Subtrochanteric Hip Fractures Clinical Presentation

Updated: Aug 25, 2020
  • Author: Mark A Lee, MD; Chief Editor: William L Jaffe, MD  more...
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Presentation

History and Physical Examination

Physical findings at the time of injury often include a shortened extremity on the fractured side. Significant swelling is frequently present, with tenderness to palpation in the proximal thigh region. The leg may lie in internal or external rotation. The patient cannot flex the hip or abduct the leg. Hemorrhage into the injured thigh may be substantial, and the patient should be monitored for systemic shock and compartment syndrome.

In high-energy fractures, a complete system examination must be performed. Associated injuries to the cranium, thorax, and abdomen (Waddell triad) must be recognized. [14]  Pelvic, spine, and long bone injuries are also common, especially on the ipsilateral side, and these should be identified early to optimize treatment and outcomes.

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Classification

A universally accepted classification system for subtrochanteric femur fractures has not been established. The Arbeitsgemeinschaft für Osteosynthesefragen–Association for the Study of Internal Fixation (AO-ASIF), along with the Orthopaedic Trauma Association, developed a complicated three-part classification system with 10 subtypes (see the image below); this system has been most useful in research settings.

The Arbeitsgemeinschaft für osteosynthesefragen–As The Arbeitsgemeinschaft für osteosynthesefragen–Association for the Study of Internal Fixation (AO-ASIF) classification of subtrochanteric femur fractures.

In 2018, the OTA/AO fracture and dislocation compendium was revised and streamlined. [15]  Further information is available on the AO Foundation Web site

In 1978, Seinsheimer presented an important classification with eight subgroups that identified fractures with loss of medial cortical stability (see the image below). [16]

The Seinsheimer classification of subtrochanteric The Seinsheimer classification of subtrochanteric femur fractures.

The Russell-Taylor classification system (see the image below) is helpful because it assists in determining the proper mode of treatment.

The Russell-Taylor classification of subtrochanter The Russell-Taylor classification of subtrochanteric femur fractures.

Russell-Taylor type 1 fractures do not involve the piriformis fossa. They are subdivided into subtypes A (for fractures below the lesser trochanter) and B (for fractures involving the lesser trochanter). Type 2 fractures involve the piriformis fossa. Type 2A fractures have a stable medial buttress. Type 2B has no stability of the medial femoral cortex. These fractures may have varying degrees of proximal comminution, sometimes with extension into the femoral neck, and may present difficulty with implant choice.

Type 1 fractures can be treated with first-generation or second-generation intramedullary devices. Historically, type 2 fractures were treated by means of open reduction and internal fixation (ORIF) with plate and screw devices or fixed-angle implants. With advanced techniques and implant design, intramedullary fixation has been a successful tool with reliable rates of healing.

A study that evaluated inter- and intra-observer reliability of current classification systems for subtrochanteric femoral fracture found both the Russell-Taylor classification and the Seinsheimer classification found to be more reliable and reproducible than the AO classification in this setting. [17]

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