title: Association of geometric factors and failure load level with the distribution of cervical vs. trochanteric hip fractures.
abstract: We experimentally studied the distribution of hip fracture types at different structural mechanical strength. Femoral neck fractures were dominant at the lowest structural strength levels, whereas trochanteric fractures were more common at high failure loads. The best predictor of fracture type across all failure loads and in both sexes was the neck-shaft angle.
  
  
  BACKGROUND
  Bone geometry has been shown to be a potential risk factor for osteoporotic fractures. Risk factors have been shown to differ between cervical and trochanteric hip fractures. However, the determinants of cervical and trochanteric fractures at different levels of structural mechanical strength are currently unknown. In addition, it is not known if the distribution of fracture types differs between sexes. The aim of this experimental study on excised femora was to investigate whether there exist differences in the distribution of cervical and trochanteric fractures between different structural mechanical strength levels and different sexes and to identify the geometric determinants that predict a fracture type.
  
  
  METHODS
  The sample was comprised of 140 cadavers (77 females: mean age, 81.7 years; 63 males: mean age, 79.1 years) from whom the left femora were excised for analysis. The bones were radiographed, and geometrical parameters were determined from the digitized X-rays. The femora were mechanically tested in a side impact configuration, simulating a sideways fall. After the mechanical test, the fracture patterns were classified into cervical and trochanteric.
  
  
  RESULTS
  The overall proportion of cervical fractures was higher in females (74%) than in males (49%) (p = 0.002). The fracture type distribution differed significantly across load quartiles in females (p = 0.025), but not in males (p = 0.205). At the lowest load quartiles, 94.7% of fractures in female and 62.5% in males were femoral neck fractures. At the highest quartiles, in contrast, only 52.6% of fractures in females and 33.3% in males were cervical fractures. Among geometric variables, the neck-shaft angle was the best predictor of fracture type, with higher values in subjects with cervical fractures. This finding was made in females (p < 0.001) and males (p = 0.02) and was consistent across all failure load quartiles.
  
  
  CONCLUSIONS
  Femoral neck fractures predominate at the lowest structural mechanical strength levels, whereas trochanteric fractures are more common at high failure loads. Females are more susceptible to femoral neck fractures than males. The best predictor of fracture type across all structural strength levels and both sexes was the neck-shaft angle.
authors.affiliation: Department of Medical Technology, Faculty of Medicine, University of Oulu, Finland. pasi.pulkkinen@oulu.fi
authors.forename: Pasi
authors.initials: P
authors.lastname: Pulkkinen
authors.forename: Felix
authors.initials: F
authors.lastname: Eckstein
authors.forename: Eva-Maria
authors.initials: EM
authors.lastname: Lochmüller
authors.forename: Volker
authors.initials: V
authors.lastname: Kuhn
authors.forename: Timo
authors.initials: T
authors.lastname: Jämsä
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002102:Cadaver; D005260:Female; D005265:Femoral Neck Fractures / Q000503:physiopathology*; D005269:Femur / Q000000981:diagnostic imaging / Q000503:physiopathology*; D006620:Hip Fractures / Q000503:physiopathology*; D006801:Humans; D008297:Male; D011859:Radiography; D012737:Sex Factors; D013314:Stress, Mechanical