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Varus impacted intracapsular hip fractures
Injury, Int. J. Care Injured (2005) 36, 627—629
www.elsevier.com/locate/injury
Varus impacted intracapsular hip fractures D.S. Damanya,*, Martyn J. Parkerb a
Trauma and Orthopaedics, University of Warwick, University Hospitals of Coventry and Warwickshire, Warwickshire, UK b Department of Orthopaedics, Peterborough District Hospital, Peterborough, UK Accepted 26 July 2004
KEYWORDS Varus; Impacted; Hip; Fractures; Non union; Avascular necrosis
Summary We describe a distinct variant of an impacted intracapsular hip fracture that is difficult to classify within any of the current fracture classification systems. Instead of impaction occurring laterally, as generally occurs with a Garden grade I fracture, there is medial impaction. We have termed this a varus impacted fracture. Nineteen such fractures were identified. The majority of these patients presented with a history of progressive hip pain over several days without a definite history of trauma. For the 16 fractures treated by internal fixation without any attempt at fracture reduction, fracture healing occurred in 11 cases. # 2004 Elsevier Ltd. All rights reserved.
Introduction Approximately half of all hip fractures are intracapsular, and of these 20% are undisplaced.1 Garden in his original classification described four radiographic types of intracapsular fractures depending on the proximal femoral trabeculae.4 Garden grade I have been termed impacted or valgus fractures, in which there is impaction of the fracture laterally and the medial cortex remains intact. The femoral head trabeculae are tilted into a valgus position. We describe a variant of the impacted intracapsular fracture in which impaction has occurred medially * Corresponding author. Present address: 14 Downgate, Longthorpe, Peterborough, PE3 6SZ, UK. Tel.: +44 1733 333 111; fax: +44 1733 753 320. E-mail address: [email protected] (D.S. Damany).
such that the trabeculae are tilted into varus. The fracture remains undisplaced on the lateral X-ray.
Patients and methods Between March 1998 and October 2003, 1929 patients with a hip fracture were admitted to our institution. Of these, 1100 (57.0%) were classified as intracapsular fractures and of these 19 (1.7%), were noted to have a characteristic varus impacted pattern. For these cases, in the antero-posterior radiograph, the femoral head is tilted in varus or adduction with infero-medial impaction denoted by a triangle of sclerosis (Fig. 1). The fracture opens up at the superior border of the femoral neck and the trabeculae angle is less than the normal value of 1608. In the lateral radiograph, the fracture is
0020–1383/$ — see front matter # 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2004.07.054
628
D.S. Damany, M.J. Parker
survivors, the mean clinical follow-up was 378 days (range 48—947) and the mean radiological follow-up was 246 days (range 15—947).
Results Nineteen varus impacted fractures were identified in 18 patients. The mean age at presentation was 80.2 years (range 62—92). Fifteen patients were females. Eleven of the 19 fractures presented with progressive hip pain over a period of several days without a definite history of trauma. The rest had a history of a mechanical fall, although there was often a long delay till seeking medical assistance. The mean time from fall to admission was 114 h (range 1—333). Table 1 lists the characteristics of these patients. Mean and median hospital stay were 9 and 6.5 days, respectively (range 2—51 days). All patients were admitted from their own homes and were discharged back home. Sixteen of the 19 fractures were treated by fixation in situ, without reduction, using three parallel 6.5 mm cannulated screws, inserted percutaneously. Ten of these operations were carried out under local nerve blocks (lumbar plexus or triple nerve block), five under general anaesthesia and one under spinal anaesthesia. Two patients were treated with a hemiarthroplasty and one non-operatively without admission to the hospital. After surgery, all patients were mobilised fully weight bearing as soon as able, with no restriction on hip function. There were no wound infections or other immediate post-operative complications. For the 16 fractures treated by internal fixation, four developed non-union, three of which were converted to an arthroplasty. A further patient, in whom the fracture healed, developed avascular necrosis of the femoral head and subsequently underwent a total hip replacement.
Discussion
Figure 1 Antero-posterior view of varus impacted intracapsular fracture. There is inferior-medial impaction with the head tilted into a varus position. The trabeculae angle is less than the normal angle of 1608.
undisplaced and the trabeculae angle is the normal 1808. The presenting characteristics and outcome after treatment for these patients was noted. For the
This type of intracapsular hip fracture does not appear to have been identified before. It cannot be classified by any of the commonly used classification systems for intracapsular hip fractures.4,6 In addition to the typical radiological appearance, many of these fractures also appear to have a distinctive clinical presentation. The majority of patients presented with a gradual onset of pain over a number of days without a definite history of trauma. For those in whom a fall was reported, the pain in the hip and impaired walking was not
Varus impacted fractures
629
Table 1 Study characteristics. Radiological Outcome Patient Age Sex Mode of Injury to Operation Hospital Clinical follow-up follow-up stay injury admission (days) (days) (days) (h) 1 2 3
78 75 83
F F F
None None Fall
N/A N/A 1
IF IF IF
6 4 8
384 379 83
384 379 83
4 5
80 62
F F
None Fall
N/A 316
IF IF
3 4
366 947
130 947
6 7 8 9 10 11
76 79 81 84 92 85
F F M F F F
Fall Fall Fall None None None
177 333 2 N/A N/A N/A
IF IF IF IF IF Hemi
2 2 14 3 5 14
365 390 48 365 358 372
133 300 48 90 15 N/A
12
84 86
F F
None None
N/A N/A
IF Hemi
4 9
365 120
191 N/A
13 14 15 16 17 18
71 91 85 88 69 75
F F F F M M
None Fall Fall Fall None None
N/A 29 51 2 N/A N/A
IF IF IF IF None IF
370 373 36 143 365 222
120 373 0 143 365 222
7 8 51 10 None 8
#Union #Union #Union died (357 days) #Union Avascular necrosis #Union Non-union Died (74 days) #Union Non-union No complications #Union No complications Non-union Non-union Died (61 days) #Union #Union #Union, died (252 days)
Salvage operation
THR
Hemi
Hemi
THR None
N/A = not applicable, IF = internal fixation, Hemi = hemiarthroplasty, THR = total hip replacement. Patient 12 had fractures of both hips on separate occasions.
significant enough to warrant an immediate referral for X-ray. The fractures appeared to have occurred spontaneously probably as a consequence of osteoporosis. This particular fracture pattern is rare and one cannot therefore be precise on the optimum method of treatment. We believe that these are essentially undisplaced fractures that have become impacted as a result of the patient walking on the fractured hip, for a few days before presentation. We suggest that these fractures should be treated with internal fixation in situ, rather than with femoral head sacrificing procedures, as this is a relatively minor operation, generally undertaken using local nerve blocks in our institution. The recovery from this is short with most patients being discharged back home within 1 week of admission. The overall non-union rate was 25%, this compares to the non-union rate of 5—6% for undisplaced intracapsular hip fractures2,3 and 33% for displaced fractures.5 Thus, the incidence of fracture healing complications with this method of treatment is inbetween that of displaced and undisplaced intracapsular fractures. When fracture-healing complications occurred, conversion to an arthroplasty was undertaken.
In conclusion, we believe that surgeons should be aware of this distinct group of patients with its characteristic clinical and radiological presentation. Whilst definite treatment methods cannot be determined from our small series of patients we feel that femoral head preservation with fixation in situ has an acceptable incidence of complications and should be used in preference to arthroplasty.
References 1. Barnes R, Brown JT, Garden RS, Nicoll EA. Subcapital fractures of the femur: a prospective review. J Bone Joint Surg (Br) 1976;58-B:2—24. 2. Chiu F-Y, Lo W-H, Yu C-T, et al. Percutaneous pinning in undisplaced subcapital hip fractures. Injury 1996;27:53—5. 3. Conn KS, Parker MJ. Treatment of undisplaced intracapsular hip fractures with parallel screws. Injury 2002;33:202—3. 4. Garden RS. Low-angle fixation in fractures of the hip. J Bone Joint Surg (Br) 1961;43-B:647—63. 5. Lu-Yao GL, Keller RB, Littenberg B, Wennberg JE. Outcomes after displaced fractures of the femoral neck: a meta-analysis of one hundred and six published reports. J Bone Joint Surg 1994;76-A:15—25. 6. Muller ME, Nazarian S, Koch P, Schatzker J, The AO Classification of fracture of long bones. Berlin/Heidelberg/New York/ London/Paris/Tokyo/Hong Kong: Springer-Verlag; 1990.
www.elsevier.com/locate/injury
Varus impacted intracapsular hip fractures D.S. Damanya,*, Martyn J. Parkerb a
Trauma and Orthopaedics, University of Warwick, University Hospitals of Coventry and Warwickshire, Warwickshire, UK b Department of Orthopaedics, Peterborough District Hospital, Peterborough, UK Accepted 26 July 2004
KEYWORDS Varus; Impacted; Hip; Fractures; Non union; Avascular necrosis
Summary We describe a distinct variant of an impacted intracapsular hip fracture that is difficult to classify within any of the current fracture classification systems. Instead of impaction occurring laterally, as generally occurs with a Garden grade I fracture, there is medial impaction. We have termed this a varus impacted fracture. Nineteen such fractures were identified. The majority of these patients presented with a history of progressive hip pain over several days without a definite history of trauma. For the 16 fractures treated by internal fixation without any attempt at fracture reduction, fracture healing occurred in 11 cases. # 2004 Elsevier Ltd. All rights reserved.
Introduction Approximately half of all hip fractures are intracapsular, and of these 20% are undisplaced.1 Garden in his original classification described four radiographic types of intracapsular fractures depending on the proximal femoral trabeculae.4 Garden grade I have been termed impacted or valgus fractures, in which there is impaction of the fracture laterally and the medial cortex remains intact. The femoral head trabeculae are tilted into a valgus position. We describe a variant of the impacted intracapsular fracture in which impaction has occurred medially * Corresponding author. Present address: 14 Downgate, Longthorpe, Peterborough, PE3 6SZ, UK. Tel.: +44 1733 333 111; fax: +44 1733 753 320. E-mail address: [email protected] (D.S. Damany).
such that the trabeculae are tilted into varus. The fracture remains undisplaced on the lateral X-ray.
Patients and methods Between March 1998 and October 2003, 1929 patients with a hip fracture were admitted to our institution. Of these, 1100 (57.0%) were classified as intracapsular fractures and of these 19 (1.7%), were noted to have a characteristic varus impacted pattern. For these cases, in the antero-posterior radiograph, the femoral head is tilted in varus or adduction with infero-medial impaction denoted by a triangle of sclerosis (Fig. 1). The fracture opens up at the superior border of the femoral neck and the trabeculae angle is less than the normal value of 1608. In the lateral radiograph, the fracture is
0020–1383/$ — see front matter # 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2004.07.054
628
D.S. Damany, M.J. Parker
survivors, the mean clinical follow-up was 378 days (range 48—947) and the mean radiological follow-up was 246 days (range 15—947).
Results Nineteen varus impacted fractures were identified in 18 patients. The mean age at presentation was 80.2 years (range 62—92). Fifteen patients were females. Eleven of the 19 fractures presented with progressive hip pain over a period of several days without a definite history of trauma. The rest had a history of a mechanical fall, although there was often a long delay till seeking medical assistance. The mean time from fall to admission was 114 h (range 1—333). Table 1 lists the characteristics of these patients. Mean and median hospital stay were 9 and 6.5 days, respectively (range 2—51 days). All patients were admitted from their own homes and were discharged back home. Sixteen of the 19 fractures were treated by fixation in situ, without reduction, using three parallel 6.5 mm cannulated screws, inserted percutaneously. Ten of these operations were carried out under local nerve blocks (lumbar plexus or triple nerve block), five under general anaesthesia and one under spinal anaesthesia. Two patients were treated with a hemiarthroplasty and one non-operatively without admission to the hospital. After surgery, all patients were mobilised fully weight bearing as soon as able, with no restriction on hip function. There were no wound infections or other immediate post-operative complications. For the 16 fractures treated by internal fixation, four developed non-union, three of which were converted to an arthroplasty. A further patient, in whom the fracture healed, developed avascular necrosis of the femoral head and subsequently underwent a total hip replacement.
Discussion
Figure 1 Antero-posterior view of varus impacted intracapsular fracture. There is inferior-medial impaction with the head tilted into a varus position. The trabeculae angle is less than the normal angle of 1608.
undisplaced and the trabeculae angle is the normal 1808. The presenting characteristics and outcome after treatment for these patients was noted. For the
This type of intracapsular hip fracture does not appear to have been identified before. It cannot be classified by any of the commonly used classification systems for intracapsular hip fractures.4,6 In addition to the typical radiological appearance, many of these fractures also appear to have a distinctive clinical presentation. The majority of patients presented with a gradual onset of pain over a number of days without a definite history of trauma. For those in whom a fall was reported, the pain in the hip and impaired walking was not
Varus impacted fractures
629
Table 1 Study characteristics. Radiological Outcome Patient Age Sex Mode of Injury to Operation Hospital Clinical follow-up follow-up stay injury admission (days) (days) (days) (h) 1 2 3
78 75 83
F F F
None None Fall
N/A N/A 1
IF IF IF
6 4 8
384 379 83
384 379 83
4 5
80 62
F F
None Fall
N/A 316
IF IF
3 4
366 947
130 947
6 7 8 9 10 11
76 79 81 84 92 85
F F M F F F
Fall Fall Fall None None None
177 333 2 N/A N/A N/A
IF IF IF IF IF Hemi
2 2 14 3 5 14
365 390 48 365 358 372
133 300 48 90 15 N/A
12
84 86
F F
None None
N/A N/A
IF Hemi
4 9
365 120
191 N/A
13 14 15 16 17 18
71 91 85 88 69 75
F F F F M M
None Fall Fall Fall None None
N/A 29 51 2 N/A N/A
IF IF IF IF None IF
370 373 36 143 365 222
120 373 0 143 365 222
7 8 51 10 None 8
#Union #Union #Union died (357 days) #Union Avascular necrosis #Union Non-union Died (74 days) #Union Non-union No complications #Union No complications Non-union Non-union Died (61 days) #Union #Union #Union, died (252 days)
Salvage operation
THR
Hemi
Hemi
THR None
N/A = not applicable, IF = internal fixation, Hemi = hemiarthroplasty, THR = total hip replacement. Patient 12 had fractures of both hips on separate occasions.
significant enough to warrant an immediate referral for X-ray. The fractures appeared to have occurred spontaneously probably as a consequence of osteoporosis. This particular fracture pattern is rare and one cannot therefore be precise on the optimum method of treatment. We believe that these are essentially undisplaced fractures that have become impacted as a result of the patient walking on the fractured hip, for a few days before presentation. We suggest that these fractures should be treated with internal fixation in situ, rather than with femoral head sacrificing procedures, as this is a relatively minor operation, generally undertaken using local nerve blocks in our institution. The recovery from this is short with most patients being discharged back home within 1 week of admission. The overall non-union rate was 25%, this compares to the non-union rate of 5—6% for undisplaced intracapsular hip fractures2,3 and 33% for displaced fractures.5 Thus, the incidence of fracture healing complications with this method of treatment is inbetween that of displaced and undisplaced intracapsular fractures. When fracture-healing complications occurred, conversion to an arthroplasty was undertaken.
In conclusion, we believe that surgeons should be aware of this distinct group of patients with its characteristic clinical and radiological presentation. Whilst definite treatment methods cannot be determined from our small series of patients we feel that femoral head preservation with fixation in situ has an acceptable incidence of complications and should be used in preference to arthroplasty.
References 1. Barnes R, Brown JT, Garden RS, Nicoll EA. Subcapital fractures of the femur: a prospective review. J Bone Joint Surg (Br) 1976;58-B:2—24. 2. Chiu F-Y, Lo W-H, Yu C-T, et al. Percutaneous pinning in undisplaced subcapital hip fractures. Injury 1996;27:53—5. 3. Conn KS, Parker MJ. Treatment of undisplaced intracapsular hip fractures with parallel screws. Injury 2002;33:202—3. 4. Garden RS. Low-angle fixation in fractures of the hip. J Bone Joint Surg (Br) 1961;43-B:647—63. 5. Lu-Yao GL, Keller RB, Littenberg B, Wennberg JE. Outcomes after displaced fractures of the femoral neck: a meta-analysis of one hundred and six published reports. J Bone Joint Surg 1994;76-A:15—25. 6. Muller ME, Nazarian S, Koch P, Schatzker J, The AO Classification of fracture of long bones. Berlin/Heidelberg/New York/ London/Paris/Tokyo/Hong Kong: Springer-Verlag; 1990.