Proximal Femur Fractures
The femur is the bone in your thigh that runs from your pelvis to the knee.
It is the longest and, arguably, the strongest bone in your body.
For this reason, when younger people present to the hospital following an incident where they sustained a femur fracture, the injury often conveys to doctors that significant trauma was sustained during that event. Femur fractures in healthy young individuals are often associated with multiple, severe injuries elsewhere in the body.
In the older population, though, it often takes only a low-impact injury to cause a fracture of the proximal femur (‘proximal’ refers to the top part of the thigh bone).
A minor incident, such as bumping one’s hip on a kitchen counter, or a simple slip and Fall From Standing Height (FFSH), can cause a significant injury in ageing bones.
Often, due to the seemingly low-energy mechanism of injury, older individuals delay seeking medical care for days or even weeks after they have sustained a fracture to the femur.
The loss of function experienced from a femur fracture, left untreated, leads to serious disability and even loss of life. This due to pain, reduced mobility, weakness and loss of function.
It is important to seek urgent medical care if you suspect you or your loved one may have sustained a broken femur.
Is it possible for me to tell whether I have broken my hip after a fall?
You may experience pain in the groin or upper thigh. Sometimes this pain may radiate all the way down to the knee.
You may lose function the entire lower limb and/or be unable to stand on the limb.
If the fracture has caused the bone fragments to shift significantly, you may see the affected limb is shortened and one’s foot may be turned outward.
If a dislocation has occurred, the knee may even turn inward and the hip may remain flexed.
By definition, proximal femur fractures may occur at:
- The head of the femur
- The neck of the femur
- The trochanters of the femur (greater and lesser) or in between (intertrochanteric area)
- In the subtrochanteric area of the femur (5cm below the lesser trochanter)
Proximal femur fractures involve the upper part of the thigh bone. Intertrochanteric fractures run diagonally between the greater and lesser trochanter.
![Anatomy of the femur (front [anterior] and back [posterior]).](https://sportsorthopaedics.co.za/wp-content/uploads/2022/08/3.png)
What else should I know about the risk factors surrounding these types of fractures and their treatment?
Because these injuries may be complex or have such varying presentations clinically, it is important to seek early medical and orthopaedic attention – irrespective of the nature and severity of the trauma sustained.
While the risk accompanying surgery itself is high in an older population, the risk of severe complications and death from remaining bedridden or immobile for prolonged periods of time is often higher.
For this reason,surgery is often undertaken at the earliest opportunity.
Delays more than 48 hours from the time of injury are avoided where possible due to an association between delayed surgery and poorer postsurgical outcomes.
Proximal femur fractures in an older population are a red flag, and are considered a symptom of musculoskeletal organ failure. These fractures in older individuals are almost always diagnostic of osteoporosis.
Akin to conditions that set in in advanced age – such as dementia (neurological ageing) and high blood pressure (cardiovascular ageing) – proximal femur fractures herald a progressive loss of function and quality of life in the elderly.
Global studies show us that the risk of dying within a year of having sustained a proximal fracture is as high as 36% in an aging population.
Those who survive and recover are often met with chronic muscular weakness and loss of mobility and independence.
In light of these worrying outcomes, it is important to avoid these injuries altogether.
For suggestions on how to avoid these injuries, read on further below and hop over to read Dr Maina’s previous blog on sarcopenia.)
How will my diagnosis be confirmed?
Usually the description of your injury guides the doctor toward the likely diagnosis. Plain x-rays of the pelvis and entire femur should generally be sufficient to confirm the diagnosis.
At this point of your care, as a specialist orthopaedic surgeon, Dr Maina is usually called upon by the GP or casualty officer to assess you and take over your care.
Further investigations may be needed to better define the fracture pattern and/or rule out other injuries. This will help guide future treatment planning.
These investigations may include a CT scan (for better definition of the fracture fragments) or an MRI (providing an MRI is safe for you) – if a stress fracture is suspected.
How serious is a proximal femur fracture? And how do you treat it?
Usually femur fractures result in significant blood loss. Monitoring and treating this means that you will require immediate admission to the hospital.
The admission staff will insert an intravenous line (for fluid administration) and will draw blood for basic heamatological investigations at the lab. Additional vials of blood may be drawn to establish whether your pre-existing medical conditions are under control (if you have any).
You may be required to stop or substitute some of your chronic medications if it is unsafe to continue these medications prior to surgery.
Immediate fracture treatment includes the use of weighted skin traction attached to a special orthopaedic bed with pulleys to minimize muscle spasms, pain and movement at the fracture site.
While confined to bed, in the presence of a long bone fracture, you are at high risk of developing a blood clot (also known as a deep vein thrombosis – DVT). This clot, untreated could expand or move resulting in life-threatening complications.
The condition where blood clots can be found in the lungs is known as a pulmonary embolism (PE). Symptoms of a PE include an acute onset of shortness of breath, chest pain and coughing (sometimes with blood) among other symptoms.
The Gold Standard of DVT prevention includes a combination of mechanical and chemical interventions. An above knee compressive TED (thromboebolic deterrent) stocking will be applied to your lower limbs and you may be placed on a calf pump machine.
You will also receive anticoagulant injections daily to keep your blood thin. Prior to surgery, anticoagulants are stopped for a few hours to reduce your risk of excessive bleeding during and immediately after surgery.
Both during your hospital stay, and after your discharge, you will need to continue taking measures that will minimize your risk of blood clots. This includes administering injections or tablets to thin your blood until you are more mobile.
Other investigations may be carried out, including an electrocardiogram (ECG) to assess your heart function and a chest x-ray. Additional imaging will be requested in keeping with your associated injuries and medical conditions.
Often, in people who have sustained major injuries, a trauma surgeon is involved.
Trauma surgeons take charge and oversee the roles and responsibilities of the various specialists, therapists and allied healthcare professionals caring for you. Trauma surgeons also conduct some of the life-saving surgeries and interventions required of multiply injured patients.
The physician in the mutlidisciplinary team is responsible for optimizing your medical condition as well as in managing your perioperative care (the time before and after surgery) in the ward or the High Care/ICU. The physician’s assessment of your clinical risk (if any) is important in surgical and anaesthetic planning .
After your surgery, you will need physiotherapy. The physio will teach you how to safely conduct exercises – important in avoiding joint stiffness and muscle weakness. The physio will also need to help you relearn how to ambulate and will assess what walking aids are best for you.
Although it may look easy, using a walking aid can be a steep learning curve. Weight bearing restrictions may also make mobilizing difficult or risky. Not using a walking aid correctly/inappropriate walking aids may lead to falls and/or other injuries.
The physiotherapist is a highly knowledgeable and vital member of the team who is essential in ensuring that any surgical interventions are successful. They will help you overcome the challenges of pain and stiffness and help build back your confidence and manage your fear of falling.
You will also receive antibiotics at the time of your surgery. This is usually administered to manage the risk of infection from colonization with the normal skin flora that may enter the soft tissues at the time of your injury or surgery.
Other treatments that may be included in your care may include a blood transfusion should you be found to have a low blood haemoglobin (Hb) before or after surgery. Transfusions are not without risk. Blood, although tested for common communicable diseases, may still transmit infection, therefore, blood is only transfised when absolutely necessary, in order to avoid serious complications. This is because a low Hb increases the working effort of the heart and compromises the flow of oxygen and nutrition to the vital organs.
A low Hb may cause dizziness, increasing the risk of falling when one becomes ambulant. A low Hb in someone with a preexisting cardiac condition may lead to cardiac failure and decompensation. This can be life-threatening. For this reason, Hb values are regularly checked throughout the perioperative period.
Head of femur fractures
Depending on the fracture pattern and location of the fracture fragments, head of femur fractures are sometimes treated with rest and physiotherapy.
Dr Maina will usually request a CT scan for these types of fractures in order to make an appropriate clinical decision on whether surgery is needed.
Large fracture fragments can block movement at the hip or have the potential to lead to bone death if untreated. Where indicated, Dr Maina will perform a surgical dislocation of the hip joint and Open Reduction and Internal Fixation (ORIF) of this fracture pattern in order to save the femoral head.
Neck of femur fractures
Neck of femur fractures are almost always treated with surgery.
This takes the form of either Closed Reduction and Percutaneous Pinning (CRPP), ORIF and/or a hip replacement.
In a younger population, this fracture pattern is usually stabilized with several screws (cannulated screws or dynamic hip screw) via a CRPP or ORIF procedure. There is, however, a risk of bone death if the blood vessels running along the neck of the femur were also damaged during the intial injury. This bone death is called avascular necrosis (AVN) and is usually assessed on x-ray several months to years after the accident.
A CRPP/ORIF is done in the hopes that this surgery will offer the younger, active individual the chance to preserve their own native, original bone. This is because there are significant concerns associated with the durability of joint replacement in young, active individuals.
Aside from AVN, an additional risk of preserving the femoral head includes the likelihood that the fracture may not heal and unite. This is because synovial fluid (the natural lubricant within the joint) is known to prevent fracture healing.
If a fracture fails to unite, this may lead to failed fracture fixation, resulting in movement of fragments at the fracture site, broken implants and pain. This usually requires further surgery to address.
In older adults, a hip replacement is recommended. This is because older populations have a diminished potential for fracture healing following injuries at this part of the femur. This may take the form of a total or partial hip replacement (hemiarthroplasty) depending on one’s age, mobility and other risk factors.
In virtually all – except the severely ill or injured individuals, surgery is recommended in order to provide the individual with early and eventually pain-free mobility.
CRPP with three cannulated screws and a dynamic hip screw used in an ORIF (pictured left and second from left) are used in younger individuals for the treatment of neck of femur fractures. Intertrochanteric fractures (pictured center) are best treated using cephalomedullary nails. Hip replacements (hemiarthroplasty and a total hip replcament – pictured second from right and extreme right, respectively) are used to treat neck of femur fractures in older population groups .
Intertrochanteric and subtrochanteric fractures
These fractures also almost always require surgery unless otherwise dictated by one’s poor clinical condition.
This involves the use of a strong nail placed within the bone (cephalomedullary nail) that stabilizes the head and neck of the bone to the rest of the femur shaft.
How do I know if what my risk factors are for a hip fracture? And how can I limit the chances of getting a proximal femur fracture?
Prevention is better than the cure. In fact, the best way of reducing fracture risk in old age is increased physical and outdoor activity as a child and young adult.
Modifiable risk factors such as generalised weakness and loss of muscle mass can be addressed through regular resistance training and exercise programmes. This in turn improves balance, mobility and bone density, resulting in improved stamina and a better managed risk of falls.
Supplements and the treatment of known conditions that cause decreased bone density also helps reduce the risk of fractures.
High dose Vitamin D and calcium supplementation may be useful in certain individuals. Medications such as hormone supplements and hormone replacements may also increase bone density.
Decreasing bone mass can be proactively assessed through investigations like regular bone density scans. Should your bone density scan demonstrate a risk of osteoporosis, treatment is usually initiated by a physician and/or endocrinologist. However these medications cannot be taken for a long time due to their side effects and risks.
This class of drug is known as bisphosphonates {pronounced: buh – sfo – fo – nayts} inhibits the function of cells that resorb bone. This in turn diminishes the progressive nature of osteoporosis. However, bisphosphonates have paradoxically been found to be associated with ‘atypical femur fractures’. For this reason, they cannot be taken over a prolonged amount of time. Repeat bone density scans are often required to assess the effectiveness of treatment and to guide when to start ones ‘bisphosphonate holiday’.
The use of walking aids and other assistive devices (handrails, etc.) also reduce ones risk of a fall.
Education at all ages helps minimize risk.
In younger individuals safe driving habits and/or defensive driving techniques may help avoid high energy accidents. Avoiding alcohol/recreational substances before operating motorized vehicles also reduces one’s risk.
Safety gear and well-established safety checks when participating in extreme sports also decreases one’s risk.
‘Fall assessments’ in the homes of older adults may help limit the likelihood of a fall. Items like loose carpets, clutter, slippery floors and bulky pieces of furniture can catch one unawares, resulting in avoidable injury. Sharp countertops may need padding, anti-slip flooring may need to be installed and handrails may be helpful in the bathroom and along stairwells.
Unfortunately there are several factors that cannot be modified, such as ones age, conditions that impair cognition (dementia) and so forth.
Certain chronic medications are also known increase one’s risk of a proximal femur fracture as they are known to decrease bone density.
Other chronic medications may impair cognition (sleeping tablets) or cause dizziness. It is important to discuss these risk factors and the side effects of your medication regularly with your GP or physician.
Dizzy spells may have many causes. These range from conditions such as heart disease, ear conditions and neurological conditions. The onset of dizziness should be met with early investigation and treatment in order to reduce avoidable injuries.
What makes proximal femur fractures so important to treat and such a challenge to recover from?
Fractures of the lower limbs in general have a significant negative impact on how one moves and cares for themselves. Loss of mobility is a massive blow on one’s level of independence, and leads to a decreased quality of life and may even cause depression.
Fractures of the proximal femur affect even basic activities of daily living – such as relieving oneself, basic care and hygiene and even sitting up in a chair.
The immobility that comes about from sustaining such an injury causes sluggish blood flow in ones legs. This, and the presence of a fracture, creates the perfect environment for the formation of blood clots (DVT). These clots can cause pain, swelling and may even spread to the lungs or other vital organs, blocking blood flow.
Swelling of the lower limb may remain for several months. This is normal. However, one’s threshold for ‘suspicious swelling’ should remain high. The symptoms of a DVT (swelling, pain and
inflammation of the calf, back of knee and groin area) need further investigation and emergency treatment.
Older patients will often require walking aids for a prolonged amount of time and lose the confidence and/or ability to resume their previous levels of activity and independence. This increased dependency may result in one’s loss of privacy. They may also have to incur the expense of an at-home caregiver, or that of having to move into an assisted living facility or back in with family.
Conclusion
The care of proximal femur fracture patterns requires the involvement of multiple medical disciplines. Dr Maina will conduct an assessment of your individual risks and needs, and will also guide your therapists on your rehabilitation protocol and follow up of your postoperative care.
It is important to continue with physiotherapy until your therapist is happy with your progress and mobility. The therapist will communicate regularly with Dr Maina on your progress.
Individuals who are unable to complete therapy and exercises remain at high risk of long-term (and sometimes permanent) loss of function and weakness.
Dr Anne Maina
Specialist Orthopaedic surgeon
MBBCh (Wits), FC Orth (SA), MMed Ortho (Wits) CIME
References:
- Moira Davenport, MD; Chief Editor: Trevor John Mills, MD, MPH. Hip Fracture in The ED. Updated: Aug 21, 2021. Accessed: 6 Aug 2022. Available from: https://emedicine.medscape.com/article/825363-overview
- Lloyd AA, Gludovatz B, Riedel C, Luengo EA, Saiyed R, Marty E, Lorich DG, Lane JM, Ritchie RO, Busse B, Donnelly E. Atypical fracture with long-term bisphosphonate therapy is associated with altered cortical composition and reduced fracture resistance. Proceedings of the National Academy of Sciences. 2017 Aug 15;114(33):8722-7. Accessed: 6 Aug 2022. Available from: https://www.pnas.org/doi/10.1073/pnas.1704460114
