股骨颈骨折的影像学诊断

January 2006Michael Monge, HMS IV Gillian Lieberman, MD Femoral Neck Fractures Michael Monge, Harvard Medical School Gillian Lieberman, MD January 2006 1 Michael Monge, HMS IV Gillian Lieberman, MD Agenda • Epidemiology • Normal anatomy of the femur • Garden classifications • Patients • Summary January 2006 2 Michael Monge, HMS IV Gillian Lieberman, MD Epidemiology 1 • 250,000 yearly hip fractures in the US • This is expected to double by 2040 • 90% occur to those over the age of fifty • 25% mortality at one year • Of patients who survive to six months, 60% will regain their pre-fracture walking ability and 50% will regain their pre-fracture activities of daily living January 2006 3 Michael Monge, HMS IV Gillian Lieberman, MD Epidemiology 2 • Falls account for 90% hip fractures for those over fifty years of age • 15% of falls result in hip fracture • The most common cause in young patients is high energy trauma • Pathologic fracture may occur at any age ex. metastasis, hyperparathyroidism, osteogenesis imperfecta, steroids, Pagets disease, infection January 2006 4 Michael Monge, HMS IV Gillian Lieberman, MD Epidemiology 3 • Risk doubles every decade after fifty • Risk factors include osteoporosis, female gender, age, excessive caffeine or alcohol consumption, smoking, dementia, visual impairment, physical inactivity, arthritis, certain psychotropic medications, low BMI, and residence in an institution January 2006 5 Michael Monge, HMS IV Gillian Lieberman, MD http://www.bartleby.com/107/illus243.html Femoral Anatomy 1 • An imaginary line can be drawn between the Greater and Lesser Trochanter called the Intertrochanteric Line • This is important for classification of fractures January 2006 6 Michael Monge, HMS IV Gillian Lieberman, MD Femoral Anatomy 2 • Lines correlating torque and mathematical expressions to endure loads follow closely to the trabecular matrix http://www.bartleby.com/107/illus248.html January 2006 7 Michael Monge, HMS IV Gillian Lieberman, MD http://www.bartleby.com/107/illus247.html Femoral Anatomy 3 • Trabeculae are arranged in a matrix that allows maximal dissipation of vertical and horizontal forces • This network is compromised in the elderly due to osteoporosis January 2006 8 Michael Monge, HMS IV Gillian Lieberman, MD http://www.bartleby.com/107/illus343.html Femoral Anatomy 4 • A fracture proximal to the Intertrochanteric line is considered intraarticular and distal is extraarticular • Important with respect to vascular complications January 2006 9 Michael Monge, HMS IV Gillian Lieberman, MD Lesser Trochanter Greater Trochanter Acetabulum Head 2. Intertrochanteric Fracture Images from BIDMC Hospital 3. Subtrochanteric fracture 1. Subcapital fracture Types of hip fractures January 2006 10 Michael Monge, HMS IV Gillian Lieberman, MD Femoral Vessels • Three vessels feed the femoral head • The Medial is considered the most important • Individual variation and/or anastomosis still exists between them all • 1. Medial femoral circumflex artery • 2. Lateral femoral circumflex artery • 3. Artery of Ligamentum Teres January 2006 11 Michael Monge, HMS IV Gillian Lieberman, MD Femoral Artery Superficial Femoral Artery Profunda Femoris Lateral Femoral Circumflex Artery RTRT 12 3 1. Medial Femoral Circumflex Artery 2. Ascending LFCA 3. Transverse LFCA 4. Descending LFCA 4 http://classes.kumc.edu/som/radanatomy/image.asp?Image=7601-001.jpg&Film=7601&Features=1 Femoral Angiogram January 2006 12 Michael Monge, HMS IV Gillian Lieberman, MD Role of imaging • Evaluation for chronic or sub acute hip pain based on physical exam, history • Trochanteric bursitis, OA, Lumbar radiculopathy, Meralgia paresthesia, Osteonecrosis, hip fracture • Plain radiograph (AP, AP with internal rotation of about 15 degrees, Lateral) • MRI, Bone scan, CT • Prognosis, planning of medical and surgical intervention January 2006 13 Michael Monge, HMS IV Gillian Lieberman, MD Garden Classifications • Studies indicate that Radiologist agree in diagnosing garden types only 22% of the time • The important distinction is I/II versus II/IV because risk of avascular necrosis jumps from 7% to 37% respectively • This distinction is clear McGraw Hill I II III IV January 2006 14 Michael Monge, HMS IV Gillian Lieberman, MD Garden Type I/II • Type I • Incomplete fracture • No displacement • Type II • Complete fracture • No displacement • Internal rotation causes hip pain • Sometimes able bear weight • Ecchymoses • Stinchfield test January 2006 15 Michael Monge, HMS IV Gillian Lieberman, MD Images from BIDMC Hospital Garden Type 1 Fracture Uptake in femoral neck on bone scan Incomplete femoral neck fracture January 2006 16 Michael Monge, HMS IV Gillian Lieberman, MD www.wheelessonline.com Garden Type II Fracture T1 MRI complete femoral neck fracture January 2006 17 Michael Monge, HMS IV Gillian Lieberman, MD Garden Type III/IV • Garden III • Complete • Partial displacement • Garden IV • Complete • Total displacement • Unable to bear weight • Groin pain • External rotation • Short limb January 2006 18 Michael Monge, HMS IV Gillian Lieberman, MD www.wheelessonline.com T1 MRI complete femoral neck fracture with partial displacement Garden Type III Fracture January 2006 19 Michael Monge, HMS IV Gillian Lieberman, MD Patient 1 • 79 year old female with history of CVA in 2002, aphasia, dementia, and COPD • Admitted for a fall in her kitchen • Unable to acquire a verbal history due to her aphasia • Found by her son who was visiting January 2006 20 Michael Monge, HMS IV Gillian Lieberman, MD Images from BIDMC Hospital P1 Hip Radiograph 1 Type IV January 2006 21 Michael Monge, HMS IV Gillian Lieberman, MD Images from BIDMC Hospital P1 Hip Radiograph 2 Femoral head replacement January 2006 22 Michael Monge, HMS IV Gillian Lieberman, MD Patient 2 • 35 year old male s/p motorcycle accident • High energy mechanism of trauma • Multiple soft tissue injuries and fractures January 2006 23 Michael Monge, HMS IV Gillian Lieberman, MD Images from BIDMC Hospital P2 Radiograph 1 Type IV fracture s/p external reduction Sacroiliac fracture and widened pubic symphysis January 2006 24 Michael Monge, HMS IV Gillian Lieberman, MD Images from BIDMC Hospital P2 CT 1 Femoral neck fracture Superomedial pubic ramus fracture January 2006 25 Michael Monge, HMS IV Gillian Lieberman, MD Images from BIDMC Hospital P2 CT 2 Sacroiliac joint fracture January 2006 26 Michael Monge, HMS IV Gillian Lieberman, MD Images from BIDMC Hospital P2 CT 3 Kidney laceration January 2006 27 Michael Monge, HMS IV Gillian Lieberman, MD Images from BIDMC Hospital P2 CT 4 Inferior pubic ramus fracture Subcutaneous emphysema January 2006 28 Michael Monge, HMS IV Gillian Lieberman, MD Images from BIDMC Hospital P2 Radiograph 2 Internal fixation with screw January 2006 29 Michael Monge, HMS IV Gillian Lieberman, MD Summary • Femoral neck fractures have a high associated mortality and morbidity • Falls are the major cause in elderly and high energy trauma in younger patients • Radiological assessment is critical for prompt surgical and medical intervention January 2006 30 Michael Monge, HMS IV Gillian Lieberman, MD Acknowledgements • Thanks to Dr. Gillian Lieberman and Pamela Lepkowski for their help and inspiration • Cristina Cavazos, MD for her help with patient cases and images • Thanks for all the help from the Radiology service and my classmates! January 2006 31 Michael Monge, HMS IV Gillian Lieberman, MD References • Zuckerman JD. Hip Fracture. NEJM 1996;334 1519-1525 • Guyton JL. Fracture of hip, acetabulum, and pelvis. Campbell’s Operative Orthopaedics • Fox KM, Magaziner J, Hebel JR, et el. Intertrochanteric versus femoral neck fractures: differential characteristics, treatments, and sequelae. J Gerontol A Biol Sci 1999;54:M635-640 • Hernandez-Avila M, Colditz GA, Stampfer MJ, et al. Caffeine, moderate alcohol intake, and risk of fractures of the hip and forearm in middle-aged women. Am J Clin Nutr 1991;54:157-163 • McGrory BJ. Stinchfield resisted hip flexion test. Hosp Physician 1999;35(9):41- 2 • Koval KJ, Zuckerman JD. Hip fractures I. Overview and evaluation and treatment of femoral-neck fractures. J Am Acad Orthop Surg 1994;2:141-149 • Cummings SR, Nevitt MC, Browner WS, et al. Risk factors for hip fracture in wh ite women. Study of Osteo-porotic Fractures Research Group. NEJM 1995; 332:767-773 • www.wheelessonline.com • www.uptodate.com • www.bartleby.com/107 • http://www.orthoassociates.com/hipfx.htm • www.emedicine.com • http://classes.kumc.edu/som/radanatomy/ Femoral Neck Fractures Agenda Epidemiology 1 Epidemiology 2 Epidemiology 3 Femoral Anatomy 1 Femoral Anatomy 2 Femoral Anatomy 3 Femoral Anatomy 4 Types of hip fractures Femoral Vessels Femoral Angiogram Role of imaging Garden Classifications Garden Type I/II Garden Type 1 Fracture Garden Type II Fracture Garden Type III/IV Garden Type III Fracture Patient 1 P1 Hip Radiograph 1 P1 Hip Radiograph 2 Patient 2 P2 Radiograph 1 P2 CT 1 P2 CT 2 P2 CT 3 P2 CT 4 P2 Radiograph 2 Summary Acknowledgements References