Subtrokanterik femur kırığı

Özet

Subtrokanterik kırıklar trokanterlerin distalindeki proksimal femurda yer alır; gençlerde genellikle yüksek enerjili, yaşlılarda osteoporoz eşliğinde düşük enerjili travmayla oluşabilir. Kontrastsız BT kırık çizgisini, kortikal parçalanmayı ve kalça bölgesinden şaft diyafizine uzanan gizli hatları gösterir. Küçük trokanter fragmanı rotasyonel deformiteyle ilişkili olabilir; varus malalignmentı ve medial kortikal desteğin kaybı kaynama sorunları açısından önem taşır. Altta yatan kemik lezyonunun ya da implant çevresi kırığın atlanması kırık bağlamının hatalı yorumlanmasına neden olabilir.

Faz ve pencere

Kontrastsız tanısal

Küçük trokanter altından proksimal şaft boyunca kortikal kırık hattı, medial/posteromedial parçalanma, angulasyon ve kemik içi lezyon değerlendirilir; kontrastlı faz kemik kırığını göstermek için gerekli değildir.

Kemik algoritması tanısal

Aksiyel görüntülerdeki kortikal kesinti koronal ve sagittal rekonstrüksiyonlarla izlenerek trokanterik bölgeye veya diyafize uzanım, implant çevresi tutulum ve fragman sayısı ortaya konur.

Önerilen pencereler: Kemik (G 1800 / M 400).

BT bulguları

• Subtrokanterik ana hat — küçük trokanter distalindeki proksimal şaft korteksini oblik veya transvers geçer.
• Medial korteks parçalanması — küçük trokanter veya posteromedial şafttan ayrılan kelebek fragman destek kaybını gösterir.
• Varus açılanma — proksimal fragman ile distal şaftın eksenleri içe açılanır; iliopsoas etkisiyle proksimal fragman fleksiyon ve dış rotasyonda olabilir.
• Kısalma ve translasyon — distal şaft proksimale ve mediale yer değiştirebilir; fragman uçlarının örtüşme miktarı ve kısalma belirtilir.
• Ters oblik/trokanterik devam — hat küçük trokanter düzeyine veya intertrokanterik kortekse uzanarak trokanterik kırıkla birleşir.
• Patolojik kırık zemini — kırık hattı çevresinde litik yıkım, skleroz, kortikal genişleme veya kemik iliğini dolduran kitle araştırılır.
• İmplant ilişkisi — protez sapı, plak veya intramedüller çivi çevresindeki kırık başlangıcı ve gevşeme/osteoliz eşlikçisi tariflenir.

Ölçütler ve sınıflamalar

Seinsheimer

I: deplasman yok veya <2 mm; II: iki parçalı (IIA transvers, IIB spiral ve küçük trokanter proksimal fragmana bağlı, IIC spiral ve küçük trokanter distal fragmana bağlı); III: üç parçalı (IIIA küçük trokanter ve alt kortikal çıkıntı üçüncü fragman, IIIB kelebek fragman); IV: ≥4 fragmanlı parçalı kırık; V: büyük trokanterden geçen proksimal uzanım. Morfolojik tanımlamadır.

Russell-Taylor

Sık kullanılan ancak evrensel olarak üstün kabul edilmiş olmayan sınıflama: tip I kırık trokanterik/piriformis fossaya uzanmaz (IA küçük trokanter sağlam, IB tutulmuş); tip II fossaya uzanır (IIA küçük trokanter sağlam, IIB küçük trokanter tutulmuş). Sınıflama trokanterik fossa ve küçük trokanter tutulumuna dayanır.

Normalde

Normal proksimal femur şaftında medial ve lateral korteks kesintisiz, kanal içi trabeküler yapı homojendir; küçük trokanterden diyafize geçişte kontur düzgündür. Karşı femurun aynı seviyesini ve varsa eski görüntüleri kıyaslayarak kortikal kalınlaşma, fokal kemik yıkımı, implant gevşemesi veya yeni eksen bozukluğunu ayırın.

Ayırıcı tanı

İntertrokanterik kırık

ana çizgi büyük ve küçük trokanterler arasındadır; subtrokanterik uzanım ikincil olarak eklenebilir.

Femur cisim kırığı

femur diyafizindeki kırık, subtrokanterik kırıklardan ayrı bir yerleşim olarak tanımlanır.

Atipik femur kırığı

lateral korteksten başlayan transvers veya kısa oblik çizgiye kortikal kalınlaşma eşlik eder; uzun süreli antiresorptif öykü görüntüleme dışı klinik bağlamdır.

Metastatik/patolojik kırık

fokal litik veya sklerotik kemik lezyonu ve kortikal destrüksiyon kırık hattının merkezinde bulunabilir.

Periprostetik kırık

hattın bir femoral protez sapı çevresindeki ilişkisi ve protezin stabilitesi ayrıca değerlendirilir.

Tuzaklar

• Küçük trokanter seviyesindeki sınır tüm yayınlarda aynı tanımlanmaz; raporda yalnız etiket vermek yerine kırığın gerçek anatomik seviyesini ve uzanımını belirtin.
• Osteoporotik veya atipik kırıkta ince başlangıç çizgisi yalnız tek kortekste belirgin olabilir; karşı korteksi ve tüm çevresel kortikal kalınlaşmayı gözden geçirin.
• Yoğun parçalanmayı kemik lezyonu sanmayın; fokal medüller yıkım veya sklerozun kırık hattından bağımsız uzanıp uzanmadığını kontrol edin.
• Kalça BT'sinin alt sınırı subtrokanterik kırığı kesebilir; görüntü hacminin distal uca kadar kırığı kapsadığını doğrulayın.

Kendini dene

1. Düşük enerjili femur kırığı olan genç bir erişkinde hangi kırık zemini özellikle düşünülmelidir?

   • Patolojik kırık
   • Femur boyun kırığı
   • Pipkin kırığı
   • Distal femur kırığı
   Cevabı göster

   Patolojik kırık. Genç erişkinlerde düşük enerjili femur kırığında patolojik kırık olasılığı düşünülmelidir; kaynakta bu durumda patolojik kırıklardan şüphelenilmesi öneriliyor.

2. Kırık seviyesinde fokal litik kemik yıkımı ve kortikal incelme de izleniyor. Ek olarak hangi bulgu özellikle aranmalıdır?

   • Patolojik kırık zemini
   • İzole eklem efüzyonu
   • Labrum yırtığı
   • Osteofit oluşumu
   Cevabı göster

   Patolojik kırık zemini. Fokal litik yıkım, kırığın neoplastik ya da başka patolojik bir kemik zemini üzerinde gelişebileceğini düşündürür. Diğer seçenekler kemik içi destrüktif odağı açıklamaz.

Kaynaklar

Bu sayfadaki 41 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla otomatik olarak karşılaştırıldı; 1 cümle bu karşılaştırmada düzeltildi (2026-10-09).

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Eğitim amaçlıdır; hasta başında tanı ve tedavi kararının yerine geçmez, tıbbi tavsiye değildir. Metinler yapay zekâ desteğiyle yazıldı ve otomatik bir adımda kaynak alıntılarıyla karşılaştırıldı; bu bir tıbbi doğrulama değildir ve içerik uzman radyolog incelemesinden geçmedi. Klinik kararlarda güncel kılavuzları, kurum protokollerini ve radyoloji raporunu esas alın.