Proximal Femur Fractures

Jeffrey Shyu, MD
 Learning Objectives
Disclosures
Learning
Objectives
Organization Provide an intuitive understanding of the
Anatomy
Imaging morphologic types, injury mechanisms, and
Osteochondral
Subchondral classification systems of adult proximal femur
Femoral Neck
Intertrochanteric fractures, using multimodality imaging
Greater Troch.
Lesser Troch. examples, 3-D models, and animations.
Subtrochanteric
Conclusion
References

Review the potential complications and

management.
 Proximal Femur Fractures:
Organization Tree
Proximal femur fractures may be divided into femoral head, intracapsular femoral neck, and
Disclosures
extracapsular fractures. Accurately categorizing the anatomic location and subtype of the
Learning
fracture has significant implications for surgical management.
Objectives
Organization
Anatomy
Imaging Proximal Femur Fractures
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch. Femoral Head Intracapsular Extracapsular
Lesser Troch.
Subtrochanteric
Conclusion
Intertrochanteric
References
Subcapital
Osteochondral
Greater Trochanter
Transcervical
Subchondral Lesser Trochanter

Basicervical*
Subtrochanteric

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

 Proximal Femur Fractures
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References

subtrochanteric
greater
lesser trochanter fracture
osteochondral
subcapital
intertrochanteric
subchondral
basicervical
transcervical fracture
fracture
 Anatomy
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References

MOVIE: Computer generated tour of the relevant muscular, ligamentous, labral, and bony
anatomy of the hip.
 Anatomy
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
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

 Anatomy: Arterial Supply
Disclosures
Learning
Medial femoral circumflex artery
Objectives Largest, most important contributor
Obdurator art.
Organization Posterior portion of vascular ring
Anatomy Supplies superolateral femoral head
Imaging
Osteochondral
Subchondral Lateral femoral circumflex artery
Femoral Neck Anterior portion of vascular ring
Intertrochanteric Supplies inferoanterior femoral head
Med. fem
Greater Troch. circumflex
Lesser Troch.
Subtrochanteric
Lat. fem
circumflex Ascending cervical arteries
Conclusion Feeder vessels arising from extracapsular ring
Deep femoral
References art. 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 Obdurator artery
avascular necrosis. In fractures, the Via ligamentum teres
intraosseous cervical vessels are Little supply to femoral head, inadequate in
disrupted. setting of displaced head/heck fractures

Trueta J et al. J Bone Joint Surg BR 1953; Ly TV et al. J Boint Joint Surg Am 2008.
 Anatomy: Stress Lines
Disclosures
Learning
Objectives
Organization
Hip experiences combined
Anatomy mechanical loads
Imaging Axial load along shaft, compressive stress
Osteochondral Bending load along neck, tensile stress applied
Subchondral at upper neck and compressive stress at lower
Femoral Neck neck
Intertrochanteric
Greater Troch. Cancellous bone arranged along
Lesser Troch.
Subtrochanteric
principal lines of stress
Conclusion Wards Triangle Primary medial trabeculae resist compression
References Primary lateral trabeculae resist tension

Stress lines explain patterns of injury

Tensile group
Compressive
Wards Triangle: Weakest point of
femoral neck

Byrne DP et al. The Open Sports Medicine Journal 2010; Bowman KF Arthroscopy 2010.
 Imaging Modalities
Disclosures
Learning
Objectives Plain Film Radiography
Organization First line study
Anatomy 90% sensitive, however 2-11% of ED patients
Imaging have radiologically occult fractures
Osteochondral
Subchondral AP and lateral radiographs of the hip
Femoral Neck AP radiograph of the pelvis, to assess for
Intertrochanteric pelvic injury and compare with contralateral
Greater Troch. hip
Lesser Troch.
Subtrochanteric
Conclusion CT
References 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 Coronal CT demonstrates a valgus impacted
femoral neck fracture
May be useful for preoperative evaluation

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
 Imaging Modalities
Disclosures
Learning MRI
Objectives Obtain if radiographs are negative/equivocal and clinical suspicion is high
Organization More sensitive than CT for evaluating occult fractures
Anatomy Best for evaluating bone marrow, joint space, osteochondral injuries, early diagnosis
Imaging and staging of AVN
Osteochondral May be limited in access in an acute ED setting
Subchondral
Femoral Neck Technique: Useful MR sequences include the following: coronal STIR, coronal T1, axial
Intertrochanteric dual-echo, axial T2 fat-saturated FSE, axial fat-saturated FSE proton density, sagittal
Greater Troch. T1, axial T1.
Lesser Troch. Most useful sequences are coronal STIR (for edema) and coronal T1 (for fracture line)
Subtrochanteric
Conclusion
References
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

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
 Occult Femoral Neck Fracture
Seen Only on MRI

Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References

AP radiograph of the hip demonstrates no On coronal T1 MRI, a hypointense fracture

evidence of fracture. line is present.

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

Dominguez S et al. Acad Emerg Med 2005

 Traumatic Femoral Head
(Osteochondral) Fractures
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References

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

 Femoral Head Fractures:
Pipkin Classification
Most commonly used classification for femoral head fractures, and used to guide
Disclosures
operative versus nonoperative management
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch. Posterior dislocation Posterior dislocation
Subtrochanteric Fracture below fovea, non-weight-bearing Fracture above fovea, weight-bearing
Conclusion
References

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

Rockwood and Greens Fractures in Adults 2010; Ross JR et al. Curr Rev Musculosk Med 2012
 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 subfoveal Femoral head fracture with posterior dislocation
involvement (Pipkin I)
 Traumatic Femoral Head Fractures:
Surgical Considerations
Disclosures Intra-capsular fracture, concern for avascular necrosis
Learning Emergent closed reduction as soon as feasible, preferably within 6 hours
Objectives
If irreducible, or with femoral neck fracture, then ORIF
Organization
Anatomy
Imaging Above or below fovea?
Osteochondral Above fovea, weight bearing
Subchondral Below fovea, non-weight bearing, could potentially be treated conservatively
Femoral Neck
Intertrochanteric
Greater Troch. Is traction indicated?
Lesser Troch. If fracture flipped, then traction indicated
Subtrochanteric
Conclusion
References 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 Greens Fractures in Adults 2010; Ross JR et al. Curr Rev Musculosk Med. 2012
 Subchondral Insufficiency
Versus Osteonecrosis
Subchondral insufficiency fractures are a recently recognized entity that may mimic osteonecrosis of the
Disclosures femoral head. However, certain clinical and imaging features will favor one diagnosis over the other.
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
A B
Greater Troch.
Lesser Troch. Subchondral Insufficiency: coronal STIR (A) demonstrates Osteonecrosis: coronal T1: bilateral decreased T1 signal in the femoral
irregular band parallel to the femoral head. Post-contrast T1 heads, and serpiginous bands concave to articular surface
Subtrochanteric image (B) in a different patient demonstrates femoral head
Conclusion enhancement
References
Subchondral Insufficiency Osteonecrosis
Biphasic pattern: elderly females and young active individuals Typically 30s-40s in age
Typically unilateral Associated with steroid/alcohol use
50-70 percent bilateral
MRI
Irregular, hypointense disconnected band that runs almost MRI
parallel to femoral head T1: Smooth band that is concave to the articular surface,
High signal proximal segment on C+ images and circumscribes necrotic segments

Treatment Treatment
No femoral head collapse No femoral head collapse: conservative treatment
Young: Trochanteric rotational osteotomy Femoral head collapse: THA or hemiarthroplasty
Elderly: THA or hemiarthroplasty

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

 Femoral Neck Fracture:
Mechanism
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References

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
 Subcapital, Transcervical,
Basicervical Fractures
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References

Subcapital Transcervical Basicervical

Treated as intracapsular fx Treated as intracapsular fx Treated as extracapsular fx
e.g. like intertrochanteric fx
 Garden Classification
Disclosures
I II
Learning
Objectives
Organization
Anatomy
Imaging Commonly used classification for
Osteochondral surgical management of femoral
Subchondral neck fractures
Femoral Neck
Intertrochanteric Valgus impacted fractures are
Incomplete Complete, non-displaced
Greater Troch. often missed
Valgus impaction + retroversion
Lesser Troch.
Subtrochanteric Good interobserver agreement
III IV
Conclusion between I-II and III-IV, but poor
References between all groups

Better to distinguish I-II and III-IV,

as types III and IV typically treated
with arthroplasty

Marked angulation Complete displacement

Minimal/no proximal translation Proximal translation

Frandsen PA et al. Acta Orthop Scand 1984; Kreder HJ J Bone Joint Surg AM 2002
 Pauwel Classification
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
Type I Type II Type III
More stable Most common More 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

 Types of Stress Fractures
Femoral neck stress fractures are often related to increased activity. The
Disclosures
pattern of the stress fracture relates to the lines of stress within the
Learning
Objectives
proximal femur and has significant management implications
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References

Tensile Compressive Displaced

Unstable, fracture can More stable Unstable
propagate Worse prognosis and risk for
avascular necrosis
Emergent operation and reduction
 Femoral Neck:
Tensile Stress Fracture
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References

Tensile Stress Fracture

Superior, 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

Tensile stress fracture in the superolateral Tensile stress fracture (Garden III) in the
femoral neck in an elderly patient. Note superolateral femoral neck in a young, active,
osteoarthritis of the hip. patient. Note the normal bone mineral density.

Bimodal distribution: elderly individuals and young runners

 Femoral Neck:
Fatigue Compression Fracture
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References

Coronal STIR image demonstrates edema at the Coronal T1 image demonstrates a hypointense
inferomedial femoral neck. region and a subtle fracture line.

Fatigue Compression Fracture

Inferior aspect of femoral neck
Active individuals
May potentially be treated non-operatively
 Femoral Neck Fractures: Surgical
Considerations
Disclosures
Learning
Objectives
Organization
AVN, nonunion may result from delayed diagnosis
Risk for AVN is greater for femoral neck fractures than for pertrochanteric fractures
Anatomy
Imaging
Osteochondral Young ( < 65) and/or active
Subchondral Goal: preserve femoral head, avoid osteonecrosis, achieve union
Femoral Neck
Intertrochanteric
Greater Troch. Old ( > 75) and/or immobile
Lesser Troch. Goal: restore mobility and minimize complications
Subtrochanteric
Conclusion
References
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
 Femoral Neck Fracture:
Treatment Algorithm
Disclosures Young Old
Learning
Objectives
Organization
Anatomy
Imaging Nondisplaced
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric Percutaneous Cancellous (PC) Screw PC Screw or Arthroplasty
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References

Displaced

Total Hip Arthroplasty

Open Reduction Internal Fixation
Hemiarthroplasty

Miler BJ et al. J Bone Joint Surg Am 2013

 Intertrochanteric Fracture

Disclosures Anatomy
Learning Intertrochanteric line: anterior ridge between greater and lesser trochanters
Objectives Extracapsular, transition between femoral neck and shaft
Organization Iliofemoral ligament attaches above, vastus medialis attaches below
Anatomy
Imaging
Osteochondral Mechanism
Subchondral Resulting from fall
Femoral Neck
Intertrochanteric
Greater Troch.
Unstable features
Lesser Troch. Loss of medial buttress
Subtrochanteric 4-part fractures, and 3-part fractures with
Conclusion lesser trochanter involvement
References Reverse obliquity
Comminution

Stable features
Near anatomic reduction achievable
Lesser trochanter nondisplaced
Medial cortices in alignment
No comminution
Nondisplaced Intertrochanteric fracture (Evans I)

Koval KJ et al. J Am Acad Orthop Surg 1994

 Evans Classification
Useful for deciding stability and treatment of intertrochanteric fractures. Also, reverse obliquity
Disclosures fractures are unstable and treated like subtrochanteric fractures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
I II III
Greater Troch.
Lesser Troch. Two part, undisplaced Two part, displaced Three part, posterolateral comminution
Subtrochanteric Stable Stable Unstable
Conclusion
References

IV V
Three part, posteromedial comminution Four Part
Unstable Unstable

Trafton PG. Orthop Clin North Am 1987; Koval KJ et al. J Am Acad Orthop Surg 1994
 Intertrochanteric Fracture:
Management
Disclosures Management depends on completeness and stability
Learning
Risk of AVN and nonunion less than in femoral neck fractures
Objectives
Organization
Again, basicervical fractures treated like intertrochanteric fractures
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References

Complete Incomplete
Stable: Dynamic plate and screw Obtain MRI to ensure fracture not complete
Unstable or reverse obliquity: If incomplete and <50% fracture width,
Intramedullary device potentially can treat conservatively
Risk of fracture completion

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

 Greater Trochanter Fracture

Disclosures
Learning
Objectives
Organization Anatomy
Anatomy Greater trochanter is the insertion site for hip
Imaging abductors (gluteus medius and minimus) and
Osteochondral external rotators (piriformis, gemelli, obdurators)
Subchondral
Femoral Neck
Mechanism
Intertrochanteric
Isolated greater trochanter fracture may be related
Greater Troch.
to impaction from fall, versus avulsion
Lesser Troch.
Subtrochanteric
Conclusion Imaging
References If incomplete, obtain MRI to assess extent of
fracture

Management
Most heal well with nonoperative management
If significant displacement, then ORIF
 Lesser Trochanter Fracture

Disclosures
Learning
Objectives
Organization Anatomy
Anatomy Lesser trochanter is attachment site for iliopsoas
Imaging
Osteochondral Mechanism
Subchondral Fracture may be due to avulsion
Femoral Neck In the absence of injury, isolated lesser
Intertrochanteric trochanter fracture is highly suspicious for an
Greater Troch. underlying malignancy
Lesser Troch.
Subtrochanteric
Imaging
Conclusion
Obtain MRI to assess extent of fracture
References
Evaluate for underlying malignancy

Management
Nondisplaced fractures heal well with
Mildly displaced lateral trochanter fracture nonoperative management
in a patient with prostate cancer and
If significantly displaced, then ORIF
diffuse blastic metastases. Also note the
extensive periosteal reaction.

James SL et al. Eur Radiol 2006

 Subtrochanteric and Proximal Femoral Shaft:
Traumatic Versus Atypical Fractures

Disclosures
It is important for the radiologist to recognize the different patterns of traumatic and
Learning
atypical subtrochanteric and proximal shaft fractures
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References Typical Fractures Atypical Fractures
Often traumatic, high impact Long-term bisphosphonate usage, o/minimal trauma

Imaging Imaging
Radiographs generally diagnostic Typically subtrochanteric or femoral shaft
Oblique or spiral in orientation Transverse or short oblique orientation
Proximal piece is flexed, abducted, and externally rotated Lateral beaking (arrow)
MR/CT if concern for pathologic fracture Normal bone mineral density

Management Management
ORIF Evaluate contralateral femur
Higher rates of failure due to high stress anatomy Treat with ORIF, intramedullary nail and screw0

Shane E et al. J Bone Miner Res 2010. Park-Wyllie LY et al. JAMA 2011
 Conclusion
Disclosures
Learning
Proximal femoral fractures can be classified as
Objectives femoral head, intracapsular, and extracapsular
Organization
Anatomy
Imaging
Osteochondral Increased concern for AVN and nonunion for
Subchondral
Femoral Neck intracapsular fractures due to vascular compromise
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric Important to understand how imaging features reflect
Conclusion
References
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
 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
Disclosures
Ly TV, Swiontkowski MF. Treatment of femoral neck fractures in young adults. J Bone Joint Surg Am. 2008;90:2. 254-66
Learning Byrne DP et al. The Open Sports Medicine Journal 2010;4;51-7.
Objectives 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
Organization standard radiographsa 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.
Anatomy
Kirby MW, Spritzer C. Radiographic detection of hip and pelvic fractures in the emergency department. AJR Am J Roentgenol 2010;194(4):1054-60.
Imaging 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.
Osteochondral
Ross JR, Gardner MJ. Femoral head fractures. Curr Rev Musculoskelet Med 2012;5(3):199-205.
Subchondral Rockwood and Greens Fractures in Adults, 7th Edition. Wolters Kluwer/Lippincott Williams & Wiilkins, New York, 2010.
Femoral Neck 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
Intertrochanteric insufficiency fracture from osteonecrosis of the femoral head. AJR Am J Roentgenol 2010;195:W63-W68.
Greater Troch. 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.
Lesser Troch. 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.
Subtrochanteric
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
Conclusion 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
References 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)