Hip Fracture (Femoral Neck and Intertrochanteric)
Hip fractures are common in elderly patients with osteoporosis, typically resulting from low-energy falls. The blood supply to the femoral head makes fracture location critical: femoral neck fractures risk avascular necrosis, while intertrochanteric fractures generally preserve blood supply but are highly unstable.
Anatomical Basis
The femoral head receives blood supply primarily from the medial and lateral circumflex femoral arteries, which form a ring at the base of the femoral neck and send retinacular vessels along the neck to the head. Intracapsular fractures (femoral neck) disrupt these vessels, risking avascular necrosis. Extracapsular fractures (intertrochanteric) preserve blood supply.
Relevant Structures
Mechanism
Low-energy fall in elderly patients with osteoporosis (90%). High-energy trauma in young patients. Risk factors: Osteoporosis, female sex, advanced age, fall risk factors, prior hip fracture, malnutrition, vitamin D deficiency.
Clinical Presentation
- âĒHip or groin pain after fall
- âĒUnable to bear weight
- âĒLeg shortened and externally rotated (classic position)
- âĒMay have pain with axial loading or log roll
- âĒElderly may present with vague symptoms (confusion, decreased mobility)
- âĒImpacted fractures may have minimal displacement and ambulatory patient
Physical Examination
- âShortened, externally rotated leg (unopposed pull of iliopsoas and gluteals)
- âInability to straight leg raise
- âPain with hip motion, especially internal rotation
- âTenderness over greater trochanter or groin
- âAssess for other injuries (wrist, spine, head)
- âComplete neurovascular exam
Treatment
- âFemoral neck, non-displaced: Internal fixation (cannulated screws or sliding hip screw)
- âFemoral neck, displaced (elderly): Hip arthroplasty (hemi or total)
- âFemoral neck, displaced (young): Open reduction internal fixation (ORIF) to preserve native hip
- âIntertrochanteric: Sliding hip screw or cephalomedullary nail (e.g., IMHS)
- âMedical optimization: DVT prophylaxis, pain control, early mobilization
- âSurgery within 24-48 hours associated with better outcomes
Prognosis
Significant morbidity and mortality in elderly. One-year mortality 20-30%. 50% do not return to prior functional status. Early surgery and mobilization improve outcomes. Young patients with preserved blood supply have better outcomes.
Study Tips
- ðĄFemoral neck = intracapsular = AVN risk (retinacular vessels disrupted)
- ðĄIntertrochanteric = extracapsular = blood supply preserved, but unstable
- ðĄGarden classification for femoral neck: I-II (non/minimally displaced), III-IV (displaced)
- ðĄShortened, externally rotated leg = classic presentation (iliopsoas pulls on lesser trochanter)
- ðĄMedial circumflex femoral artery is the primary blood supply to the femoral head
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Common questions about this condition
The femoral head receives blood supply primarily from the medial circumflex femoral artery via retinacular vessels that run along the femoral neck. Femoral neck fractures disrupt these vessels. Additionally, the fracture is intracapsular, so hematoma increases intracapsular pressure, further compromising blood flow.
After hip fracture, the iliopsoas (attached to lesser trochanter) pulls the distal fragment proximally, causing shortening. The gluteal muscles and short external rotators, which attach to the greater trochanter, rotate the leg externally. Without the intact neck to resist these forces, the leg assumes this characteristic position.