Fracture neck of femur

1. FRACTURE OF NECK OF THE FEMUR Dr. Prateek Singh (intern) Department Of Orthopedics B.P. Koirala Institute of Health Sciences

2. INTRODUCTION The structure of the head and neck of femur is developed for the transmission of body weight efficiently, with minimum bone mass, by appropriate distribution of the bony trabeculae in the neck.  The tension trabeculae and compression trabeculae along with the strong calcar femorale on the medial cortex of the neck of the femur form an efficient system to withstand load bearing and torsion under normal stresses of locomotion and weight bearing. 10/16/2012 2

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4. ANATOMY OF NECK OF FEMUR Neck connects head with shaft and is about 3.7 cm long. It makes angle with the shaft 130+/- 7 degree ( less in female due to their wider pelvis). It facilitate movements of hip joint. It is strengthened by calcar femorale (bony thickening along its concavity). 10/16/2012 4

5. 2 borders and 2 surfaces - upper border – concave and horizontal meets the shaft at greater trochanter . - lower border – straight and oblique meet the shaft at lesser trochanter . - anterior surface- flat .meet shaft at intertrochanteric line . Entirely intra capsular. -posterior surface- convex from above downwards and concave from side to side.meets shaft at intertrochanteric crest.it is crossed by horizontal groove for tendon of obturator externus . 10/16/2012 5

6. Blood sypply Crock described the arteries of the proximal end of the femur in three groups (a) an extracapsular arterial ring located at the base of the femoral neck; (b) ascending cervical branches of the extracapsular arterial ring on the surface of the femoral neck (known as retinacular arteries) (c) the arteries of the ligamentum teres 10/16/2012 6

7. a) The extracapsular arterial ring is formed posteriorly by a large branch of the medial femoral circumflex artery and anteriorly by branches of the lateral femoral circumflex artery . The superior and inferior gluteal arteries also have minor contributions to this ring The ascending cervical arteries can be divided into four groups (anterior, medial, posterior, and lateral) based on their relationship to the femoral neck. lateral group provides most of the blood supply to the femoral head and neck. 10/16/2012 7

8. The artery of the ligamentum teres is a branch of the obturator or the medial femoral circumflex artery only small & variable amount of femoral head is nourished by artery of ligamentum teres . 10/16/2012 8

9. 10/16/2012 9 Vascular anatomy of the femoral head and neck

10. 10/16/2012 10 Anterior aspect

11. PATHO-ANATOMY Most fracture are displaced with distal fragment – externally rotated, adducted, and proximally migrated. These displacement are less marked than in intertrochanteric fracture because the capsule of hip joint is attached to distal fragment and prevent extreme rotation and displacement of distal fragment. 10/16/2012 11

12. Displacement of the lower bone fragment caused by the pull of the powerful muscles. In particular the outward rotation of the leg so that the foot characteristically points laterally. (GM) gluteus maximus ; (PI) piriformis ; (OI) obturator internus ; (GE) gemelli ; (QF) quadratus femoris ; (RF) rectus femoris ; (AM) adductor muscles; (HS) hamstring muscles 10/16/2012 12

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14. ETIOLOGY Commonest site of # in elderly(7 th /8 th decade). Post menopausal women, osteomalacia , diabetes, stroke, alcoholism, chronic debilitating disease. Old people– weak muscle, poor balance – increased tendency to fall. Fall directly onto greater trochanter . Fall from height, RTA 10/16/2012 14

15. CLASSIFICATION - ANATOMICAL LOCATION - subcapital - transcervical - basicervical (base of the neck fracture) 10/16/2012 15

16. - PAUWEL This is based on the angle of fracture from the horizontal Type I: 30 degrees Type II: 50 degrees Type III: 70 degrees 10/16/2012 16

17. 10/16/2012 17 As the fracture progresses from type 1 to type 3, the obliquity of the fracture fracture line increases, thus the shear force at the fracture site increases

18. 10/16/2012 18 - GARDEN This is based on the degree of valgus displacement Type I: Incomplete/ valgus impacted Type II: Complete and nondisplaced on AP and lateral views Type III: Complete with partial displacement; trabecular pattern of the femoral head does not line up with that of the acetabulum Type IV: Completely displaced; trabecular pattern of the head assumes a parallel orientation with that of the acetabulum

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21. - Orthopaedic Trauma Association (OTA) Classification B1 group fracture is nondisplaced to minimally displaced subcapital fracture B2 group includes transcervical fractures through the middle or base of the neck B3 group includes all displaced nonimpacted subcapital fractures 10/16/2012 21

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23. MECHANISM OF INJURY Low-energy trauma (most common in older patients) - Direct: A fall onto the greater trochanter ( valgus impaction) or forced external rotation of the lower extremity impinges an osteoporotic neck onto the posterior lip of the acetabulum (resulting in posterior comminution ). - Indirect : Muscle forces overwhelm the strength of the femoral neck 10/16/2012 23

24. High-energy trauma- accounts for femoral neck fractures in both younger and older patients, such as motor-vehicle accident or fall from a significant height. Cyclical loading-stress fractures: These are seen in athletes, military recruits, ballet dancers; patients with osteoporosis and osteopenia are at particular risk. 10/16/2012 24

25. CLINICAL PRESENTATIONS H/O fall from height. nonambulatory on presentation (EXCEPT impacted fracture patient may still be able to walk) shortening and external rotation of the lower extremity. 10/16/2012 25

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27. CLINICAL EVALUATION Pain is evident on range of hip motion, with possible pain on axial compression and tenderness to palpation of the groin. Tenderness over Scarpa`s triangle Active SLR not possible 10/16/2012 27

28. DIAGNOSIS Situations in which femoral neck fracture may be missed- Stress fractures- elderly patient with unexplained pain in the hip should be considered to have stress fracture until proven otherwise. Undisplaced fracture- impacted fracture may be difficult to visualise on plain x-ray. Painless fracture -a bed ridden patient may develop a silent fracture. 10/16/2012 28

29. Multiple fractures -patient with a femoral shaft fracture may also have a hip fracture which is easily missed unless the pelvis is x rayed. 10/16/2012 29

30. RADIOGRAPHIC EVALUATION An anteroposterior (AP) view of the pelvis both hip in 15 ° internal rotation and a cross-table lateral view of the involved proximal femur are indicated Technetium bone scan or preferably magnetic resonance imaging may be of clinical utility in delineating nondisplaced or occult fractures that are not apparent on plain radiographs. 10/16/2012 30

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32. The Importance of a True AP Hip Position 10/16/2012 32

33. 10/16/2012 33 Cross table view

34. Modified Rolled Lateral HipIII (Modified Friedman Method) 10/16/2012 copyright (your organization) 2003 34

35. The patient is positioned as shown above with a slightly raised knee (15-20 degrees) and a smaller cephalic tube angle (15-20 degrees). 10/16/2012 35

36. Shenton's Line Shenton's line is a line formed by the inferior aspect of the superior pubic ramus and the medial aspect of the upper femur. Shenton's line should describe a smooth curve. If there is any sharp angulation of Shenton's line the patient could have a neck of femur fracture. An abnormal Shenton's line can be the most obvious indicator of a patient's fractured neck of femur demonstrated on an AP pelvis /hip image. 10/16/2012 36

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38. TREATMENT Goals of treatment are to minimize patient discomfort, restore hip function, allow rapid mobilization by obtaining early anatomic reduction and stable internal fixation or prosthetic replacement. 10/16/2012 38

39. In children- close reduction and Hip spica . If not reduced then ORIF with Moore`s pins. Adults impacted or garden type 1 & 2 Non-operative Treatment- bed rest for elderly person whose medical condition carries an excessively high risk of mortality from anesthesia and surgery 10/16/2012 39

40. Operative Treatment- include the following Internal fixation with multiple cancellous lag screws.( preffered treatment) Sliding hip screw – advantages- 1) biomechanical strength greater than multiple cancellous screws. 2) minimization of risk of subsequent subtrochanteric fracture secondary to a stress riser effect. 3) placement of compression across the fracture at the time of reduction 10/16/2012 40

41. Disadvantages- 1) stabilization include a larger surgical exposure 2) potential to create rotational malalignment of the femoral head at the time of screw insertion. 10/16/2012 41 Fracture of the femoral neck stabilized with three well-placed, 6.5-mm, short threaded cancellous lag screws.

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43. displaced or garden type 3& 4 age less than 60 years- internal fixation by 1)Multiple cancellous screw-most commonly used. 2)Dynamic hip screw (DHS) 3)smith peterson nail (S.P. nail) 10/16/2012 43

44. age more than 60 years normal hip - Hemiarthroplasty with Austin-Moore prosthesis. 10/16/2012 44

45. Indications for hemiarthroplasty Comminuted, displaced femoral neck fracture in the elderly Pathologic fracture Poor medical condition Poorer ambulatory status before fracture Neurologic condition (dementia, ataxia, hemiplegia , parkinsonism) 10/16/2012 45

46. Advantages of Hemiarthroplasty over open reduction and internal fixation : It may allow faster full weight bearing It eliminates nonunion, osteonecrosis , failure of fixation risks . Disadvantages: It is a more extensive procedure with greater blood loss A risk of acetabular erosion exists in active individuals 10/16/2012 46

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48. preexisting degenerative condition - total hip replacement Indications osteoarthritis, rheumatoid arthritis, severe osteoporosis pathologic conditions with acetabular involvement such as Paget's disease 10/16/2012 48

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50. COMPLICATIONS General- Deep vein thrombosis Pulmonary embolism Pmeumonia Bed sores Osteoarthritis Avascular necrosis Non-union 10/16/2012 50

51. cause of AVN and non-union Tearing the capsular vessels the injury deprives the head its main blood supply Intra articular bone has only flimsy periosteum and no contact with soft tissue which could promote callus formation Synovial fluid prevents clotting of the fracture hematoma 10/16/2012 51

52. refrences Essential orthopaedics – J. Maheshwari Handbook of Fractures- Kenneth J. Koval M.D & Joseph D. Zuckerman M.D Rockwood & Green's Fractures in Adults- Robert W. Bucholz MD, James D. Heckman MD, Charles M. Court-Brown MD. Apleys System of orthopaedics and fractures David Warwick MD. 10/16/2012 52

53. GREY’S ANATOMY B.D. chaurasia’s human anatomy 10/16/2012 53

54. 10/16/2012 copyright (your organization) 2003 54 THANK YOU