Burgio, V

D'ARIENZO, Michele

Gallo, M

Morello, S

SANFILIPPO, Antonino

Archivio istituzionale della ricerca - Università di Palermo

FRACTURES OF THE PROXIMAL EXTREMITY OF THE FEMUR: CURRENT DIAGNOSTIC AND THERAPEUTIC CLASSIFICATION OVERVIEW.   Massimiliano Gallo, Salvatore Morello, Valeria Burgio,  Antonino Sanfilippo, Michele D'Arienzo. Introduction Fractures of the proximal extremity of the femur are the most frequently encountered lesions in traumatology departments. Due to the progressive aging of the population, the incidence of these fractures is increasing in most Western populations (Fig. 1) to the point of reaching epidemic proportions and threatening to undermine the balance of many health care systems due to excessive treatment costs (1). These extremely common fractures are characteristically diagnosed in two patient groups: - In adults, more rarely, caused by high-energy trauma, mostly due to traffic or work accidents, or occurring during sports activities. - The elderly, with greater frequency, caused by low-energy trauma. In most cases, the traumatic event is an accidental fall; in some cases, when the patient is confused and poorly cooperative, it may even be impossible to determine the etiology of the fracture. The elderly, especially women, are predisposed to this type of injuries due to osteoporo-sis, which weakens the bone tissue by reducing the bone mass, particularly at the femo-ral neck and trochanteric region (2). The World Health Organization has estimated that in 2050, 6.3 million (4.6 million more than in 1990) femur fractures will occur, and it is estimated that in Italy, between 70 000 and 90 000 femur fractures are treated each year. In industrialized countries, the incidence of femur fractures is constantly increasing (by 1-3% per year), almost exclusively in the elderly population. The "lifetime risk" for hip fractures is currently about 18% for women and 6% for men. The prevalence increases by about 3% for women between 65 and 74 years of age, and by 12.6% for women older than 85.  Review © EUROMEDITERRANEAN BIOMEDICAL JOURNAL  2012, 7(12):55-60. DOI: 10.3269/1970-5492.2012.7.12 Available on-line at: http://www.embj.org SUMMARY Fracture of the proximal (upper) extremity of the femur is a very common occurrence, especially in the elderly population. This type of injury causes pain and complete func-tional impairment, and the overall incidence of such fractures has been increasing nota-bly. Surgical treatment of these fractures is considered the gold standard approach to minimize the bed rest period and ensure a very early mobilization and weight bearing, restoring patients’ autonomy and function as close as possible to their pre-fracture levels. In this article, we illustrate the epidemiological aspects of fractures of the proximal third of the femur, different classification systems and available treatment options depending on the type of fracture and conditions of the patient.  Address of the authors  Orthopedic and Traumatology Unit, University of Palermo, Italy.  Send correspondence to: Dr. Massimiliano Gallo, massimilianogallo5@gmail.com Received: March 28th, 2012 — Revised: April 24th, 2012 — Accepted: May 1th, 2012  ISSN 2279-7165 - Euromediterranean Biomedical Journal [online] Classification  The AO classification (Arbeidsgemeinshaft für osteosynthese fragen) divides hip frac-tures  into  three  groups:  extracapsular fractures, fractures of the femoral neck, and fractures of the femoral head (Figure 2) (3). Each of these three groups is further divided  into  three  subgroups,  each  of which, in turn, comprises three sub-sub-groups.  Although  this  classification  in-cludes  27 groups, it  does not  allow to properly distinguish between trochanteric and subtrochanteric fractures (4). There-fore, we prefer to use a more practical classification system, that allows to orien-tate the treatment in an effective manner distinguishing between medial and lateral fractures in relation to the joint capsule.  - Medial fractures: these are subdivided into subcapital and transcervical fractures. They can also be classified, according to the Garden system (Figure 3), into: incom-plete fractures with valgus impaction (type I); complete fractures without displacement (type II);  complete fractures with partial varus displacement (type III); and complete fractures with total displacement (type IV). The first two types are considered stable or directly stabilizable (through osteosynthe-sis); the III and IV type fractures are consid-ered unstable, or stabilizable only by re-duction.  - Lateral fractures: these are subdivided into  basicervical,  intertrochanteric  and subtrochanteric  (below  the  lesser  tro-chanter) fractures. Depending on the num-ber of fragments and the obliquity of the fracture, lateral fractures are divided into stable  and  unstable  (comminuted)  frac-tures.  PROXIMAL FRACTURES OF THE FEMUR, p.56 EMBJ, 7(12), 2012 — www.embj.org Figure 2: The AO classification system of proximal femur fractures (reproduced with modifications from: www.gpini.it). Figure 3: The anatomo-radiological Garden classification system (reproduced with modifications from: www.gpini.it).  Figure 1: The steady increase in the inci-dence of femur fractures (1-3% per year) in most Western populations. This increase af-fects almost exclusively the elderly popula-tion (reproduced with modifications from: Cochrane Database Syst Rev 2009).  Diagnosis During the diagnostic phase, it is essential to obtain a detailed medical history and perform a thorough physical examination. It is important to investigate how the even-tual fall happened in order to immediately identify any underlying pathological origin. Hip fractures are typically characterized by external rotation and shortening of the lower limb, associated with pain and in-ability to bear weight. However, impacted or non-displaced femoral neck fractures, as well as isolated fractures of the lesser or greater trochanter, can present as pain in the groin or trochanter area with no apparent deformity or functional impair-ment. In most cases, anteroposterior and lateral radiographs centered on the hip joint, together with an anteroposterior one of the entire pelvis, can be used to deter-mine the diagnosis. If physical examina-tion is inconclusive (presenting groin pain during mobilization of the hip without apparent cause), but radiographic findings result negative, a CT scan can be per-formed (1).   Treatment Treatment goals differ depending on the age of the patient. In fact, in younger pa-tients, the aim is to perform a reconstruc-tion that is as anatomically correct as pos-sible for an optimal functional recovery. In the elderly, however, treatment is aimed at mobilizing the patient as quickly as possi-ble, to avoid the risks related to prolonged bed rest (thromboembolic disease, urinary tract infections, hypostatic pneumonia and bedsores). When choosing the most appro-priate treatment approach, it is essential to take into account, apart from the age of the patient the type of fracture, keeping in mind that generally the prognosis of me-dial fractures is poorer than that of the lateral ones, due to the diverse vascularity of these two areas.  The femoral head in adults is vascularized by the intracapsular terminal branches of the lateral and medial circumflex femoral arteries, intraosseous vessels within the femoral neck and the round ligament ar-tery, which tends to become obliterated in the elderly. A medial fracture can disrupt intraosseous vessels and damage or compress intracap-sular vessels due to the pressure exerted by the hematoma. This causes a high risk of aseptic necrosis of the femoral head, especially if the fracture is displaced. Fur-thermore, medial  fractures, in  particular basicervical ones, occur in an area of corti-cal bone tissue with reduced repair poten-tial, with the consequent additional risk of delayed union and pseudarthrosis (2,5).  Treatment of impacted and compound medial fractures (Garden type I and II) The surgical treatment consists in reduc-tion and fixation, allowing for early mobili-zation and minimizing complications re-lated to prolonged bed rest; this has be-come the treatment of choice for femoral neck fractures, with the exclusion of pa-tients with high surgical risk.  Surgical approach options:  -  Osteosynthesis  with  cancellous  bone screws: a non-displaced or valgus impacted fracture should be stabilized with internal fixation by three parallel cancellous bone screws. - Sliding screw plate: this has greater bio-mechanical stability compared to cancel-lous bone screws and minimizes the risk of a  subsequent  subtrochanteric  fracture, linked  to  the  concentration  of  tensile stress, in addition to offering the possibil-ity to compress the fracture at the time of reduction. The disadvantages include: the requirement for a larger surgical access, and the chance of causing a poor rota-tional alignment of the femoral head upon insertion of the screw. Treatment of displaced medial fractures (Garden III and IV) The treatment of these fractures consists in partial or total hip replacement, depend-ing on the more or less advanced age of the patient. In older subjects, the replace-ment of the femoral epiphysis with a pros-thesis may be sufficient (Figure 4): in order to reduce hypermobility and friction at the interface between the metal head of the prosthesis  and  the  acetabular  articular cartilage, that causes a progressive dete-rioration of the latter, bi-articular prosthe-ses may be employed. These are equipped with a second articulation inside the head. If life expectancy is still relatively long, it is preferable to use a total hip prosthesis (5). In  younger  patients  (under  60 years  of age), fracture reduction followed by osteo-synthesis with multiple screws should be attempted in order to preserve the natural articulation.   GALLO ET AL., p.57 EMBJ, 7(12), 2012 — www.embj.org Treatment of lateral fractures  Lateral fractures are extracapsular and located in an area of cancellous bone with high repair capabilities: aseptic necrosis and non-union are thus very rare. There-fore, these fractures are treated with re-duction and internal fixation. In the case of stable fractures, basicervical or pertro-chanteric fractures with two fragments, sliding screw plates are recommended. In unstable fractures, with multiple frag-ments and disruption of the medial wall or reverse obliquity, cephalomedullary distal locking screws are preferred (Figure 5); their use allows obtaining a greater stabil-ity with osteosynthesis, enabling immedi-ate mobilization and full weight bearing (6). An intramedullary prosthesis has sev-eral advantages: this type of implant offers a more efficient load distribution than a sliding plate device; reduction of tension on the implant, thanks to the shortened lever arm, with a consequent decrease in the risk of failure. The insertion of the intramedullary implant requires less time and causes less soft tissue damage, thus reducing morbidity. More specifically, a study by Audige, Hanson and Swiont-kowski, comparing intramedullary systems involving single or double cephalic screws, concluded that there are significant differ-ences in terms of recovery and healing. Cut-out phenomena are more common with the single screw device, while secon-dary varus angulation was more common with the double screw implant (7).  Complications Fracture of the femoral neck is one of the leading  causes  of  death  in  the  elderly (Figure 6). The mortality rate in such pa-tients varies from 14 to 30% during the first year, whilst after the first year, the mortality rate approaches that of the simi-larly aged population (8-11). The risk of death is greater in the perioperative pe-riod, and gradually decreasing with time; however, it still remains high during the first six months following surgery (11). A serious complication with a high mortality rate associated with femoral neck fractures is  pulmonary  embolism  resulting  from deep vein thrombosis. Post-operative infec-tion incidence varies from 2 to 20% (12).  When medial fractures are treated by inter-nal  fixation,  pseudarthrosis,  malunion, aseptic necrosis of the femoral head, pain and arthritis may occur. The incidence of secondary displacement or pseudarthrosis during the first two years following osteo-synthesis of a displaced medial fracture of the femoral neck has been estimated at between 5 and 37% (1). In younger sub-jects, it is 5-15%, while in patients aged over 80 years, the incidence is  25-30% (13). Necrosis of the femoral head during the first two years following osteosynthesis occurs in approximately 7-24% of patients (1, 8). In case of joint replacement, disloca-tion or loosening of the implant can occur (table 1).  In lateral fractures, the incidence of failure of fixation reaches 20% in unstable frac-EMBJ, 7(12), 2012 — www.embj.org Figure 4:  Biarticular endoprosthesis.  PROXIMAL FRACTURES OF THE FEMUR, p.58 Figure 5:  Endovis implant: double parallel cephalic screws.  tures. Failure of sliding compression screw plates  or  intramedullary  nail  devices  is commonly characterized by a varus col-lapse of the proximal femoral fragment and a subsequent cut-out of the cephalic screw from the femoral head. Nonunion following the surgical treatment of a per-trochanteric fracture occurs in less than 2% of patients (12, 14); this is due to the fact that these fractures are located in well-vascularized  cancellous  bone.  The  inci-dence of nonunion is rather high in unsta-ble lateral  fractures. The most  frequent cause of malrotation deformity presenting after the fixation of a pertrochanteric frac-ture is internal rotation of the distal frag-ment during surgery, while osteonecrosis of the femoral head is rare in this type of fracture (12).   Conclusions These fractures represent a major health complication in developed countries, where prevention is a key health care objective. The aim of treatment is to restore to often elderly patients, a function and a motion range as similar as possible to his/her pre-fracture abilities, using the least aggres-sive  approach  possible,  in  the  shortest possible  time,  and  as  economically  as possible. Understanding and identification of risk factors for each individual patient allows  the  application  of  personalized treatment plans, and can lead to a more favorable end result. The current  differ-ences in treatment reflect the lack of ade-quate  evidence  on  the  benefits  of  one treatment approach over another, as well as diverse clinical experience, approaches and cultural preferences of the health care professionals.   References 1. Scheerlinck T, Haentjens P: Fractures de l'extrémité supérieure du fémur chez l'adulte, Cap. 14, Edition Scientifiques et Médicales Elsevier SAS (Paris), 2003. 2. Grassi F A, Pazzaglia U, Pilato G, Zatti G: Manuale di ortopedia e traumatologia, Cap. 17, Elsevier Masson, 2007. 3. Müller ME, Nuzarian S, Koch P, Schotz-ker J: The comprehensive classification of fractures of long bones, Springer-Verlag, 1990. 4. Blundell CM, Parker MJ, Pryor GA, Hop-kinson-Woolley J, Bhonsle SS: Assessment of the AO classification of intracapsular fractures of the proximal femur. J Bone Joint Surg Br 1998; 80:679-683. 5. Benazzo F, Ceccarelli F, Cerulli G, D'Ari-enzo M, De Palma L, Franchin F, Gatto S, Guzzanti V, Mora R, Patella V, Ronca D, Rosa M A, Sessa G, Tarantino U, Villani C: Ortopedia e Traumatologia, Cap. 54, Mon-duzzi Editore, 2010. 6. Kuntscher G: Trocanter implantation by means of straight intermedullary nailing of the femur. Z Orthop Ihre Grenzgeb 1957; 89:406-409. 7. Audige L, Hanson B, Swiontkowski MF: Implant related complications in the treat-GALLO ET AL., p.59 EMBJ, 7(12), 2012 — www.embj.org Figure 6:  High mortality rates: up to 35% during the first year. High morbidity rates: losing self-sufficiency and need for assisted living arrangements for over one year in 25% of patients. Of all fractures, femur fractures have the greatest prog-nostic impact (reproduced with modifica-tions from: Journal of the American Geri-atrics Society 2003).  Complications of femoral  neck fractures Early  complications Late  complications Mortality Pseudarthrosis Infection Aseptic necrosis Deep vein  thrombosis, with or without pulmonary embolism Heterotopic  ossification Dislocation Persistent pain Table 1:  Early and late complications of femoral neck fractures.  ment  of  unstable  intertrochanteric  frac-tures:  meta-analysis  of  dynamic  screw plate versus dynamic screw-intramedullary nail devices. Int Orthop 2003; 27:197-203. 8.  Lu-Yao GL, Keller RB, Littenberg B, Wennberg JE: Outcomes after displaced fractures of the femoral neck: a meta-analysis of one hundred and six published reports. J Bone Joint Surg Am 1994; 76:15-25. 9. Nilsson LT, Johansson A, Strömqvist B: Factors predicting healing complications in femoral neck fractures: 138 patients fol-lowed for 2 years. Acta Orthop Scand 1993; 64:175-177. 10. Nilsson LT, Strömqvist B,Thorngren KG: Nailing of femoral neck fracture: clinical and sociologic 5-year follow-up of 510 consecutive hips. Acta Orthop Scand 1988; 59:365-371. 11. Ohman U, Bjorkegren N, Fahlstrom G: Fracture of the femoral neck. Acta Chir Scand 1969; 135:27-42. 12. Heckman, Bucholz, Court-Brown:  Rock-wood & Green's fractures in adults, Cap. 44, Lippincott, Williams & Wilkins, 2009. 13. Parker MJ: The cervical hip fracture. Eur Instr Course Lect 2001; 5:67-77. 14.  Altner PC. Reasons for failure in treat-ment of intertrochanteric fractures. Orthop Rev 1982; 11:117. PROXIMAL FRACTURES OF THE FEMUR, p.60 EMBJ, 7(12), 2012 — www.embj.org 

Fractures of the proximal extremity of the femur: current diagnostic and therapeutic classification overview.

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Fractures of the proximal extremity of the femur: current diagnostic and therapeutic classification overview.

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