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Fractures of the hip and pelvis are frequent and serious injuries in elderly patients. Due to the aging population, their incidence should double by 2050. Therefore, the social and economical implications of these fractures are significant. Delay in diagnosis increases the associated morbidity and mortality. The purpose is to review the imaging features of these fractures, the imaging techniques (projections, CT) to depict them and their classification based on severity., (Copyright © 2011 Elsevier Masson SAS and Éditions françaises de radiologie. All rights reserved.)

We present a fixation system for trochanteric or subtrochjanteric fractures using a dynamic external fixator. The Citieffe/CH-N fixator was proposed for elderly patients with a significant operative risk (ASA III or IV). A long dynamic screw measuring 9 mm in diameter is inserted into the neck and the head of the femur on a guide wire through a tube protecting skin and muscles. This long screw is connected to the body of the fixator to enable impaction at the fracture level if compression is needed. The dynamic screw can be released to allow free gliding to achieve a dynamic fixation of the fracture. Distraction with the fixator can also be used for subtrochanteric unstable fractures to correct a varus deformity. This technique is a simple rapid solution with minimal operative risk. Complications are minimal and generally temporary, e.g. pin tract infections.

Avulsion fractures of the greater trochanter are very rare in children. We report two such cases which led to femoral head necrosis. Based on these two cases and an extensive review of the literature, we discuss the pathophysiology of this complication and propose a new classification system. Three types of lesions can be identified as a function of the mechanism causing fracture. Type 1 lesions are avulsion fractures of the greater trochanter secondary to acute contraction of the gluteus muscles. This contraction produces a vertical displacement of the greater trochanter. Femoral head necrosis has never been reported as a complication after this type of fracture mechanism. Type 2 avulsion fractures are associated with fracture of the femoral neck with a subsequent risk of femoral head necrosis. Type 3 associates hip dislocation with apophyseal avulsion with, according to the literature, an inevitable progression to head necrosis. The two cases reported look identical with those described by Linhart and Kawenblum illustrate type 3 avulsion fractures of the greater trochanter.

Introduction: The sliding plate has appeared to be a reliable answer for trochanteric fractures. However, impaction allowed by the material may, have an adverse effect (medialisation, shortening, jutting out of the lag screw). The aim of our study was to measure the sliding of the screw in order to assess the impaction in various types of fracture, according to the Ender classification., Material and Methods: Hundred trochanteric fractures have been treated between 1991 and 1993. Eighty four have been analyzed with a follow-up of three months after surgery. The average age was 80.1 years with a 4.2 sex ratio (16 males). One hundred and thirty five degrees free sliding plates were employed for fracture fixation. Full weight bearing was allowed in 78.6 per cent of patients. According to Ender classification, 35 per cent of fractures were type 1, 4 or 5. This was the first group. The second group consisted of types 2 and 3 and the third group of types 6, 7 and 8. The results were assessed on AP and lateral X-rays. The ratio between screw thread length (constant) and screw outside the barrel length, was used to measure impaction on AP view. Osteoporosis was evaluated according to Singh., Results: Despite two screw protrusions out of the femoral head and two failures of the plate, we have observed a healing rate of 100 per cent after three months. Sliding averaged 6.2 mm in group 1, 10.5 mm in group 2 and 16.4 mm in groupe 3. Weight bearing had a low influence on the amount of sliding., Discussion: Group 1 consists of fractures (types 1, 4 and 5) which are two parts fractures considered as stable. Group 2 corresponds to types 2 and 3 considered as intermediate fractures with relative stability. In group 3 (types 6, 7 and 8) we have observed major fracture instability. Osteoporosis does not seem to be the major factor regarding screw sliding., Conclusion: The sliding plate is reliable. However, complex fractures healed in a wrong position which is definitely not acceptable, especially for young patients. Therefore, we advise to avoid the use of sliding plate in case of Ender type 6, 7 and 8.

The authors report 10 segmental fractures of the femoral head associated with a dislocation of the hip. Using PIPKIN's classification, they noted 1 type I, 7 type II and 2 type III fractures. The initial treatment of the hip dislocation was conservative in all cases. Failure of reduction was noted in 6 cases and was complicated by fracture of the femoral neck in 2 cases. The attitude regarding the head fragment was: conservative in 5 cases, the reduction was considered satisfactory in 4 cases and poor in 1 case; surgical in the other 5 cases: screw fixation in 1 case, excision of the fragment in 1 case and prosthetic replacement of the femoral head in 3 cases. After a mean follow-up of 5 years, functional results were satisfactory in the majority of cases. The radiological assessment showed malunion without osteoarthrosis in one case and avascular necrosis of the femoral head in three cases. The authors propose a treatment policy based upon their experience and a review of the literature.

The authors present 76 cases of trochanteric fractures, treated by a Gamma nail. The minimal follow-up was 6 months, with clinical and roentgenographical check-ups. The mean age was 74 years, with a female majority as classically; the most common cause was a simple fall. Unstable fractures represented 53% of the cases, with 39% subtrochanteric; nevertheless, full weight bearing was possible in 83% of the cases. The mechanical complications of this new technique have been studied in details and compared with other most common methods of osteosyntheses: the Ender rod and the sliding screw plate. The Gamma nail shows an uncontestable superiority compared to Ender's rods, but it has little advantage to D.H.S.-T.H.S., particularly because of the delay in full-weight bearing and deep infection rate. The Gamma nail moreover seems to be better adapted for the treatment of subtrochanteric fractures.