Intracapsular fracture neck of femur

#neck of femur

1. INTRACAPSULAR FRACTURE NECK OF THE FEMUR Dr.HARSHA NANDINI TALASILA M.S. ORTHO

2. 50% of the fractures of hip. 80% of these fractures occur in women. Most common in elderly,resulting from low energy falls. In young patients it is a result of high energy mechanism.

3. RISK FACTORS Female sex White race Increasing age Poor health Tobacco and alcohol use Previous history of trivial trauma Previous fractures Low estrogen levels

4. RELEVANT ANATOMY Neck shaft angle : 120 to 135 degrees Femoral anteversion : 10 to 15 degrees CALCAR FEMORALE : vertically oriented plate from the posteromedial portion of the femoral shaft radiating superiorly towards the greater trochanter The capsule of the hip joint is attached anteriorly to the intertrochantric line and posteriorly 1 to 1.5cm proximal to the intertrochantric crest.

5. VASCULAR ANATOMY Extracapsular arterial ring at the base of femur neck Artery of ligamentum teres Epiphyseal blood supply Metaphyseal blood supply

6. EXTRACAPSULAR ARTERIAL RING Anastomosis of medial and lateral circumflex femoral artery. Ascending cervical arteries arise from the anastomosis. They penetrate the anterior capsule. On the posterior aspect of the neck,they pass beneath the orbicular fibres of the capsule and are called as retinacular arteries. 4 groups : medial , lateral,anterior and posterior. At the junction of the head with the neck is the SUBSYNOVIAL INTRA-ARTICULAR RING. These capsular vessels are vulnerable to damage in displaced fractures neck of femur

7. INTERNAL ANATOMY The direction of trabeculae parallels the direction of compressive forces. The bony trabeculae are laid down along the lines of internal stress. A set of vertically oriented trabeculae results from the weight bearing forces across the femoral head. A set of horizontally oriented trabeculae results from the force of the abductor muscles. These two trabecular systems cross each other at right angles.

8. MECHANISM OF INJURY LOW ENERGY TRAUMA: most common in older patients. DIRECT: A fall onto the greater trochanter-VALGUS IMPACTION. Forced external rotation of the lower extremity impinges osteoporotic neck onto the posterior lip of the acetabulum resulting in posterior comminution. HIGH ENERGY TRAUMA : in motor vehicle accidents or fall from a significant height

9. CLASSIFICATIONS

10. ANATOMICAL CLASSIFICATION

11. PAUWELS CLASSIFICATION PAUWEL’S ANGLE : the angle of inclination of the fracture in relation to the horizontal plane. TYPE I: 0 to 30 degrees TYPE II: between 30 and 50 degrees TYPE III: more than 50 degrees

12. GARDEN’S CLASSIFICATION STAGE I: incomplete fracture line (valgus impacted) STAGE II: Complete fracture line NON DISPLACED STAGE III: complete fracture line PARTIALLY DISPLACED Fracture maintain contact between the femur neck and femur head STAGE IV: complete fracture line COMPLETELY DISPLACED Fractures donot maintain contact between the femur head and neck,the trabecular patterns between the head and acetabulum is realigned

13. CLINICAL EVALUATION Non ambulatory on presentation shortening of the lower limb Extended,abducted and external rotation of lower extremity.

14. RADIOGRAPHIC EVALUATION Antero posterior view of the pelvis Cross table lateral view of the involved proximal femur Internal rotation view of the injured hip is helpful to clarify the fracture pattern and treatment plans. MRI is the choice in delineating nondisplaced or occult fractures that are not apparent on plain radiographs.

15. REDUCTION WHITMAN TECHNIQUE Traction to the abducted,extended and externally rotated hip with subsequent internal rotation. LEADBETTER TECHNIQUE The affected limb is flexed at hip to 90 degrees,and the thigh is slightly internally rotated,traction is then applied in line with the femur.

16. GARDEN’S ALIGNMENT INDEX To evaluate femoral neck angulation and alignment. On the anteroposterior image, the angle between the medial shaft and the central axis of the medial compressive trabeculae.

17. Normal: 160 and 180 degrees. Angle less than 160 - varus angle of more than 180 degrees indicates excessive valgus. On the lateral image, angulation should be approximately 180 degrees and deviation of more than 20 degrees indicates excessive anteversion or retroversion

18. TREATMENT

19. CHILDREN CLOSED REDUCTION AND POP APPLICATION(HIP SPICA) MOORE’S PINS FIXATION

20. ADULTS: C-C SCREW FIXATION DYNAMIC HIP SCREW FIXATION

21. CANNULATED CANCELLOUS SCREW Multiple screws fixation in inverted triangle fashion One screw adjacent to the inferior femur neck One screw adjacent to the posterior femur neck.

22. COMPRESSION HIP SCREW A second pin has to be introduced superior to the compression hip screw to control rotation while inserting the screw.

23. ADULTS: MC MURRAYS OSTEOTOMY

24. Mc MURRAY’S OSTEOTOMY Oblique osteotomy at the inter trochantric region The direction of osteotomy is medially upwards. From base of greater trochanter to just above the lesser tro chanter. The distal fragment is displaced medially and adducted. The shearing forces are converted into compressive forces at the fracture site. The line of weight bearing passes from the head directly to the distal fragment.

25. ELDERLY: HEMIARTHROPLASTY TOTAL HIP REPLACEMENT GIRDLESTONE’S PSEUDOARTHROPLASTY

26. PROXIMAL FEMUR LOCKING PLATE High incidence of failure. Use is reserved for fractures with significant femur neck comminution.

27. PROSTHETIC REPLACEMENT ADVANTAGES: Allow faster fullweight bearing. Eleminates risks of non- union,osteonecrosis and failure of fixation. DISADVANTAGE: Extensive procedure with a greater blood loss

28. BIPOLAR Vs UNIPOLAR IMPLANTS There is no proven benefit of bipolar over unipolar implants. Overtime the bipolar implant may lose motion at its inner bearing and functionally become unipolar. Unipolar implant is less expensive implant

29. CEMENTED Vs NONCEMENTED Lower incidence of intraoperative fracture. Risk of intraoperative hypotension and death with pressurization of the cement.

30. TOTAL HIP REPLACEMENT It eliminates the potential for acetabular erosion seen with hemiarthroplasty.

31. COMPLICATIONS

32. NON UNION Usually apparent by 12 months as groin pain,pain on hip extension,pain with weight bearing. Incidence: 5% of undisplaced fractures 25% of displaced fractures.

33. OSTEONECROSIS They may present as groin,buttock or proximal thigh pain Incidence: 10% of non displaced fractures 30% of displaced fractures

34. FIXATION FAILURE Usually related to osteoporotic bone or technical problems( malreduction,poor implant insertion)

35. REFERENCES Campbell’s Operative Orthopaedics Rockwood and Green’s Fractures in adults

36. THANKYOU