What is the diagnosis?

This is an intertrochanteric femur fracture.

• Pearl: Intertrochanteric femur fractures are a common injury seen in the emergency department. In fact, about half of all femur fractures annually are intertrochanteric femur fractures. They are described as extracapsular fractures of the proximal femur at the level of the greater and lesser trochanter [1,2]. 

What are expected physical exam findings?

Classically, proximal femur fractures present with a shortened leg that is externally rotated and abducted in the supine position. Ecchymosis and swelling may be present. Patient’s will have painfully limited hip range of motion. There can be tenderness to palpation within the inguinal area and the proximal thigh. 

Which imaging modalities can be used? Is there a role for other diagnostic modalities such as ultrasound?

Radiographs are the gold standard imaging modality. Recommended views include an AP pelvis, AP hip, cross table lateral, and a full length femur film [2]. CT and MRI are typically not indicated, but due to their high specificity can be used when there is high clinical suspicion and initial films are negative.  

Ultrasound (Image 3 & 4), however, may offer an accurate means for diagnosis. Though sensitivities and specificities of ultrasound in diagnosis of femur fractures have not been well described, some authors have attempted to explore its utility. Bozorgia et al. found that ultrasound has a 90% sensitivity for detecting femur shaft fractures in adults [4]. The benefit of ultrasound is that it can rapidly be incorporated into a physician’s initial evaluation of a patient, potentially reduce the necessity of painful manipulation required by radiographs, and allow for simultaneous evaluation for ultrasound-guided regional nerve blocks.

Figure 1. Suggested initial orientation of the ultrasound probe to evaluate the femoral neck and proximal femur. Author’s own image

Image 3 and 4.  Linear (top) and curvilinear (bottom) ultrasound show a cortical irregularity (blue arrow) at the level of the femoral neck/intertrochanteric femur. Author’s own images.

What is the management in the ED?

Patients can have significant blood loss from fractures in this region, so monitor for signs of hemorrhage. Prompt resuscitation may be necessary. Monitor for signs of compartment syndrome. 

Traction splints are often not necessary. You can consider placing a pillow or blanket under the knee to keep the hip in slight flexion. Traction splinting is only considered if there is significant neuro-vascular compromise, however these patients should ideally be taken immediately to the operating room [5]. 

Acute pain management is important. Consider a multimodal approach.

• Pearl: Nerve blocks such as fascia iliaca block, femoral nerve block, or a pericapsular nerve group block are increasingly being used and quickly becoming the gold standard for these patients [6]. 

When do you consult Orthopedics?

Patients with neurovascular compromise require an immediate emergent reduction. 

Orthopedics should be consulted in the ED for intertrochanteric hip fractures. Unless a patient is non-ambulatory or has an exceedingly high perioperative mortality, then operative treatment is almost always indicated. The type of surgical treatment is based on the fracture pattern. There are four main options: sliding hip screw (SHS), cephalomedullary nail (CMN), open reduction and internal fixation (ORIF), and arthroplasty. The most common technique is CMN as it can be used in unstable fracture patterns and can be performed using a closed technique [7,8].