management of neck of femur fracture

it comprises of the anatomy, epidemiology, mechanism of injury and management options.
there is also the fracture classifications
management was grouped into operative and conservative
there is also a section for children.

1. MANAGEMENT OF NECK OF FEMUR FRACTURE DR P. MENSAH 1

2. SCOPE OF WORK Introduction Epidemiology Surgical Anatomy Classification Mechanism Of Injury Clinical Presentation Investigations Management Options Complication Neck Of Femur Fracture In Children Conclusion References 2

3. Introduction The femur being the longest bone in the human body has different parts among which are the head, neck, greater and lesser trochanters, shaft and the distal condyles, and therefore fracture can occur in any of these areas. Its also the strongest and largest bone in the human body. It therefore requires high-energy trauma for it to fracture unless there is an ongoing pathology that weakens the bone 3

4. Introduction Neck of femur fracture is the most common fracture requiring surgical treatment. It is a typical fragility fracture in the elderly, as a consequence of osteoporosis, advancing age or chronic disease. The fracture is often indicative of a generalized decline in health, including cognitive ability, balance, muscle power and eyesight. 4

5. Introduction In addition, an acute inter-current illness, such as urinary tract infection, is often the precipitant of the fall that breaks the neck of femur. These patients are often medically and socially vulnerable and have a high level of perioperative and postoperative mortality and dependency . Prompt and effective surgical and medical care has a substantial effect on improving this prognosis . The associated annual healthcare costs in the UK amount to £2 billion and € 2–4 billion in Germany 5

6. Epidemiology In 2000, there were an estimated 424,000 neck of femur fractures worldwide in men and 1,098,000 in women. Based on changing demographics and the increase in life expectancy, by 2025 neck of femur fractures in men are expected to rise by 89%, resulting in 800,000 neck of femur fractures per year in men, while the number of neck of femur fractures in women will rise by 69% and reach 1.8 million. AO PRINCIPLES OF FRACTURE MANAGEMENT 6

7. Epidemiology In addition, 5% of patients with neck of femur fracture have a simultaneous fragility fracture (most commonly at the wrist or proximal humerus ) There is also an 8% chance of sustaining a fracture of the contralateral neck of femur in the next 8 years. Up to 50% of women are expected to suffer a neck of femur fracture in their lifetime. 7

8. Epidemiology Around 30% will die within a year of their fall and 25% of the remainder will never return to independent living. There is a significant risk of mortality and morbidity post injury; according to the National Hip Fracture Database England, Wales and Northern Ireland in 2015, 7.5% of patients will die within 1 month of hip fracture rising to 24% within 12 months. 8

9. Epidemiology Hip fracture rates are highest in Northern and Central Europe, moderate in North America, Japan and Oceania and at the lowest in south Asia and Africa. For each decade after 50 the risk of hip fracture doubles . Numbers of annual hip fracture cases treated are: UK=100,000 Germany=135,000 Netherlands 18,500 More than 50% of femoral neck fractures are intracapsular and up to 80% are displaced 9

10. Epidemiology In 2014, Ejimofor et al, published an article on “The Pattern of femoral fracture and associated injuries in a Nigerian tertiary trauma centre . It was a 10 year (1994 to 2004) retrospective study. Their results 562 femoral fractures were seen over the period with 63.7% males and 36.3% females MOI= RTA – 62.8%, Minor falls/trips – 18%, fall from height – 11.2 % AREA OF FRACTURE= Neck – 16%, mid-shaft – 26.5%, Head – 0.9%, Pertrochanteric – 9.8%, Subtrochanteric – 12.5% 10

11. Epidemiology - In CCTH – from Jan 2018 – Oct 2021 46 cases in total – Neck of femur Fracture 19 males and 27 females 0 -19 = 4 20-39 = 2 40-59 = 9 60-79 = 11 > 80 = 20 11

12. Surgical Anatomy 12

13. Surgical Anatomy 13

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15. Surgical anatomy 15

16. Types of Neck Of femur Fracture Based on capsule – its important because of blood supply Intracapsular Extracapsular 16

17. Types of Intracapsular 17

18. Classification of Intracapsular Garden Classification Pauwels Classification 18

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20. Garden Classification 20

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22. Types of Extracapsular Fractures involving the trochanters are extracapsular and occur in metaphyseal bone with a good blood supply and do not threaten the vascularity of the femoral head. The aim of treatment is immediate full weight bearing and early rehabilitation, thus the treatment is operative 22

23. Classification of Extracapsular Fracture 23

24. Mechanism of Injury Low Energy falls in Elderly Falling directly onto the hip Twisting Mechanism Sudden completion of an impartial fracture Pathological fracture High Energy in the Y oung Motor Vehicle Accident Pedestrian Vehicle Accident Fall from height 24

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26. Clinical Presentation Pain in the affected hip There will be tenderness over the groin There will be pain on attempted passive rotation of the limb. The patient will be unable to perform a straight-leg raise . The lower limb will be shortened and externally rotated if the fracture is displaced. Bruising only appears later. 26

27. Investigation Xray – is the preferred initial modality: Universally available Ease of Acquisition Easy to read Recommended Views - Obtain A-P View pelvis - This is required to allow full assessment of the hip and pelvic ring. - Cross-table lateral - assess for any displacement of the head , which should normally be aligned centrally on the neck full length femur of ipsilateral side - to use as template Garden Classification is based on AP pelvis 27

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30. CT- Scan is required in the evaluation of complex hip injury , such as a native hip dislocation or femoral head fracture. It can also be used in the assessment of occult hip fracture . MRI is also a suitable modality for the assessment of occult hip fracture , and it will also demonstrate other soft tissue causes of hip pain , such as a psoas abscess. 30

31. Management Options Initial Management Save life before limb Young Old Once the safety of the patient has been established, attention is directed to the fracture A treatment algorithm should address The age The level of activity Bone density Additional diseases (comorbidities) Estimated life expectancy The compliance of the patient 31

32. Management Options Conservative (Non-operative) Operative 32

33. Conservative (Non-operative) Not advised – fractures at this level have poor capacity for union due to the following: Interference with blood supply to proximal fragment Difficulty in controlling the small proximal fragment The lack of organization of the fracture haematoma due to the presence of the synovial fluid Also it is : Cumbersome for the patient Labour intensive for Nurses Bad outcomes for Clinicians 33

34. Conservative (Non-operative) Only considered in situations where there is no facility or skill for operative management. Also for patient who have a lot of co-morbidities and is unfit for surgery 5 – 8% of elderly patients would not be fit for surgery because of terminal illness Traction is the non-operative management – for at least 6 – 8 weeks but often 10 – 12 weeks Skin Traction Skeletal traction 34

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36. Disadvantages of prolonged skin traction Loosening Constriction Friction with skin irritation Allergy 36

37. Operative 37

38. Operative Two essential principles to be followed in the operative management of this fracture Perfect anatomical reduction Rigid internal fixation The type of surgery done is dependent on Characteristics of fracture Age of Patient 38

39. Methods of Internal fixation Cannulated screws Dynamic Hip Screw Proximal Femoral Nailing Arthroplasty 39

40. Cannulated screws Indications Nondisplaced transcervical fracture Garden I and II fracture patterns in the elderly Can be done percutaneously 40

41. Traction table 41

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43. Dynamic Hip Screws The dynamic (or sliding) hip screw (DHS) is a remarkably successful device comprising a lag screw in the femoral head and neck, which articulates with the barrel of a side plate that is secured to the femoral shaft. The screw has flat sides that correspond to the internal shape of the barrel, allowing longitudinal sliding but preventing postoperative rotation. This construct allows maintenance of fixed neck-shaft angle, and linear controlled collapse and compression of the fracture, as the lag screw slides into the barrel of the plate during postoperative mobilization. 43

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47. DHS : Tip – Apex Ratio 47

48. Proximal femoral Nailing Its an intramedullary fixation device used for Extracapsular fracture. The shaft of the nail prevents lateral displacement of the fragments (or the corollary— medialization of the femoral shaft ).   Fixation may be associated with shorter operation time, less blood loss, and earlier weight bearing 48

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53. DHS VS PFN 53

54. DHS VS PFN Like the DHS, The PFN has: L ag screw that is placed centrally adjacent to the apex of the head A fixed angle between the femoral neck and shaft to allow controlled linear collapse In contrast to the DHS, it has the advantages that it: H as a relatively short lever arm between the device and the fracture, making it more suited to comminuted fractures or those involving the subtrochanteric region H as a reduced sliding distance of the lag screw which minimizes the distance by which the femoral neck shortens in comminuted intertrochanteric fractures, (in theory) improving subsequent function by maintaining hip offset C an be implanted percutaneously. 54

55. DHS VS PFN However, it has some disadvantages compared with the DHS, in that: T here is a higher rate of implant-related fracture, principally at the distal tip of the nail, and particularly with short nails I t is considerably more expensive I t is a technically more difficult operation Despite its theoretical advantages, it has not been shown conclusively that any intertrochanteric fractures (i.e. excluding reverse oblique and subtrochanteric patterns) have a better clinical outcome with a nail than with a DHS. 55

56. A rthroplasty 56

57. Arthroplasty – replacement of the hip Patients older than 80 years, or patients with accompanied ipsilateral arthrosis, rheumatoid arthritis, or a fracture in pathological bone should be treated with replacement arthroplasty, either hemiarthroplasty or total hip replacement. Patients of any age with severe chronic illness or a limited life expectancy should also be managed with a prosthesis S urgeons must be aware that some women develop osteoporosis at an earlier age . 57

58. Its either hemi-arthroplasty or total hip replacement The head of the hemiarthroplasty may be a single block (unipolar) or may have an independent articulation between a small head and a larger outer shell (bipolar). The latter theoretically reduces acetabular wear but this advantage has yet to be proven conclusively . 58

59. Set up and procedure for Arthroplasty 59

60. Hemiarthroplasty 60

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62. Total hip replacement 62

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66. Femoral Neck Fractures in children Hip fractures rarely occur in children but, when they do, they are potentially very serious. There is a high risk of complications, such as osteonecrosis, premature physeal closure and coxa vara . The fracture is usually due to high-energy trauma (e.g . falling from a height or an RTA) Pathological fractures sometimes occur through a bone cyst or benign tumour . Also look for evidence of possible child abuse 66

67. Growth centers of the proximal femoral epiphysis Accounts for 13 – 15% of leg length 30% of length of femur Proximal femoral physis grows 3mm/ yr Entire lower limb grows 23mm/ yr 67

68. Delbet’s Classification This is based on the location of the fracture. Type I – a fracture-separation of the epiphysis. The epiphyseal fragment may also be dislocated from the acetabulum. Type II – a transcervical fracture of the femoral neck . This is the commonest variety, accounting for almost 50% of paediatric hip fractures . Type III – a basal ( cervicotrochanteric ) fracture. This is the second most common injury. Type IV – an intertrochanteric fracture. 68

69. Classification 69

70. Treatment Non-operative Indication – type I, II, III, UNDISPLACED TYPE IV, < 4years Hip Spica cast in abduction Weekly radiographs for 3 weeks Operative Closed reduction and internal fixation – if can be reduced closed Open reduction and internal fixation 70

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72. Operative Management – Cannulated Screws 72

73. Case Study – 9 year Old female 73

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77. Conclusion The ABC’s of primary care for the injured always takes precedence over the fracture treatment. Because of the Nature of the blood supply, Neck of Femur fractures are to be reduced and kept reduced as soon as possible. 77

78. References Keith Moore – Clinical Oriented Anatomy 7 th Edition AO principles of fracture Management Apley Solomons system of orthopaedics and trauma McRae's Orthopaedic Trauma and emergency fracture management 78

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80. Thank You 80