Neck of femur fracture

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[2]

Neck of femur fracture is an orthopedic emergency. Femoral neck fractures are a commonly encountered injury in orthopaedic practice and result in significant morbidity and mortality. It is becoming increasingly common due to aging population. United states has highest incidence of hip fracture rates worldwide. Women are more commonly affected than men. It is essential to recognize specific fracture patterns and patient characteristics that dictate the use of particular implants and methods to effectively manage these injuries. Neck of femur fracture must be differentiated from other causes of acute hip pain, restriction of movements, and deformity such as intertorchanteric hip fracture, osteoarthritis, avascular necrosis, septic arthritis, trochanteric bursitis, slipped capital femoral epiphysis and acute synovitis. Garden and Pauwels classification systems has remained the practical mainstay of femoral neck fracture characterization that help dictate the appropriate treatment. Operative interventions include in situ fixation using cannulated cancellous screws, closed or open reduction and internal fixation using sliding hip screw, hemiarthroplasty, and total hip arthroplasty.

In 1600s, Ambrose Pare, a French surgeon described the neck of femur fracture. In 1825, Sir Astley Paston Cooper delineated between intracapsular fractures from other fractures about the hip. In 1858, Von-Langen Beck, the German surgeon performed the first internal fixation of the femoral neck fracture with silver-plated screws. In 1932, Johansson devised a guide pin for easy positioning of the nail. In 1936, Knowle advocated multiple threaded pins for stabilization of neck of femur fractures. In 1936, Mc Murray performed oblique osteotomy for non union fractures. In 1986, O.N. Nagi, V.K. Gautham and S.K. Smarya introduced cancellous screw fixation and fibular graft for comminuted femoral neck fractures.

There are multiple classifications available for neck of femur fracture. The most common classification systems for neck of femur fracture include Anatomical, Garden’s, Pauwel’s and AO/OTA classification.

The pattern of fracture and degree of comminution are the resultant of several factors or variables such as the nature of injury, the bone quality, the age and weight of the patient, the energy involved, and the position of the hip and leg at the time of impact. Various combinations of these variables lead to a variety of different fracture patterns.

The most common cause of neck of femur fracture is trauma in form of motor vehicle accident and fall.

Neck of femur fracture must be differentiated from other causes of acute hip pain, restriction of movements, and deformity such as intertorchanteric hip fracture, osteoarthritis, avascular necrosis, septic arthritis, trochanteric bursitis, slipped capital femoral epiphysis and acute synovitis.

The incidence of neck of femur fracture is approximately 146 per 100,000 individuals worldwide. Neck of femur fracture showed bimodal distribution among women and a unimodal distribution among men. Men had an increasing incidence of fractures until 50 to 60 years of age, followed by a decline in incidence. Women showed a peak incidence between 20 and 30 years of age. The median age at diagnosis is 57.7 years for women and 46.8 years for men. There is no racial predilection to neck of femur fracture. Women are more commonly affected by neck of femur fracture than men. Surgical management for neck of femur fracture is done in 92.1% of the cases.

Common risk factors in the development of neck of femur fracture include age, female gender, and health conditions.

The risk of neck of femur fracture due to osteoporosis is threatening, affecting one out of two postmenopausal women and one out of five men older than 50 years. The 10-year risk for osteoporosis-related neck of femur fracture in a 65-year-old white woman with no other risk factor is 9.3%. According to the guidelines of USPSTF, all women ≥ 65 years old along with women < 65 years old with a high risk of fracture are the target of screening for osteoporosis, but there is not any recommendation to screen men for the disease. Dual energy x-ray absorptiometry (DXA) of both hip and lumbar spine bones and quantitative ultrasonography of the calcaneus are two major methods suggested for screening osteoporosis.

If left untreated, 30% of patients with neck of femur fracture may progress to develop non union and avascular necrosis. Common complications of neck of femur fracture include infections and thromboembolism. Prognosis is generally poor, and the 1 year mortality rate of patients with neck of femur fracture is approximately 25-30%.

Computed tomography (CT) is the gold standard test for the diagnosis of neck of femur fracture. Computed tomography (CT) with two-dimensional reconstruction in the sagittal and coronal planes provides more detailed information than radiographs. CT helps in fracture fragment orientation and surgical planning.

A positive history of pain, deformity, and restricted hip movements is suggestive of neck of femur fracture.

Patients with neck of femur fracture usually appears well. Physical examination of patients with neck of femur fracture is usually remarkable for swelling, tenderness, bruises, ecchymosis, deformity and restricted range of motion of the leg.

There is a limited role for laboratory tests in the diagnosis of neck of femur fracture; however, elderly women may have some abnormal laboratory findings suggestive of osteoporosis.

There are no ECG findings associated with neck of femur fracture.

Radiographic imaging is important in diagnosis, classification, treatment and follow-up assessment of neck of femur fracture. The routine minimal evaluation for neck of femur fracture must include two views – an anteroposterior (AP) view and lateral view.

There are no echocardiography/ultrasound findings associated with neck of femur fracture.

Computed tomography (CT) with two-dimensional reconstruction in the sagittal and coronal planes provides more detailed information than radiographs. CT also helps in fracture fragment orientation and surgical planning.

MRI helps in identifying occult fracture of neck of femur.

There are no other imaging findings associated with neck of femur fracture.

There are no other diagnostic findings associated with neck of femur fracture.

The mainstay of treatment for neck of femur fracture is surgery. Non-operative management is reserved for a very small proportion of patients.

There are no interventions associated with neck of femur fracture.

Surgery is the mainstay of treatment for neck of femur fracture. It is a surgical emergency as the risk of avascular necrosis and non union increases as time passes by. The decision-making process for determining the best surgical procedure uses both the fracture type and the patient’s activity level to choose between internal fixation and arthroplasty. The types of surgery include femoral pinning, sliding hip screw and prosthetic replacement.

There are no established measures for the primary prevention of neck of femur fracture. Healthy diet and regular exercises like running and weight lifting help decrease the chances of fracture.

Effective measures for the secondary prevention of neck of femur fracture include early detection and management of osteoporosis.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[2]

In 1600s, Ambrose Pare, a French surgeon described the neck of femur fracture. In 1825, Sir Astley Paston Cooper delineated between intracapsular fractures from other fractures about the hip. In 1858, Von-Langen Beck, the German surgeon performed the first internal fixation of the femoral neck fracture with silver-plated screws. In 1932, Johansson devised a guide pin for easy positioning of the nail. In 1936, Knowle advocated multiple threaded pins for stabilization of neck of femur fractures. In 1936, Mc Murray performed oblique osteotomy for non union fractures. In 1986, O.N. Nagi, V.K. Gautham and S.K. Smarya introduced cancellous screw fixation and fibular graft for comminuted femoral neck fractures.

• In 1600s, Ambrose Pare, a French surgeon described the neck of femur fracture.^[1][2][3]
• In 1825, Sir Astley Paston Cooper delineated between intracapsular fractures from other fractures about the hip.
• In 1859, Gross described non union in cases of intracapsular fracture neck of femur.

• In 1858, Von-Langen Beck, the German surgeon performed the first internal fixation of the femoral neck fracture with silver-plated screws.^[4][5][3]
• In 1897, Royal Whitman advocated forcible manipulative reduction and immobilization in a hip spicca cast.
• In 1931, Marius Nygard Smith Peterson from Boston was responsible for reviving and popularizing the procedure of internal fixation for femoral neck fractures.^[6]
• In 1932, Johansson devised a guide pin for easy positioning of the nail.
• In 1936, Knowle advocated multiple threaded pins for stabilization of neck of femur fractures.
• In 1936, Mc Murray performed oblique osteotomy for non union fractures.
• In 1941, AAOS recommended for femoral neck The fracture was fixed with a three-wing nail.
• In 1958, Muller popularized the ideas of laterally based wedge so as to keep the pseudorthrosis site at right angles to the deforming forces.^[7][8]
• In 1959, Massi introduced a sliding nail plate to fix neck of femur fracture.
• In 1962, Judet described the role of quadratus femoris muscle pedicle graft as a method for improving blood supply to the head in displaced fracture and to promote union of the fracture.
• In 1973, Weber and Cech reported good results after primary subtrochanteric valgus osteotomy in the management of femoral neck fractures.^[9]
• In 1975, Mayers used muscle pedicle graft to increase the blood supply to femoral head.^[10]
• In 1986, O.N. Nagi, V.K. Gautham and S.K. Smarya introduced cancellous screw fixation and fibular graft for comminuted femoral neck fractures.^[11]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[2]

There are multiple classifications available for neck of femur fracture. The most common classification systems for neck of femur fracture include Anatomical, Garden’s, Pauwel’s and AO/OTA classification.

There are multiple classifications available for neck of femur fracture. The most common classification systems for neck of femur fracture include Anatomical, Garden’s, Pauwel’s and AO/OTA classification.^[1][2]

• Anatomical classification is the commonly used classification for eck of femur fracture.^[3][4]

Schatzker Classification
Type I	Supcapital fracture
Type II	Transcervical fracture
Type III	Basicervical fracture

• Garden’s classification of neck of femur fracture is most commonly used classification.^[5]
• It is based on anterioposterior (AP) radiographs and does not consider lateral or sagittal plane alignment.

Garden’s Classification
Type I	Incomplete, valgus impacted fracture
Type II	Complete, nondisplaced fracture
Type III	Complete, partially displaced fracture
Type IV	Complete, fully displaced fracture

• Pauwel’s classified for neck of femur fracture is based on vertical orientation of fracture line.^[6]
• Pauwel’s angle is defined as the angle formed between the line of a fracture of the neck of the femur and the horizontal on an anterioposterior radiograph.
• The greater the angle, the more unstable the fracture and thus worse the prognosis.

Pauwel’s Classification
Type I	< 30 degree from horizontal
Type II	30 to 50 degree from horizontal
Type III	> 50 degree from horizontal

• AO/ASIF classification is also a widely accepted classification.^[7]
• Proximal femur is given the number 31 based on the classification.
• It is further subdivided as:

OTA System
A	Femoral Trochanteric fractures
	A1	Simple peritrochanteric
	A2	Multifragmentary peritrochanteric, lateral wall incompetent (< 20.5 mm)
	A3	Intertrochanteric (reverse obliquity)
B	Femoral Neck fractures
	B1	Subcapital
	B2	Transcervical
	B3	Basicervical
C	Femoral Head fractures
	C1	Split fracture
	C2	Depression fracture

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[2]

The pattern of fracture and degree of comminution are the resultant of several factors or variables such as the nature of injury, the bone quality, the age and weight of the patient, the energy involved, and the position of the hip and leg at the time of impact. Various combinations of these variables lead to a variety of different fracture patterns.

• The fracture pattern and severity of comminution depends on multiple factors including:^[1]
  • Nature of the fall
  • Bone quality
  • Age of the patient
  • Weight of the patient
  • Energy involved
  • Position of the hip and leg at the time of impact
• Decrease in bone mass density involves following process:^[2]
  • Autophagy is the mechanism through which osteocytes evade oxidative stress.
  • The capability of autophagy in cells decreases as they age, a major factor of aging.
  • As osteocytes grow, viability of cells decrease thereby decreasing the bone mass density.

• The femoral neck of femur is supported by five groups of trabecular bone.^[3][4]
• The thickest trabeculae bone is situated at the medial femoral neck, the calcar, and is known as the primary compressive trabeculae.
• The primary tensile group stretches from the inferior part of the femoral head, across the superior region, and ends in the lateral femur just distal to the greater trochanter .
• However, Ward’s triangle an area of relative weakness , is situated in the femoral neck which is formed by the intersections of three groups of trabeculae.
• The neck–shaft angle in a normal adult is between 125 and 135°.
• Femoral anteversion is defined as the angle subtended by the long axis of the femoral head and transverse axis of the femoral condyles and has a mean value of 8°.
• The blood supply to the femoral head derives from three main sources:
  • Medial femoral circumflex artery
  • Lateral femoral circumflex artery
  • Obturator artery
• These vessels subdivide into ascending retinacular arteries while course along the femoral neck and are at risk of disruption in the event of a femoral neck fracture, thus leading to a substantial risk of developing avascular necrosis.

• Femoral neck fractures tend to occur in older adults due to low energy trauma such as fall.^[5]
• The mechanisms of injury in elderly include:
  • A direct impact onto the lateral hip.
  • A twisting injury in which the patient’s foot is planted and the body rotates leading to fracture.
  • A sudden spontaneous completion of a stress fracture, which may lead to a fall.
• In younger adults, femoral neck fractures occur as a result of high energy trauma such as a motor vehicle accident.
• The femur is usually axially loaded.
• If the hip is in abduction at the time of injury, a femoral neck fracture occurs.
• If the hip is in adduction, it results in a fracture-dislocation.

Factors Affecting Healing

• Factors hampering healing include:^[6][7]
  • As the fracture is intracapsular, it is bathed in synovial fluid.
  • The synovial fluid has a tamponade effect.
  • In addition, it also lacks periosteal layer thus callus formation limited, which hampers healing.

Conditions associated with poor bone quality leading to neck of femur fracture include:^[8]

• Osteoporosis
• Osteopenia
• chronic stroke
• Diabetes
• Rheumatoid arthritis
• Chronic kidney disease
• Hyperparathyroidism
• Hypophosphatemic rickets
• Immobility
• Menopause
• Multiple myeloma
• Mixed connective tissue disease
• Paget’s disease of bone
• Primary hypoparathyroidism
• Short stature
• Chronic corticosteroid use

On gross pathology, decreased bone density and small pores in diaphysis of bones are characteristic findings of osteoporosis, leading to distal radius fracture.^[9]

• On microscopy, characteristic findings of bone with osteoporosis is increased number of osteoclasts and decreased number of osteoblasts under the microscope.^[2]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[2]

The most common cause of neck of femur fracture is trauma in form of motor vehicle accident and fall.

The most common cause of neck of femur fracture is trauma in form of motor vehicle accident and fall.^{[1][2][3][4][5]}

• There are no life-threatening causes of neck of femur fracture, however complications resulting from neck of femur fracture is common.

Common causes of neck of femur fracture may include:

• Trauma (motor vehicle accident and fall)

Less common causes of neck of femur fracture include conditions that predisposes to fracture:

• Osteoporosis
• Osteopenia

Cardiovascular	No underlying causes
Chemical/Poisoning	No underlying causes
Dental	No underlying causes
Dermatologic	No underlying causes
Drug Side Effect	No underlying causes
Ear Nose Throat	No underlying causes
Endocrine	No underlying causes
Environmental	No underlying causes
Gastroenterologic	No underlying causes
Genetic	No underlying causes
Hematologic	No underlying causes
Iatrogenic	No underlying causes
Infectious Disease	No underlying causes
Musculoskeletal/Orthopedic	Osteoporosis and osteopenia.
Neurologic	No underlying causes
Nutritional/Metabolic	Osteoporosis and osteopenia.
Obstetric/Gynecologic	No underlying causes
Oncologic	No underlying causes
Ophthalmologic	No underlying causes
Overdose/Toxicity	No underlying causes
Psychiatric	No underlying causes
Pulmonary	No underlying causes
Renal/Electrolyte	No underlying causes
Rheumatology/Immunology/Allergy	No underlying causes
Sexual	No underlying causes
Trauma	Fall on an outstretched hand.
Urologic	No underlying causes
Miscellaneous	No underlying causes

List the causes of the disease in alphabetical order:

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[2]

Neck of femur fracture must be differentiated from other causes of acute hip pain, restriction of movements, and deformity such as intertorchanteric hip fracture, osteoarthritis, avascular necrosis, septic arthritis, trochanteric bursitis, slipped capital femoral epiphysis and acute synovitis.

• Neck of femur fracture must be differentiated from other causes of acute hip pain, restriction of movements, and deformity such as intertorchanteric hip fracture, osteoarthritis, avascular necrosis, septic arthritis, trochanteric bursitis, slipped capital femoral epiphysis and acute synovitis.^{[1][2][3][4][5][6][7]}

Diseases	Clinical manifestations						Para-clinical findings			Gold standard	Additional findings
	Symptoms			Physical examination
							Imaging
	Pain	Restriction of Movements	Deformity	Tenderness	Active Straight Leg Raising	Distal Pulses	X-ray	CT scan	MRI
Neck of Femur Fracture	+	+	Shortening Externally rotated leg	+	–	+	Fracture fragment displacement Fracture fragment angulation	Accurate diagnosis of fracture pattern ans aids in classification. Useful for preoperative surgical planning for patients with complex, multifragmentary fractures.	Useful in diagnosing occult fractures.	X-ray	Bone scan shows increased uptake of radioactivity in region of fracture.
Intertrochanteric Hip Fracture	+	+	Shortening Externally rotated leg	+	–	+	Fracture fragment displacement Fracture fragment angulation	Accurate diagnosis of fracture pattern ans aids in classification. Useful for preoperative surgical planning for patients with complex, multifragmentary fractures.	Useful in diagnosing occult fractures.	X-ray	Trochanteric Thump test is positive.
Subtrochanteric Femur Fracture	+	+	Thigh is deformed	+	–	+	Fracture fragment displacement Fracture fragment angulation	Accurate diagnosis of fracture pattern ans aids in classification. Useful for preoperative surgical planning for patients with complex, multifragmentary fractures.	Useful in diagnosing occult fractures.	X-ray
Acetabular Fracture	+	+	–	+	+/-	+/-	Fracture fragment displacement Fracture fragment angulation	Accurate diagnosis of fracture pattern ans aids in classification. Useful for preoperative surgical planning for patients with complex, multifragmentary fractures.	Useful in diagnosing occult fractures.	CT	It is a medical emergency as there is a large amount of blood loss. Per urethral blood may be present. Swelling may be present in the scrotal or perineal area.
Pubic Rami Fracture	+	+	–	+	+/-	+	Fracture fragment displacement	Accurate diagnosis of fracture pattern ans aids in classification.	Useful in diagnosing occult fractures.	MRI
Femoral Head Fracture	+	+	May be associated with flexion, adduction and internal rotation deformity.	+	–	+	Fracture fragment displacement Fracture fragment angulation	Accurate diagnosis of fracture pattern ans aids in classification. Useful for preoperative surgical planning for patients with complex, multifragmentary fractures.	Useful in diagnosing occult fractures.	CT	It may be associated with dislocation. It may be associated with foot drop due to compression of the sciatic nerve.
Osteoarthritis	+	+	Flexion and external rotation deformity	+	+	+	Joint space narrowing, osteophytes, subchondral sclerosis and subchondral cysts.	Normal	MRI shows cartilage defects and bone marrow lesions.	X-ray	Hip locking, instability and catching sensation.
Trochanteric Bursitis	+	+/-	–	+	+	+	Normal	Normal	Increased signal in bursa due to inflammation on T2 images.	MRI	Lateral hip pain near the greater trochanter and patients points to greater trochanter. Patient may have trendelenburg gait.
Septic Arthritis	+	+	+/-	+	+	+	Normal	Normal	Joint fullness and capsular dilation. It also demonstrates damage to the articular cartilage.	MRI	Fever and chills may be present. Hip aspiration may reveal frank pus or a turbid fluid. Culture of the infecting organisms in the fluid is confirmatory. Leukocytosis.
Avascular Necrosis of Head of Femur (Osteonecrosis)	+	+	Adduction deformity	+	+	+	Early x-ray findings include lucency of the femoral head and subchondral sclerosis. In advanced stage, subchondral collapse (ie, crescent sign), femoral head flattening and joint space narrowing is seen.	CT shows subchondral collapse.	MRI shows bone marrow edema and rail track sign.	MRI	Patient may have trendelenburg gait. Passive internal and external rotation of the extended leg may elicit pain due to synovitis. Ficart and Arlet as well as Steinberg classification of avascular necrosis is done radiologically.
Diseases	Pain	Restriction of Movements	Deformity	Tenderness	Acitve Straight Leg Raising	Distal Pulses	X-ray	CT scan	MRI	Gold standard	Additional findings
Femoroacetabular Impingement (FAI)	+	+	External rotation deformity	+	+	+	Pistol grip deformity: It is asphericity and contour of femoral head and neck indicating Cam impingement. Crossover sign: It is a sign of acetabular retroversion seen in Pincer impingement.	Confirms X-ray findings.	Evaluates articular cartilage damage, and labral degeneration and tears.	MRI	Anterior impingement test: On flexion, adduction, internal rotation of the hip produces pain.
Idiopathic Transient Osteoporosis of the Hip (ITOH)	+	+	–	+	+	+	Subchondral cortical loss. Diffuse osteopenia of femoral head and neck. Joint effusion Joint space is always preserved	Confirms X-ray findings.	Marrow edema of femoral head and neck	MRI	Commonly seen among women in 3rd trimester of pregnancy and middle aged men. Bone scan shows increased uptake in the femoral head.
Transient Synovitis of the Hip	+	+	Flexion, abduction and external rotation deformity	+	+	+	Normal	Normal	Joint space effusion	USG	History of recent upper respiratory tract infection or trauma to the hip. Fever may be present. Involuntary muscle guarding on log rolling of the leg. Ultrasound shows intracapsular effusion and synovial membrane thickening.
Slipped Capital Femoral Epiphysis (SCFE)	+	+	Adduction and external rotation defromity	+	+	+	Klein’s line: A line drawn along superior border femoral neck will intersect less of the femoral head or not at all in a child with SCFE. Epiphysiolysis Blanch sign of Steel: Proximal femoral metaphyseal blurring	Confirms X-ray findings.	Growth plate widening Edema in metaphysis	MRI	Antalgic gait Drehmann sign: External rotation during passive flexion of the hip. Externally rotated foot progression angle.
Adult Dysplasia of the Hip	+	Increased internal rotation due to increased femoral anteversion	External rotation deformity may be present in the late stages.	+	+	+	Decreased femoral head sphericity. Crossover sign results from increased retroversion. Acetabular protrusio: Decreased lateral center-edge angle < 20°. Increased Tonnis angle ( angle between the horizontal line and line along the superior acetabulum) > 10°. Decreased head-neck offset ratio. Increased femoral neck-shaft angle. Decreased vertical center anterior margin angle.	Structural abnormalities of the femoral head and neck is seen.	–	X-Ray	Positive anterior impingement test may be seen.
Diseases	Pain	Restriction of Movements	Deformity	Tenderness	Acitve Straight Leg Raising	Distal Pulses	X-ray	CT scan	MRI	Gold standard	Additional findings
Iliospoas Tendinitis	+	–	Flexion and external rotation deformity	+	+	+	Normal	Normal	T2 images show an increased signal intensity associated with swelling and inflammation.	MRI	Anterior pelvic tilt due to tightening of the iliopsoas muscle. Ludloff sign: Patient asked to sit with knees extended and subsequent elevation of the heel on the affected side causes pain. Ultrasound demonstrates thickened band and fluid in the iliospoas bursa.
Hip Pointer (Contusion of the Iliac Crest)	+	+/-	Adduction and internal rotation deformity may be present.	+	+	+	Normal	Normal	Swelling of the surrounding soft tissues may be seen.	–	Contusion or swelling may be present.
Snapping Hip Syndrome (Coxa Saltans)	+/-	–	–	+/-	+	+	Normal	Normal	May show inflamed bursa.	Ultrasound	External snapping hip: Palpate the greater trochanter as hip is actively flexed and applying pressure will likely stop snapping if external band present. Ober’s Test: Limited hip adduction when hip held in extension indicate tightness of tensor fascia lata. Internal snapping hip: Snapping is reproduced by passively moving hip from a flexed and externally rotated position to an extended and internally rotated position. Ultrasound shows the snapping band in either internal or external snapping.
Osteitis Pubis	+	–	–	+	+	+	Osteolytic pubis with bony erosions	CT confirms x-ray findings	Bone marrow edema is seen.	MRI	Bone scan shows increased activity in area of pubic symphysis.
Referred Pain from Lumbosacral Plexus	+	–	–	+	+	+	Narrowing of the disc space	Normal	Compression of the nerve root and disc bulge Osteophytes may be seen.	MRI	Pain on passive straight leg raising.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[2]

The incidence of neck of femur fracture is approximately 146 per 100,000 individuals worldwide. Neck of femur fracture showed bimodal distribution among women and a unimodal distribution among men. Men had an increasing incidence of fractures until 50 to 60 years of age, followed by a decline in incidence. Women showed a peak incidence between 20 and 30 years of age. The median age at diagnosis is 57.7 years for women and 46.8 years for men. There is no racial predilection to tibial plateau fracture. Men are more commonly affected by tibial plateau fracture than women. Surgical management for tibial plateau fracture is done 92.1% of the cases.

• The incidence of neck of femur fracture is approximately 146 per 100,000 individuals worldwide.^[1]

• Patients of all age groups may develop tibial plateau fracture.^[2][3]
• Tibial plateau fracture showed bimodal distribution among women and a unimodal distribution among men.
• Men had an increasing incidence of fractures until 50 to 60 years of age, followed by a decline in incidence.
• Women showed a peak incidence between 20 and 30 years of age.
• After the age of 40 years, they had an increase in incidence throughout life compared with men.
• Tibial plateau fractures are most common between the ages of 30 and 60 years.
• The median age at diagnosis is 57.7 years for women and 46.8 years for men.

• There is no racial predilection to tibial plateau fracture.^[4]

• Men are more commonly affected by tibial plateau fracture than women.^[3][5]
• The male to female ratio is approximately 2.4 to 1.

• Conservative management for tibial plateau fracture is done 7.9% of the cases.^[6]
• Surgical management for tibial plateau fracture is done 92.1% of the cases.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[2]

Common risk factors in the development of distal radius fracture include age, female gender, and health conditions.

Many neck of femur fracture in people over 60 are due to osteoporosis if the fall was relatively minor such as a fall from a standing position. They can happen even in healthy bones if the trauma was severe enough such as a car accident or a fall off a bike.^[1][2][3][4]

• The incidence of neck of femur fracture has a bimodal distribution during the life span.
• The incidence is high in the pediatric population, drops during young to middle adulthood, and increases again in older adults.

• Gender distribution curves for neck of femur fracture incidence in the pediatric group indicate that boys have a higher risk of neck of femur fracture than girls.
• This gender difference continues during young to middle adulthood with men aged 19-49 years having more neck of femur fracture than women of the same age.
• Beyond that age, the rate of neck of femur fracture increases markedly such that women older than 50 years have a 15% lifetime risk, whereas the incidence in men remains low until they reach the age of 80 years.
• Globally, injury rates remain significantly higher in elderly women as compared with elderly men.

• Neck of femur fracture appears to occur less often in individuals with significant dementia.
• Health conditions resulting in poor bone quality include:^[5][6][7]
  • Osteoporosis
  • Chronic stroke
  • Diabetes
  • Rheumatoid arthritis
  • Chronic kidney disease

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[2]

The risk of neck of femur fracture due to osteoporosis is threatening, affecting one out of two postmenopausal women and one out of five men older than 50 years. The 10-year risk for an osteoporosis-related neck of femur fracture in a 65-year-old white woman with no other risk factor is 9.3%. According to the guidelines of USPSTF, all women ≥ 65 years old along with women < 65 years old with a high risk of fracture are the target of screening for osteoporosis, but there is not any recommendation to screen men for the disease. Dual energy x-ray absorptiometry (DEXA) of both hip and lumbar spine bones and quantitative ultrasonography of the calcaneus are two major methods suggested for screening osteoporosis.

The risk of neck of femur fracture due to osteoporosis is threatening, affecting one out of two postmenopausal women and one out of five men older than 50 years. Osteoporosis usually affects the Caucasian population. The rate of osteoporosis is higher in the elderly. The 10-year risk for osteoporosis-related distal radius fracture in a 65-year-old white woman with no other risk factor is 9.3%. .

The US Preventive Services Task Force (USPSTF) divides the population into three groups, categorizing them on the basis of their need to be screened for osteoporosis. They include:

• Women of age ≥ 65 year, without any fracture history or pathological reason for osteoporosis
• Women of age <65 years, with 10-year fracture risk of not less than a 65-year-old white woman (who has not any other risk factor)
• Men with no history of osteoporosis

According to the guidelines of USPSTF, the first two groups (women) are the target of screening for osteoporosis. There is no recommendation to screen the third group (men) for the disease.^[1]

The USPSTF recommendations from 2002 included:

• All women of 65 and older should be screened by bone marrow densitometry.^[2]
• Women aged 60-64 years old, who are at increased risk of fracture. The most significant risk factor for indicating an increased probability of having osteoporosis is low body weight (< 70 kg).
• Clinical prediction rules are available to guide the selection of women for screening.
• The Osteoporosis Risk Assessment Instrument (ORAI) is the most sensitive strategy.^[3]
• Regarding the screening process for men, a cost-analysis study suggests that screening may be “cost-effective for men with a self-reported prior fracture beginning at age 65 years, and for men 80 years and older with no prior fracture“.^[4]

There are two major methods, that are suggested to be used for screening for osteoporosis:

• Dual energy x-ray absorptiometry (DEXA) of both hip and lumbar spine bones
• Quantitative ultrasonography of the calcaneus

Advantages of ultrasonography over DXA scan:

Although quantitative ultrasonography has numerous advantages when compared to DXA but still current diagnostic and treatment criteria rely on DXA of the hip and lumbar spine. The advantages include:

• Lower cost
• More portable
• Lower ionizing radiation exposure

After an initial screening is done for bone mineral density (BMD), optimal intervals to repeat the tests include:^[5]

• 15 years for women with normal bone density or mild osteopenia: T-score of greater than −1.50
• 5 years for women with moderate osteopenia: T-score of −1.50 to −1.99
• 1 year for women with advanced osteopenia: T-score of −2.00 to −2.49

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[2]

If left untreated, 30% of patients with neck of femur fracture may progress to develop non union and avascular necrosis. Common complications of neck of femur fracture include infections and thromboembolism. Prognosis is generally poor, and the 1 year mortality rate of patients with neck of femur fracture is approximately 25-30%.

• If left untreated, 30% of patients with neck of femur fracture may progress to develop non union and avascular necrosis of head of femur.^[1][2]

• Common complications of neck of femur fracture include:^[3][4]
  • Nonunion
    • Varus malreduction most likely leads to non union.
  • Infection
  • Chronic pain
  • Dislocation
  • Avascular necrosis (AVN)
  • Posttraumatic arthritis
  • Complications Of Prolonged Recumbency such as:
    • Hypostatic pneumonia
    • Pressure sores
    • Deep venous thrombosis
    • Pulmonary embolism
    • Cardiac failure due to weakening of the cardiac muscle and poor venous return
    • Muscle wasting
    • Common peroneal nerve palsy
    • Stiffening of joints
    • Osteoporosis
    • Urinary tract infections
    • Depression

• Prognosis is generally poor, and the 1 year mortality rate of patients with neck of femur fracture is approximately 25-30%.^[5][6][7][4]

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