Proximal Femur Fractures

Jeffrey Shyu, MD

Learning Objectives

Provide an intuitive understanding of the

morphologic types, injury mechanisms, and

classification systems of adult proximal femur

fractures, using multimodality imaging

examples, 3-D models, and animations.

Review the potential complications and

management.

Disclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References

Proximal Femur Fractures:

Organization Tree

* Basicervical fractures, although intracapsular, are managed like intertrochanteric fractures.

Proximal Femur Fractures

Femoral Head

Osteochondral

Subchondral

Extracapsular

Intertrochanteric

Greater Trochanter

Lesser Trochanter

Subtrochanteric

Intracapsular

Basicervical*

Transcervical

Subcapital

Proximal femur fractures may be divided into femoral head, intracapsular femoral neck, and

extracapsular fractures. Accurately categorizing the anatomic location and subtype of the

fracture has significant implications for surgical management.

Disclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References

osteochondral fracture subchondral fracture subcapital fracture transcervical fracture basicervical fracture intertrochanteric fracture greater trochanter fracture lesser trochanter fracture subtrochanteric fracture

Proximal Femur Fractures

Disclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References

Anatomy

MOVIE: Computer generated tour of the relevant muscular, ligamentous, labral, and bony

anatomy of the hip.

Disclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References

Anatomy

The hip is a synovial joint with wide range of rotational motion and stability

Stability is conferred by its ball and deep socket configuration, acetabular labrum, a strong joint capsule,

articular cartilage, and surrounding muscle

One of the few inherently stable joints because of its bony anatomy

Iliofemoral and pubofemoral ligaments cover hip joint anteriorly. Ischiofemoral ligament covers hip joint

posteriorly

Byrne DP et al. The Open Sports Medicine Journal 2010

Disclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References

Anatomy: Arterial Supply

Medial femoral circumflex artery• Largest, most important contributor

• Posterior portion of vascular ring

• Supplies superolateral femoral head

Lateral femoral circumflex artery• Anterior portion of vascular ring

• Supplies inferoanterior femoral head

Obdurator artery• Via ligamentum teres

• Little supply to femoral head, inadequate in

setting of displaced head/heck fractures

Ascending cervical arteries • Feeder vessels arising from extracapsular ring

• Penetrate capsule

• Run parallel to femoral neck towards the head

• Lateral vessels provide greatest supply

A major concern of femoral head and

neck fractures is disruption of the

arterial supply, which results in

avascular necrosis. In fractures, the

intraosseous cervical vessels are

disrupted.

Trueta J et al. J Bone Joint Surg BR 1953; Ly TV et al. J Boint Joint Surg Am 2008.

Disclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References

Lat. fem

circumflex

Med. fem

circumflex

Deep femoral

art.

Obdurator art.

Hip experiences combined

mechanical loads• Axial load along shaft, compressive stress

• Bending load along neck, tensile stress applied

at upper neck and compressive stress at lower

neck

Cancellous bone arranged along

principal lines of stress• Primary medial trabeculae resist compression

• Primary lateral trabeculae resist tension

Stress lines explain patterns of injury

Ward’s Triangle: Weakest point of

femoral neck

Tensile groupCompressive group

Ward’s Triangle

Anatomy: Stress Lines

Byrne DP et al. The Open Sports Medicine Journal 2010; Bowman KF Arthroscopy 2010.

Disclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References

Imaging Modalities

Dominguez S et al. Acad Emerg Med 2005; Frihagen F et al. Acta Orthop 2005; Kirby MW et al. AJR Am J Roentgenol 2010; Khurana B et al. AJR 2012

Plain Film Radiography• First line study

• 90% sensitive, however 2-11% of ED patients

have radiologically occult fractures

• AP and lateral radiographs of the hip

• AP radiograph of the pelvis, to assess for

pelvic injury and compare with contralateral

hip

CT• More readily accessible than MRI in acute ED

settings

• Useful in trauma for detecting intra-articular

extension, acetabular fracture, pelvic ring, and

sacral fractures

• However, second-line compared to MRI

because of concerns for missing fracture lines

• May be useful for preoperative evaluation

Disclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References

Coronal CT demonstrates a valgus impacted

femoral neck fracture

Imaging Modalities

Dominguez S et al. Acad Emerg Med 2005; Frihagen F et al. Acta Orthop 2005; Kirby MW et al. AJR Am J Roentgenol 2010 Khurana B et al. AJR 2012

MRI• Obtain if radiographs are negative/equivocal and clinical suspicion is high

• More sensitive than CT for evaluating occult fractures

• Best for evaluating bone marrow, joint space, osteochondral injuries, early diagnosis

and staging of AVN

• May be limited in access in an acute ED setting

• Technique: Useful MR sequences include the following: coronal STIR, coronal T1, axial

dual-echo, axial T2 fat-saturated FSE, axial fat-saturated FSE proton density, sagittal

T1, axial T1.

• Most useful sequences are coronal STIR (for edema) and coronal T1 (for fracture line)

Bone Scan• Indicated for suspected fracture or AVN not demonstrated on plain film, and where MRI

unavailable

• High sensitivity, but poor specificity

• Minimum of 4 hours to perform, and may take up to 24-48 hours

• Relatively less useful in osteoporotic patients

• Poor spatial localization of fracture lines

Disclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References

Occult Femoral Neck Fracture

Seen Only on MRI

Dominguez S et al. Acad Emerg Med 2005

AP radiograph of the hip demonstrates no

evidence of fracture.On coronal T1 MRI, a hypointense fracture

line is present.

Up to 11% of ED patients have radiologically occult hip fractures

Disclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References

Traumatic Femoral Head

(Osteochondral) Fractures

Traumatic femoral head fractures typically result from high energy impact, and are often

associated with hip dislocations

Posterior dislocations 9x more common than anterior

Partial flexion, internal rotation typically leads to a posterior fracture-dislocation pattern

Ross JR et al. Curr Rev Musculosk Med. 2012

Disclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References

Femoral Head Fractures:

Pipkin Classification

Posterior dislocation

Fracture below fovea, non-weight-bearing

Posterior dislocation

Fracture above fovea, weight-bearing

Associated femoral neck fracture Type I, II, or III, associated acetabular fracture

Rockwood and Green’s Fractures in Adults 2010; Ross JR et al. Curr Rev Musculosk Med 2012

Most commonly used classification for femoral head fractures, and used to guide

operative versus nonoperative managementDisclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References

Traumatic Femoral

Head Fractures

Disclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References

Femoral head fracture with posterior dislocationFemoral head fracture with subfoveal

involvement (Pipkin I)

Traumatic Femoral Head Fractures:

Surgical Considerations

Intra-capsular fracture, concern for avascular necrosis

• Emergent closed reduction as soon as feasible, preferably within 6 hours

• If irreducible, or with femoral neck fracture, then ORIF

Above or below fovea?

• Above fovea, weight bearing

• Below fovea, non-weight bearing, could potentially be treated conservatively

Is traction indicated?

• If fracture flipped, then traction indicated

Congruent?

• If incongruent, then operative management

Management Strategies

• Conservative management: Pipkin I

• ORIF: Pipkin II, Pipkin III, IV, irreducible fracture-dislocation

• Core decompression for osteonecrosis is controversial

Rockwood and Green’s Fractures in Adults 2010; Ross JR et al. Curr Rev Musculosk Med. 2012

Disclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References

Subchondral Insufficiency

Versus Osteonecrosis

Osteonecrosis• Typically 30s-40s in age

• Associated with steroid/alcohol use

• 50-70 percent bilateral

MRI

• T1: Smooth band that is concave to the articular surface,

and circumscribes necrotic segments

Treatment• No femoral head collapse: conservative treatment

• Femoral head collapse: THA or hemiarthroplasty

Yamamoto T Clin Orthop Surg 2012; Ikemura S et al. AJR 2010

Subchondral insufficiency fractures are a recently recognized entity that may mimic osteonecrosis of the

femoral head. However, certain clinical and imaging features will favor one diagnosis over the other.

Osteonecrosis: coronal T1: bilateral decreased T1 signal in the femoral

heads, and serpiginous bands concave to articular surface

Disclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References

A B

Subchondral Insufficiency• Biphasic pattern: elderly females and young active individuals

• Typically unilateral

MRI

• Irregular, hypointense disconnected band that runs almost

parallel to femoral head

• High signal proximal segment on C+ images

Treatment• No femoral head collapse

• Young: Trochanteric rotational osteotomy

• Elderly: THA or hemiarthroplasty

Subchondral Insufficiency: coronal STIR (A) demonstrates

irregular band parallel to the femoral head. Post-contrast T1

image (B) in a different patient demonstrates femoral head

enhancement

Femoral Neck Fracture:

Mechanism

Caused by fall with applied force to the greater trochanter

High energy impact in younger patients, and low energy impact in elderly patients

Weakest site just below articular surface

Disclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References

Subcapital, Transcervical,

Basicervical Fractures

TranscervicalTreated as intracapsular fx

BasicervicalTreated as extracapsular fx

e.g. like intertrochanteric fx

SubcapitalTreated as intracapsular fx

Disclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References

Incomplete

Valgus impaction + retroversionComplete, non-displaced

Marked angulation

Minimal/no proximal translationComplete displacement

Proximal translation

Commonly used classification for

surgical management of femoral

neck fractures

Valgus impacted fractures are

often missed

Good interobserver agreement

between I-II and III-IV, but poor

between all groups

Better to distinguish I-II and III-IV,

as types III and IV typically treated

with arthroplasty

IVIII

I II

Garden Classification

Frandsen PA et al. Acta Orthop Scand 1984; Kreder HJ J Bone Joint Surg AM 2002

Disclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References

Pauwel Classification

Type IMore stable

Type IIIMore unstable, higher energy injury

Determined by angle of fracture from horizontal plane

Increased shear forces with increased angles worsens prognosis

Better categorizes stability than the Garden Classification

Better predicts difficulty of obtaining stable fixation

More vertically oriented fractures may also require plate fixation

Type III fractures complicated by nonunion may require intertrochanteric osteotomy to reorient the fracture

line to a more Type 1 (stable) angle

Ly TV et al. J Bone Joint Surg Am 2008

Disclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

ReferencesType II

Most common

Types of Stress Fractures

TensileUnstable, fracture can

propagate

CompressiveMore stable

DisplacedUnstable

Worse prognosis and risk for

avascular necrosis

Emergent operation and reduction

Disclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References

Femoral neck stress fractures are often related to increased activity. The

pattern of the stress fracture relates to the lines of stress within the

proximal femur and has significant management implications

Tensile Stress FractureSuperior, lateral aspect of the femoral neck

Bimodal distribution: Elderly individuals and young runners

Potentially unstable, obtain MRI to assess fracture extent

Warrants internal fixation (nail fixation in young athletes)

Femoral Neck:

Tensile Stress Fracture

Disclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References

Femoral Neck:

Tensile Stress Fracture

Tensile stress fracture in the superolateral

femoral neck in an elderly patient. Note

osteoarthritis of the hip.

Tensile stress fracture (Garden III) in the

superolateral femoral neck in a young, active,

patient. Note the normal bone mineral density.

Bimodal distribution: elderly individuals and young runners

Disclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References

Femoral Neck:

Fatigue Compression Fracture

Fatigue Compression FractureInferior aspect of femoral neck

Active individuals

May potentially be treated non-operatively

Coronal STIR image demonstrates edema at the

inferomedial femoral neck.Coronal T1 image demonstrates a hypointense

region and a subtle fracture line.

Disclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References

Femoral Neck Fractures: Surgical

Considerations

AVN, nonunion may result from delayed diagnosis• Risk for AVN is greater for femoral neck fractures than for pertrochanteric fractures

Young ( < 65) and/or active• Goal: preserve femoral head, avoid osteonecrosis, achieve union

Old ( > 75) and/or immobile• Goal: restore mobility and minimize complications

Fracture pattern determines treatment• Basicervical fracture treated like intertrochanteric fracture

• Nonoperative management associated with higher complication and increased risk of

displacement

• If nondisplaced, internal fixation preferred

• If displaced fracture, elderly, arthroplasty preferred

• Most studies find improved function with THA compared to hemiarthroplasty

Miler BJ et al. J Bone Joint Surg Am 2013; Goh SK et al. J Arthroplasty 2009; Cserhati P et al. Injury 1996

Disclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References

Femoral Neck Fracture:

Treatment Algorithm

Nondisplaced

Displaced

Total Hip Arthroplasty

Hemiarthroplasty

OldYoung

PC Screw or ArthroplastyPercutaneous Cancellous (PC) Screw

Miler BJ et al. J Bone Joint Surg Am 2013

Open Reduction Internal Fixation

Disclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References

Intertrochanteric Fracture

Koval KJ et al. J Am Acad Orthop Surg 1994

Nondisplaced Intertrochanteric fracture (Evans I)

Disclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References

Anatomy• Intertrochanteric line: anterior ridge between greater and lesser trochanters

• Extracapsular, transition between femoral neck and shaft

• Iliofemoral ligament attaches above, vastus medialis attaches below

Mechanism• Resulting from fall

Unstable features• Loss of medial buttress

• 4-part fractures, and 3-part fractures with

lesser trochanter involvement

• Reverse obliquity

• Comminution

Stable features• Near anatomic reduction achievable

• Lesser trochanter nondisplaced

• Medial cortices in alignment

• No comminution

Evans Classification

Trafton PG. Orthop Clin North Am 1987; Koval KJ et al. J Am Acad Orthop Surg 1994

Disclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References

I II III

Two part, undisplaced

Stable

Two part, displaced

Stable

Three part, posterolateral comminution

Unstable

Three part, posteromedial comminution

Unstable

Four Part

Unstable

Useful for deciding stability and treatment of intertrochanteric fractures. Also, reverse obliquity

fractures are unstable and treated like subtrochanteric fractures

IV V

Intertrochanteric Fracture:

Management

Incomplete• Obtain MRI to ensure fracture not complete

• If incomplete and <50% fracture width,

potentially can treat conservatively

• Risk of fracture completion

Complete• Stable: Dynamic plate and screw

• Unstable or reverse obliquity:

Intramedullary device

Management depends on completeness and stability

Risk of AVN and nonunion less than in femoral neck fractures

Again, basicervical fractures treated like intertrochanteric fractures

Su BW, Orthopedics 2006; Forte ML et al. J Bone Jint Surg Am 2008

Disclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References

Greater Trochanter Fracture

Anatomy• Greater trochanter is the insertion site for hip

abductors (gluteus medius and minimus) and

external rotators (piriformis, gemelli, obdurators)

Mechanism• Isolated greater trochanter fracture may be related

to impaction from fall, versus avulsion

Imaging• If incomplete, obtain MRI to assess extent of

fracture

Management• Most heal well with nonoperative management

• If significant displacement, then ORIF

Disclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References

Lesser Trochanter Fracture

Anatomy• Lesser trochanter is attachment site for iliopsoas

Mechanism• Fracture may be due to avulsion

• In the absence of injury, isolated lesser

trochanter fracture is highly suspicious for an

underlying malignancy

Imaging• Obtain MRI to assess extent of fracture

• Evaluate for underlying malignancy

Management• Nondisplaced fractures heal well with

nonoperative management

• If significantly displaced, then ORIF

James SL et al. Eur Radiol 2006

Mildly displaced lateral trochanter fracture

in a patient with prostate cancer and

diffuse blastic metastases. Also note the

extensive periosteal reaction.

Disclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References

Subtrochanteric and Proximal Femoral Shaft:

Traumatic Versus Atypical Fractures

Shane E et al. J Bone Miner Res 2010. Park-Wyllie LY et al. JAMA 2011

Atypical FracturesLong-term bisphosphonate usage, o/minimal trauma

ImagingTypically subtrochanteric or femoral shaft

Transverse or short oblique orientation

Lateral beaking (arrow)

Normal bone mineral density

ManagementEvaluate contralateral femur

Treat with ORIF, intramedullary nail and screw0

It is important for the radiologist to recognize the different patterns of traumatic and

atypical subtrochanteric and proximal shaft fracturesDisclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References Typical FracturesOften traumatic, high impact

ImagingRadiographs generally diagnostic

Oblique or spiral in orientation

Proximal piece is flexed, abducted, and externally rotated

MR/CT if concern for pathologic fracture

ManagementORIF

Higher rates of failure due to high stress anatomy

Conclusion

• Proximal femoral fractures can be classified as

femoral head, intracapsular, and extracapsular

• Increased concern for AVN and nonunion for

intracapsular fractures due to vascular compromise

• Important to understand how imaging features reflect

underlying mechanical forces and mechanisms of

injury, and how these in turn guide management

• If a patient has hip pain and negative x-rays, strongly

consider further imaging with MRI

Disclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References

References

• Trueta J, Harrison MH. The normal vascular anatomy of the femoral head in adult man. J Bone Joint Surg Br. 1953;35:442-61

• Ly TV, Swiontkowski MF. Treatment of femoral neck fractures in young adults. J Bone Joint Surg Am. 2008;90:2. 254-66

• Byrne DP et al. The Open Sports Medicine Journal 2010;4;51-7.

• Bowman KF Jr, Fox J, Sekiya JK. A clinically relevant review of hip biomechanics. Arthroscopy 2010;26(8):1118-29.

• Dominguez S, Liu P, Roberts C et al. Prevalence of traumatic hip and pelvic fractures in patients with suspected hip fracture and negative initial

standard radiographs—a study of emergency department patients. Acad Emerg Med 2005;12(4):366-9.

• Frihagen F, Nordsletten L, Tariq R, et al. MRI diagnosis of occult hip fractures. Acta Orthop 2005;76(4):524-30.

• Kirby MW, Spritzer C. Radiographic detection of hip and pelvic fractures in the emergency department. AJR Am J Roentgenol 2010;194(4):1054-60.

• Khurana B, Okanobo H, Ossiani M, et al. Abbreviated MRI for patients presenting to the emergency department with hip pain. AJR Am J Roentgenol

2012;198(6):581-8.

• Ross JR, Gardner MJ. Femoral head fractures. Curr Rev Musculoskelet Med 2012;5(3):199-205.

• Rockwood and Green’s Fractures in Adults, 7th Edition. Wolters Kluwer/Lippincott Williams & Wiilkins, New York, 2010.

• Yamamoto T. Subchondral insufficiency fractures of the femoral head. Clin Orthop Surg. 2012:4(3):173-80.

• Ikemura S, Yamamoto T, Motomura G, et al. MRI evaluation of collapsed femoral heads in patients 60 years old or older: differentiation of subchondral

insufficiency fracture from osteonecrosis of the femoral head. AJR Am J Roentgenol 2010;195:W63-W68.

• Frandsen PA, Andersen PE Jr, Christoffersen H et al. Osteosynthesis of femoral neck fracture. The sliding-screw-plate with or without compression.

Acta Orthop Scand 1984;55(6):620-3.

• Kreder HJ. Arthroscopy led to fewer failures and more complications than did internal fixation for displaced fractures of the femoral neck. J Bone Joint

Surg Am 2002;84:2108.

• Miller BJ, Lu X, Cram P. The Trends in Treatment of Femoral Neck Fractures in the Medicare Population from 1991 to 2008. J Bone Joint Surg Am

2013:95(18):1-8.

• Goh SK, Samuel M, Su DHC et al. Meta-analysis comparing total hip arthroplasty with hemiarthroplasty in the treatment of displaced neck of femur

fracture. J Arthroplasty. 2009:24(13):400-6.

• Koval KJ, Zuckerman JD. Hip fractures, II: evaluation and treatment of intertrochanteric fractures. J Am Acad Orthop Surg 1994;2(3):150-6.

• Trafton PG. Subtrochanteric-intertrochanteric femoral fractures. Orthop Clin North Am 1987;18(1):59-71.

• Su BW, Heyworth BE, Protopsaltis TS et al. Basicervical versus intertrochanteric fractures: an analysis of radiographic and functional outcomes.

Orthopedics 2006;29(10):919-25.

• Forte ML, Vimig BA, Kane RL. Geographic variation in device use for intertrochanteriic hif fractures. J Bone Joint Surg Am 2008;90(4):691-9.

• James Sl, Davies Am. Atraumatic avulsion of the lesser trochanter as an indicator of tumour infiltration. Eur Radiol. 2006;16(2):512-4

• Shane E, Burr D, Ebeling PR et al. Atypical subtrochanteric and diaphyseal femoral fractures: report of a task force of the American Society of Bone

and Mineral Research 2010; 25(11):2267-94

• Park-Wyllie LY, Mamdani MM, Juurlink DN. Bisphosphonate use and the risk of subtrochanteric or femoral shaft fractures in older women. JAMA

2011;305(8):783-9.

• Tornetta P III. Subtrochanteric femur fracture. J Orthop Trauma 2002;16(4);280-3

Thank You For Viewing Our Exhibit – Jeffrey Shyu (jshyu@partners.org)

Disclosures

Learning

Objectives

Organization

Anatomy

Imaging

Osteochondral

Subchondral

Femoral Neck

Intertrochanteric

Greater Troch.

Lesser Troch.

Subtrochanteric

Conclusion

References