II. Epidemiology

  1. Incidence as high as 19 per 100,000 in U.S. (250,000 cases per year)
  2. Uncommon in children (2% of all Pediatric Fractures)

III. Pathophysiology

  1. Images
    1. hipFractureRegions.jpg
  2. High energy injury (often in young adults)
    1. Motor Vehicle Accident
    2. Pedestrian accident
    3. Fall from height
  3. Toddlers and preschool children
    1. Falls
    2. Nonaccidental Trauma
  4. Atypical Femur Fractures
    1. May be associated with prolonged use of Bisphosphonates or Denosumab
    2. Stop these medications if atypical Femur Fracture occurs

IV. Diagnosis

  1. See Hip Fracture
  2. Distal to first 5 cm of femoral shaft
    1. Below Subtrochanteric Fracture
  3. Descriptive Classification
    1. Proximal or distal location
    2. Transverse or oblique angle
    3. Comminuted (common)

V. Pitfalls: Associated injuries (common)

  1. Hip Fracture including Femoral Neck Fracture
  2. Supracondylar Femur Fracture
  3. Patella Fracture
  4. Knee ligament injury
  5. Vascular Injury
    1. Evaluate for pulseless limb or Hemorrhagic Shock
    2. Consider CT angiogram of leg

VI. Imaging

  1. See Femur Fracture
  2. XRay
    1. Obtain AP and Lateral Femur
    2. Consider Pelvic XRay
    3. Consider Knee XRay
    4. Consider Lumbar Spine XRay
  3. Advanced Imaging (CT, MRI)
    1. See Femur Fracture

VII. Management

  1. See Trauma Evaluation
  2. See Femur Fracture (includes Hare Traction Splint)
  3. Immobilize hip and knee
  4. Evaluate for associated injuries (see pitfalls above)
  5. Strongly consider regional Nerve Block (Fascia Iliaca Block or PENG Block) in hip and Femur Fractures
  6. Closely manage fluid status
    1. Initial Resuscitation with isotonic crystalloid
    2. Average blood loss from Femur Fracture: 1.2 units
    3. Type and Cross for 2 Units pRBC
    4. Continually reassess hemodynamic status
  7. Fracture Management (per orthopedic Consultation)
    1. Age <2 years
      1. Closed reduction and Casting (6-8 weeks)
        1. Indicated if no significant angulation, rotation, comminution (otherwise surgical management)
        2. Diaphysis Fracture Splinting in hip spica (hips and knees both at 90 degrees)
    2. Age 2 to 16 years
      1. Best management is controversial and varies by local expert opinion
      2. Splinting risks immobilization complications (joint rigidity, altered gait, pressure wounds)
      3. Flexible nails and titanium elastic nails (TENS) may allow for growth and avoid Splinting complications
    3. Age >16 years and adults
      1. Open reduction and internal fixation (typically intramedullary rods)

VIII. Complications

  1. Significant blood loss and hemodynamic instability
  2. Peroneal artery and peroneal nerve injury
    1. Associated with distal Femur Fracture

IX. References

  1. Gurr in Marx (2002) Rosen's Emergency Med, p. 655-60
  2. Warren (2021) Crit Dec Emerg Med 35(6):16-7
  3. Russell (2002) Orthop Clin North Am 33(1):127-42 [PubMed]

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