fracture of neck of femur

This presentation describes the femoral neck fracture, femoral neck fracture classification,types, treatment and management in brief.

1. Fracture Of Neck of Femur BY: DR. KASHIF HUSSAIN

2. In the name of Allah, the most beneficent, the most merciful.

3. INTRODUCTION: The structure of the head of the femur is developed for the transmission of body weight efficiently, with bone mass, by appropriate distribution of the bony trabeculae in the neck. The tension trabeculae and compression trabeculae along with the strong C alcar femoral on the medial cortex of the femur forms an efficient system to withstand load bearing and torsion under normal stresses of locomotion and weight bearing .

4. According to Definition: ‘’It is a fracture through the intra articular part of the femoral neck is referred as FEMORAL NECK FRACTURE.’’

5. ANATOMY OF NECK OF FEMUR: Femoral neck connects head with shaft and is about 3.7 cm long. It makes angle with the shaft 130+/-7 (less in females due to their wider pelvis). It facilitates movement of hip joint. It is strengthened by Calcar femoral(bony thickening along its concavity). 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 SURFACES - flat , meet shaft at intertrochanteric line. POSTERIOR SURFACE- convex from above downwards and concave from side to side. Meet shaft at the intertrochanteric crest. It is crossed by horizontal groove for tendon of obturator Externus .

6. BLOOD SUPPLY The profunda femoris artery arising from the femoral artery gives off medial circumflex artery. This gives off the lateral epiphyseal & superior and inferior metaphyseal artery. Lateral epiphyseal artery supplies the lateral 2/3 of the femoral head. Superior metaphyseal artery supplies the superior part of the femoral neck & inferior metaphyseal artery supplies the inferior part of the neck & adjacent part of head derived from metaphysis. Medial epiphyseal artery (obturator artery)supplies a circumfoveal sector of the head.

7. RISK FACTORS: Female sex White race Increasing age(6 th & 7 th decade) Poor health Tobacco and alcohol use Previous fracture History of fall Low oestrogen

8. CLINICAL PRESENTATION History of fall Non-ambulatory on presentation(EXCEPT impacted fracture patient may still be able to walk). Shortening and external rotation of the lower extremity. Movements are extremely painful

9. FRACTURE CLASSFICATION According to Anatomical site, It is Sub capital Trans cervical Basicervial (Base of the neck fracture)

10. PAUWELS CLASSIFICATION ‘’This classification which is still frequently used at present calculates the angle between the fracture line of the distal fragment and the horizontal line to determine shearing stress and compressive force .’’ Type I: up to 30 ° Type II: 30°–50 ° Type III: 50 °-70°

11. GARDEN CLASSIFICATION The Garden classification is  a system of categorizing intra capsular hip fractures of the femoral neck . This fracture often disrupt the blood supply to the femoral head.

12. MECHANISM OF INJURY Low energy trauma (MC in Older patient): Direct: A fall on to the greater trochanter (valgus impaction) OR FORCED EXTEENAKL 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. High energy trauma : Accounts for femoral neck fractures in both younger and older patients such as motor vehicle accident or fall rom a significant height. Cyclical loading-stress fractures : These are seen in athletes, military recruits, ballet dancers are at particular risk.

13. RADIOGRAPH EVALUATION Standard Antero-posterior(AP) pelvic view. Cross table lateral view. Traction internal rotation view. MRI has become the image of study of choice to evaluate occult femoral neck fracture. CT-scan is not routinely being used for femoral neck fracture. Bone scan- to rule out occult(hidden) fracture. Break in shenton’s line (an imaginary line drawn along the inferior border of the superior. pubic ramus and along the inferiomedial border of the neck of femur.

14. XRAY (AP & LATERAL) VIEW OF FRACTURE OF NOF THOMSON’S IMPLANT

15. SHENTON’S LINE DHS

16. TREATMENT: The main aims of treatment are: To minimize patient discomfort, Restore hip function Allows rapid mobilization by obtaining early anatomic reduction and stable internal fixation or prosthesis replacement. TREATMENT (IN CHILDREN): Closed reduction and hip- spica . If not reduced then ORIC with Moore’s pin. TREATMENT (IN ADULT): (In Garden type I,II classification fracture) Non-operative treatment: Bed rest for elderly person whose medical condition carries an excessively high risk of mortality from anaesthesia and surgery.

17. Operative T reatment: Internal fixation with multiple cancellous lag Screws(preferred treatment) Sliding hip screw ADVATANGES Biochemical strength greater than multiple cancellous screws. Minimizes the risk of subsequent sub-trochanteric fracture secondary to a stress rises effect. Placement of compression across the fracture at the time of reduction. DISADVANTAGE Stabilization include a larger surgical exposure. Potential to create rotational mal-alignment of the femoral head ar the tome of screw insertion.

18. TREATMENT IN ADULT ( Ingarden Type III, IV Femoral Fracture) If a ge < 60 years then: Internal Fixation by Multiple cancellous screw most commonly used. Dynamic hip screw(DHS) Smith Peterson nail(S.P. nail) If age >60 years then: N ormal hip: hemiarthroplasty with Austin-Moore presentation. INDICATION FOR HEMIARTHROPLASTY Comminuted, displaced femoral neck fracture in the elderly. Pathological fracture Poor medical condition Poorer ambulatory status before fracture Neurologic condition (dementia, ataxia, hemiplegia, parkinsonism).

19. Advantages of Hemiarthroplasty over ORIF : It may allow faster full weight bearing. It eliminates non union , osteonecrosis, failure of fixation risks. Disadvantage: It is a more extensive procedure with greater blood loss. A risk of acetabular erosion exists in active individuals. If Pre-existing degenerative condition occurs then plan for total hip replacement(THR). INDICATIONS: Osteoarthritis Rheumatoid arthritis Severe osteoporosis Pathologic conditions with acetabular involvement such as P aget’s disease.

20. COMPLICATIONS: Deep vein thrombosis(DVT) Pulmonary embolism Pneumonia Bed sores Osteoarthritis Avascular necrosis Non-union

21. POST OPERATIVE MANAGEMENT: Inspected the wound for prevent infection Pulmonary embolism and hypovolemia Prevent bedsores change the position every 2 hours. patient treated with hemiarthroplasty should avoid keeping the hip Joint adduction or internal rotation to prevent re-dislocation. Movement Exercises Weight bearing Activities of daily living

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