INTRACAPSULAR FRACTURE NECK OF FEMUR.ppt

What is intracapsular fracture neck of femur and it's fracture classification and treatment modalities

1. INTRACAPSULAR
FRACTURE NECK OF
FEMUR
Dr. J H VIDYA SAGAR
MS ( Ortho), DNB, FIJR
ASSISTANT PROFESSOR
OSMANIA MEDICAL COLLEGE

2. Anatomy
Physeal closure age 16
Neck-shaft angle
130° ± 7°
Anteversion
10° ± 7°
Calcar Femorale
Posteromedial
dense plate of
bone
calcar

3. FEMUR ANTEVERSION

4. Profunda
Femoris artery
gives medial and
lateral
circumflex
arteries
These two form
the Extra
capsular arterial
ring
Blood Supply to Proximal femur

5. Blood supply to the Femoral
Head
This arterial ring gives
retinacular vessels
which go along the neck
of the femur so they are
called ascending
cervical arteries

6. Blood Supply to the femoral head
These form a ring just
below the head called
the Sub Synovial Intra
Articular arterial ring
From this intra articular
ring of arteries
epiphyseal vessels go
into the head of the
femur
Head is also supplied by
the artery of
ligamentum teres

7. Vascular Anatomy of Femur

8. Bony Trabecular Pattern in
Proximal Femur
Calcar femorale

9. Fracture of Neck of Femur
Intra – Capsular Fracture of
Proximal Femur

10. “We come to the world under the
brim of pelvis and go out of the
world thru the neck of the
femur”
Enigma of an
Orthopedic Surgeon

11. Types
Intra Capsular –
–Subcapital
–Transcervical
–Basal

12. Extra Capsular –
–Inter Trochanteric
–Sub Trochanteric

13. Why fractures of neck fail to heal?
No Cambium layer in the intra capsular area,
so peripheral callus
Synovial fluid lyses the fracture hematoma
Avascularity of the head is imminent due to
the peculiarity in the blood supply

14. Etiology
Osteoporosis in elderly patients
Usually lateral rotation of femur cracks the
fragile neck and then the patients fall
Osteomalacia in the young
Major trauma in young adults

15. Fracture of Neck of Femur
Most of these are displaced
A few are impacted.

16. Anatomical Classification
Depending on the
place of the fracture
Into –
–Sub capital
–Trans Cervical
–Basal

17. Pauwel’s Types
Depends on the angle the fracture line makes with the horizontal

18. Garden’s Classification
Garden I Garden II

19. Garden’s Classification
Garden III Garden IV

20. Garden Classification
I Valgus impacted or
incomplete
II Complete
Non-displaced
III Complete
Partial displacement
IV Complete
Full displacement

21. Plain Film
–Consider traction-internal
rotation view if comminuted
CT scan
– Displacement
– comminution
Diagnosis

22. 22
MRI
–For evaluation of
occult femoral neck
fracture
•Consider MRI in an
elderly patient who is
persistently unable to
weight bear
–100% sensitive and
specific
•May reduce cost by
shortening time to
diagnosis
Diagnosis

23. Treatment Goals:
Geriatric Patients
Mobilize
–Weight bearing as tolerated
–Minimize period of bedrest
Minimize surgical morbidity
–Safest operation
–Decrease chance of reoperation

24. Treatment
Depends on the age of the patient
Aim in children, young adults and upto
60 Y – save the head
–Risk of non-union and avascular necrosis of the
head is always there
After 60 Years or if the bone is osteoporotic
– replace the head

26. In patients less than 16 Y
The capital epiphysis is open and viable
Try to protect it
Closed reduction under C-arm control and
fixation with Austin Moore Pins (Smooth)

28. Patients above 16-18Y
Epiphysis is fused, no more growth
expected
Closed reduction under C-arm control and
fixation with cancellous screws
If it is more than 3 weeks old – fix it and
graft it with muscle pedicle graft

29. Reduction and Fixation

30. Good Union after 3 Months

31. Meyer’s Muscle Pedicle Graft

32. In old patients
Head is osteoporotic
No chance of healing of fracture
Hemi replacement with
–Austin Moore prosthesis if the calcar is
present
–Thompson's prosthesis if the calcar is
absent

33. Fracture of Neck in old
Hemireplacement Arthroplasty

34. Patient is an old geriatric
There will be lot of oteoporosis
Femur will also be weak
The prosthesis may sink
So cemented prosthesis – cement in the
shaft of femur holds the prosthesis from
sinking

35. Case example
78 Y old lady
H/O trivial fall one month ago
H/O Hemi-replacement on one hip an year
ago
The other one is painful after fall

36. Case
The previous one is the cause of fall???

37. Case
Problems
Gross osteoporosis
Absorbed neck
Wide medullary canal

38. Answer
Cemented prosthetic
replacement

40. Complications
Post-traumatic arthrosis
•Joint penetration with hardware
•AVN related
Blood Transfusions
–THR > Hemi > ORIF
–Increased rate of post-op infection
DVT / PE
–Multiple prophylactic regimens exist
–Low dose subcutaneous heparin not effective