differs from immobilization and arthrogenic contractures in that it occurs after a short-term (2-3 months) fixation of the limb and with an intact knee joint.
The diagnostics are characterized by a feeling of an obstacle at the fusion site, absence of pain during development, atrophy of the thigh muscles, mainly in the middle third, and impaired mobility of the skin-fascial case of the thigh. Mobility is checked by moving the soft tissues with the hands up, down, and around the longitudinal axis. Existing scars after operations are retracted and are retracted even more when trying to move the knee joint. Displacement of the patella upward and outward is noted, as well as limitation of its mobility.
With long-term contractures, valgus deviation of the tibia and recurvation of the knee joint develop.
Symptoms of tension disturbance and uneven muscle tone are characteristic. In the first case, passive flexion of the shin leads to a well-defined muscle tension up to the fusion site. Tension does not extend to the proximal sections. In the second case, with active flexion of the shin, muscle tension occurs above the fusion and is absent in the distal sections.
Radiographically, excess bone callus with awl-shaped outgrowths, retraction of soft tissues, muscle atrophy and an increase in the subcutaneous fat layer are found.
In the knee joint area there is regional osteoporosis, the femoral condyles are deformed: lowered and stretched in the anteroposterior direction (the "boot" symptom). The lateral condyle is particularly affected.
The angle of the patella changes. If the normal angle between the posterior surface of the patella and the axis of the femur is 27.1°, then with myofasciotinodesis the angle decreases to 11.1°. The patella itself changes its structure and shape. The cortical layer becomes thinner, the body becomes porous and rounded - the "lens" symptom. On the electromyogram above the fusion site, the changes are minimal, but below the fusion, the oscillations are sharply reduced, uneven in height and frequency, and sometimes the curve approaches a straight line.
All identified symptoms of dysfunction of the knee joint are grouped into a differential diagnostic table, which is necessary to distinguish the three most common contractures: immobilization, arthrogenic and myofasciotendosis.
It should be noted that myofasciotinodesis of the knee joint in most cases does not respond to conservative treatment and requires surgical intervention. The operation consists of tenomyolysis, separation of the heads of the quadriceps muscle and subsequent plastic surgery. In the postoperative period, early functional treatment is mandatory.
In the clinic of Samara State Medical University, surgical treatment of myofasciotinodesis of the knee joint has been performed since 1961 using various methods: Payra, Jude, Thompson-Kaplan. In recent years, operations have been performed using the technique developed by A.F. Krasnov and V.F. Miroshnichenko.
The rectus and intermediate heads are separated longitudinally from the broad muscles of the thigh and mobilized as much as possible beyond the adhesion process. After this, the tendon of the rectus and intermediate muscles of the thigh is divided in the frontal plane and cut off from the patella. By traction along the length and flexion of the lower leg, these muscles are stretched and the lower leg is flexed to the maximum possible angle, usually to the norm (30-40°). The tendon of the intermediate muscle of the thigh is dissected lengthwise, and the ends are brought out to the right and left of the rectus femoris. The leg is bent at an angle of 90-100° and plastic surgery of the quadriceps femoris is performed, using flaps of the intermediate muscle tendon not only to restore functions, but also to plastic surgery of defects that occur during flexion in the knee joint. Then the tissues on the semi-bent knee joint are sutured in layers, a plaster cast is applied for 2-3 weeks, then a removable one for another 10-12 days. Two drainage tubes are left in the wound for 1-2 days, preferably with active aspiration. From the 2nd-3rd day, physiotherapy and passive exercise therapy are indicated. From the 4th-5th day, exercise therapy is performed for the knee joint: active flexion and passive extension of the shin. From the 7th-8th day, the patient extends the shin while lying on the side, and from the 10th-12th day - in a sitting position. After removing the plaster, mechanotherapy, a pool and exercise therapy in water, exercises on exercise machines, and crutches when walking are indicated. Loading the limb is allowed 2-3 weeks after the operation, but it should be remembered that in the first months after surgery, a deficit of active extension of 10-15 ° remains.
What do need to examine?
Treatment of hip fracture
Conservative treatment of hip fracture
Treatment can be conservative and surgical. Fractures without displacement are treated by fixing the limb with a large hip bandage, following the rule: "The higher the fracture, the greater the hip abduction."
In case of oblique and spiral fractures, it is advisable to use skeletal traction. The needle is passed through the femoral epicondyles, using a weight of 8-12 kg. The limb is placed on a splint. Taking into account the displacement of the central fragment and to avoid the angular deformation of "breeches" in case of high femoral fractures, the limb is abducted by at least 30° from the axis of the body. In case of fractures in the middle third, abduction does not exceed 15-20°. In both cases, flexion in the knee and hip joints corresponds to 140°, in the ankle - 90°.
In case of hip fractures in the lower third, to avoid damage to the neurovascular bundle and to obtain a comparison of the fragments, it is necessary to place the adducted limb on a functional splint and bend it at an angle of 90-100° at the knee and hip joints. A soft cushion is placed under the peripheral fragment. The state of the neurovascular bundle is monitored.
The duration of immobilization with conservative treatment methods is 10-12 weeks.
Surgical treatment of hip fracture
Open reposition is completed by fastening the fragments in one of the ways. Most often, intramedullary metal osteosynthesis is used, less often - extramedullary. The operation is completed by suturing the wound with catgut and applying a plaster hip bandage.
In operated patients, limb fixation continues for 12 weeks.
Currently, the capabilities of traumatologists in the treatment of femur fractures have expanded significantly. The reserved attitude of doctors to the use of spoke devices on the hip due to frequent suppuration of soft tissues has been replaced by the active use of rod devices for external fixation, both as an independent method of treatment and for the preparation of future interventions. A series of powerful and large-sized plates has appeared, allowing for the successful treatment of multi-fragmentary fractures of the femur. Particular attention should be paid to the modern, most promising method of intramedullary osteosynthesis with locking pins.
There are four methods of intramedullary osteosynthesis of the femoral body: reconstructive, compression, dynamic and static.
The pin can be inserted into the femur antegradely (through the proximal part) or retrogradely (through the distal part).
Antegrade method
The operation is performed on an extension operating table under X-ray control. The patient is placed on his back.
An 8-10 cm long incision is made above the apex of the greater trochanter. The apex of the greater trochanter is released. A little more medially and anteriorly there is a depression through which a Kirschner wire is passed into the medullary canal.
The hole is widened along the spoke with a cannulated awl, and then deepened by 8 cm. The diameter of the hole should be 2 mm larger than the diameter of the pin. The depth of the medullary canal is measured to the distal section. The intraosseous rod is connected to the proximal and distal guides and, by repositioning the fragments, is passed into the medullary canal.
Reconstructive nails are used for intraosseous osteosynthesis of the proximal femur in fractures of the femoral neck and trochanteric fractures. Due to the angular installation of reconstructive screws, the head and trochanteric region are in an anatomical position relative to the body of the bone. First, the proximal section is blocked, and then the distal section.
Compression rods are used for intraosseous osteosynthesis of the femur, and the fracture must be located at a distance of at least 3 cm from the locking screw.
The design of the rod allows the use of compression, dynamic and static methods, and the locking screws in these methods are first placed in the distal and then in the proximal part of the bone. The target guides are removed. In the compression method, a compression screw is screwed into a threaded hole inside the rod, in the dynamic and other methods, a blind screw is screwed in there.
Retrograde method
It is used for low diaphyseal fractures of the femur or when it is impossible to work on the proximal section - the presence of metal structures, endoprosthesis, etc.
Before the operation, the nature of the fractures and the size of the implanted rod are determined using X-ray images. The patient lies on the table with the knee joint bent at 30°. The knee joint is opened from the medial side using a small Payre incision. The intercondylar fossa is exposed, through which a canal is formed in the femur, which becomes a continuation of the medullary canal. Its depth should be 6 cm, the width - 1.5-2 cm more than the diameter of the rod. The latter is connected to the target guide and inserted into the medullary cavity. Blocking of the rod begins with the most distal hole, and then in the proximal section. The operation is completed by inserting a blind screw into the distal end of the intraosseous rod and suturing the knee joint wound. External immobilization is not required.