Management of osteoporotic proximal intertrochanteric/subtrochanteric femoral fractures
Peter V. Giannoudis, Thomas A. Einhorn in Surgical and Medical Treatment of Osteoporosis, 2020
The proximal femur is surrounded by large and powerful muscles. These together with the interplay of gravity result in characteristic deformities in the case of subtrochanteric fractures. The iliopsoas flexes, abducts, and externally rotates the proximal fragment. The adductors lead to adduction of the shaft. This deformity complicates attempts at closed reduction. Shortening, of course, occurs as a result of the contraction of all the long muscles that span the length of the shaft. Thus, the characteristic deformity is an anterior and lateral bowing of the femoral shaft combined with considerable shortening (Figure 22.2). The angle formed by the axis of femoral neck and femoral shaft is 130 ± 7. If the angle is reduced as would occur with varus reduction of fracture, the distance between the head and shaft is increased, with the increased moment arm and the bending forces across the fracture, and may produce varus collapse (77).
Absorptiometric measurement
C M Langton, C F Njeh in The Physical Measurement of Bone, 2016
The proximal femur is also a frequent site of osteoporotic fracture. The structure of the femur is very complex, with two major trabecular systems arranged along the lines of compressive and tensile stresses produced during weight bearing [29]. Bone loss in the proximal femur also follows a pattern that reflects a hierarchy of trabecular groups in meeting the demands of weight bearing [30]. The proximal femur is usually measured with the BMD assessed at the femoral neck, trochanter, Ward’s triangle and total hip (figure 8.14). These femoral region of interest were chosen to capture these different loss patterns. These are also the sites in the hip where most fractures occur (figure 8.14). Ward’s triangle measures the earliest site of post-menopausal bone loss in the hip and should in theory give the best measure of trabecular bone in the proximal femur. However, poor precision has limited the utility of this site. Femoral neck BMD has been the hip parameter most frequently used for making the diagnosis of osteoporosis. Other ROIs are intertrochanter and total hip: the latter an area weighted mean of the trochanter, intertrochanter and femoral neck. The international committee for standards in bone measurements recommended that all manufacturers should standardize BMD measurements on a common scale using the total hip ROI [31]. Apart from the total hip ROI, the determination of femur ROI is not yet standardized and significant differences exist between different makes of equipment.
Musculoskeletal trauma
Ian Greaves, Keith Porter, Chris Wright in Trauma Care Pre-Hospital Manual, 2018
Injury to the hip usually results in the patient complaining of pain in the joint itself, the proximal femur or the groin. Elderly patients and those with osteoporosis are particularly prone to fragility fractures of the neck of the femur. The exact location of the fracture within the femoral neck determines the surgical treatment, but cannot be determined by the pre-hospital clinician. This is an injury with significant long-term morbidity, particularly in older patients. Patients usually complain of pain associated with a fall, often onto the hip itself. The affected leg may be externally rotated and shortened when the patient is in the supine position. A history of minimal or no trauma and signs suggestive of proximal femur fracture should raise the possibility of a pathological fracture. Analgesia will be required for extrication and transfer. Intravenous opiates are appropriate. Where skill and expertise are available, a femoral nerve block offers good analgesia of the hip, which usually lasts for several hours. In the elderly, femoral neck fractures may appear to be associated with surprisingly little discomfort until the patient is moved.
Distribution of Femoral Metastases; Potential Role for Extended FDG PET/CT Scanning
Published in Cancer Investigation, 2020
Ghada Issa, Sonya Khan, Michael Mulligan
Images were reviewed by a musculoskeletal radiologist (more than 25 years’ experience) and by 2 senior radiology residents. Imaging studies, with positive reports for metastatic disease that included at least the proximal femur (e.g. pelvic CT, FDG PET/CT) were included. The femur was divided into proximal and distal halves with respect to its midpoint on all studies that included the entire femur. The location of all femoral metastatic lesion(s) was recorded. Images were evaluated for the usual appearance of a osteolytic or osteoblastic metastatic lesion on radiography or CT. All additional relevant imaging modalities for each patient were reviewed including conventional radiographs, CT, MRI, FDG PET/CT, and whole body Tc99m bone scans. Additional relevant imaging modality criteria for metastasis included focal bone marrow replacement on MRI, FDG PET SUV max >2.5 with concordant CT abnormality, and/or abnormal uptake on Tc99m bone scan.
Serum lipid level and lifestyles are associated with carotid femoral pulse wave velocity among adults: 4.4-year prospectively longitudinal follow-up of a clinical trial
Published in Clinical and Experimental Hypertension, 2018
XiaoXiao Zhao, Hongyu Wang, LiuJin Bo, Hongwei Zhao, Lihong Li, Yingyan Zhou
After a 10-min episode of horizontal resting, by using an age-appropriate blood pressure cuff, arterial blood pressure was measured on the subjects’ right arm. CF-PWV between the carotid and femoral artery was measured by means of the validated Vicorder™ device. This was performed by measuring the distance between the midpoints of two oscillometric cuffs, (i) placed at the collar (carotid artery) and (ii) at the proximal right femur (femoral artery). To account for the difference between the tape-measured distance between both cuffs and the reference distance, a correction factor of 0.8 was used. Subsequently, the automatically recorded transit time, reflecting the time lag between pulse wave registration at the carotid and femoral cuffs, was divided by distance (m). Data were obtained by using the same device and measurement protocol as were used to derive pediatric age, gender, and height-related reference values for CF-PWV, which were modeled using the modified LMS method of Cole and Green. The mean CF-PWV of three measurements was taken as the primary outcome. Data were expressed in m/s and z scores, according to Fischer and colleagues.
Lower extremity fractures in patients with spinal cord injury characteristics, outcome and risk factors for non-unions
Published in The Journal of Spinal Cord Medicine, 2018
Lukas Grassner, Barbara Klein, Doris Maier, Volker Bühren, Matthias Vogel
In almost half of all cases, falls out of the wheelchair were the cause for the lower extremity fractures. Together with accidents during transfers and unnoticed traumas, these incidents account for over three quarters of all fractures. The most prevalent fracture region was identified around the knee with a total of 47 fractures of the supracondylar femur (35.6%) and 27 of the proximal tibia (20.5%). These fractures were treated conservatively or surgically. Fractures of the proximal femur (n=26; 19.7%) and shaft (n=13; 9.8%) occurred relatively frequently as well. All tibial shaft fractures (n=9; 6.8%) were treated operatively, whereas this was not the case for distal tibial fractures (n=10; 7.6%). Fracture management is outlined in Table 2. Almost 63% of all fractures were managed surgically. A further subcategorization of treatment strategies did not show significant differences of chosen treatment options between patients whose fractures healed and those suffering from non-unions (Table 3). However, fracture classification and their localization differed significantly between the union and non-union groups (P < 0.002 and P < 0.0001) (Table 2; Fig. 3, Fig. 4).
Related Knowledge Centers
- Hindlimb
- Thigh
- Tibia
- Femoral Head
- Patella
- Long Bone
- Hip
- Knee
- Leg
- Femoral-Tibial Angle