NECK OF FEMUR FRACTURE ORTHOPAEDICS.pptx

NECK OF FEMUR FRACTURES
INVESTIGATIONS, MANAGEMENT, COMPLICATIONS

1. Neck Of Femur Fractures – Investigations, Management & Complications Moderator – Dr. Panduranga B V Presenter – Dr. Karthik M V

2. Investigations X-ray CT MRI Bone scan

3. X-ray X-ray AP view taken with traction and internal rotation - to eliminate anteversion of femur Better visualisation of neck and calcar femorale Cross table lateral view

4. X-ray Break in the medial cortex of the neck Overriding of greater trochanter, so that it lies at the level of the head of the femur Break in the trabecular stream Break in Shenton’s line

5. CT Scan Assess fracture comminution preoperatively Determine extent of union postoperatively Bone Scan Shows increased Uptake 80% fracture shows after 24hrs 95% fracture shows after 7 days

6. Magnetic Resonance Imaging In cases where the diagnosis is doubtful, a magnetic resonance imaging (MRI) scan is probably the most useful To diagnose occult fractures MRI images show an undisplaced intracapsular hip fracture

7. Anatomical classification Based on fracture location Subcapital Transcervical Basicervical

8. Garden’s Classification Described in 1961 Based on Degree of displacement Relationship of the trabecular lines in the femoral head to those in the acetabulum In the nonfractured hip, the trabecular lines in the femoral head are in the same orientation as those of the acetabulum

9. Garden’s type 1 Garden I fracture is a valgus-impacted subcapital fracture. fracture is incomplete with a lateral fracture line No breach in medial cortex trabecular lines in the femoral head therefore form an angle with those in the acetabulum

10. Garden’s type 2 Fracture is complete but undisplaced the trabecular lines in the head are colinear with those in the acetabulum and the femoral neck distal to the fracture

11. Garden’s type 3 Incompletely displaced fractures. The femoral head has not lost contact with the femoral neck and head in varus and extended resulting in angulation of the trabecular lines The angulation is in the opposite direction to that described for Garden type 1 fractures

12. Garden’s type 4 Fracture is completely displaced The trabecular lines of femoral head returns to a neutral position within the acetabulum. The femoral neck loses contact with the head and externally rotates, so the trabecular lines in the neck are not colinear with head

13. Pauwel’s classification Pauwels's classification indicates the orientation of the fracture. Based on whether the fracture plane was vertical, oblique, or transverse While type 1 and 2 fractures are relatively stable and can be fixed with screws Type 3 fractures are subject to shear and may be better treated with angle stable fixation such as the use of a dynamic hip screw (DHS).

14. AO/OTA Classification Femoral neck is designated 31B B1 group describes undisplaced femoral neck fractures B2 transcervical fractures B3 category describes displaced subcapital fractures

15. Delbit’s Classification

16. Anatomical influence of fractures Hip axis length is the distance from the lateral aspect of the trochanteric region along the axis of the femoral neck to the inner table of the pelvis Neck shaft angle Increase in Hip axis length and decrease in Neck shaft angle increases risk of neck of femur Fracture

17. Timing of Surgery Early surgical intervention is advantageous because Relieves compression trapping and kinking of the retinacular vessels Restores the physiologic position of the femoral neck and associated vasculature.

18. Nonoperative Treatment of Undisplaced Femoral Neck Fractures Patients can be mobilized touch weight-bearing with crutches. Fracture can be expected to heal in 4 to 6 weeks. The risk of displacement varies from 19% to 46%. Patients with a poor chance of survival due to medical comorbidities or malignancy

19. Types of Surgical fixation Closed reduction and internal fixation Open reduction and internal fixation Prosthetic replacement Hemiarthroplasty Total Hip replacement

20. Closed reduction techniques Hip in Flexion Leadbetter method Hip flexed to 90degree, traction applied along long axis of femur Hip is internally rotated Leg is circumducted into abduction maintaining IR and brought down to table level in extension

21. Flynn Method Hip flexed 90 degree and traction applied laterally in axis of femoral neck Limb is extended and IR by assistant while lateral traction is maintained Smith Peterson Method Gentle traction in slight hip flexion and counter traction on pelvis F/b IR, abduction and extension

22. In Extension Whittman Method Traction of limb in extension Internal rotation in extension 20degree of abduction

23. Traction is increased to correct length and varus deformity at the fracture site The leg is internally rotated and adducted to a neutral position to correct anterior angulation of the apex and to oppose the fracture surfaces Distal fragment is too anterior, the leg is externally rotated again, and pressure is firmly applied to the proximal part of the thigh while the leg is rotated internally

24. ACCURACY OF REDUCTION Garden’s Alignment Index Accuracy of reduction in lateral view as best Mirror of reduction and best guide of prognosis AP view – angle formed by central axis of medial trabecular system in femoral head and medial cortex of femoral shaft (160 degree) Lateral view – Central axis of head and central axis of neck lie in straight line (180 degree)

25. Garden reported good results when the angle was between 155 and 180 degrees on either view. When outside this range, the risk of fixation failure and AVN increased AP view, a valgus reduction is preferable to a varus reduction

26. Lowell Method Cortices of an anatomically aligned femoral head and neck will project shallow S- or reverse S-shaped curves on both x-ray views Malalignment is demonstrated by a flattening of one curve and a sharp apex on the opposite side

27. Closed reduction & internal fixation Cannulated screw fixation Screw diameter – 6.5mm Starting point Entry point for the guide wire is at the level of the lesser trochanter. More distal position causes a stress riser in the lateral cortex lead to Sub-trochanteric fractures.

28. The first guide wire is placed low in the neck (1), immediately above the calcar and into the femoral head. It acts as a cantilever, maintaining reduction in standing position & prevent Varus The second wire is placed posteriorly (2), to lie adjacent to the posterior cortex of the neck on the lateral view. It acts as a cantilever, maintaining reduction patient is sitting or rising. Prevent retroversion The third wire is placed anteriorly and superiorly (3), well away from the first two.

29. A fourth screw ( Diamond configuration ) may be used in patients with significant posterior comminution

30. Cancellous Screw Fixation Concepts ‘Inverted Triangle’ Inferior screw within 3 mm of cortex/calcar Posterior screw within 3 mm of cortex Booth et al. Orthopaedics 1998. Threads > 5 mm from subchondral bone Anticipate some collapse Multiple fluoroscopic views to ensure screws are not intra-articular Do not start below the lesser trochanter Avoid stress riser

31. Dynamic Hip Screw Barrel:– Short barrel—25 mm Standard barrel—38 mm Barrel inner diameter—8.2 mm Barrel outer diameter—12.5 mm

32. Plate: – 4.5 mm screw Hole arrangement—staggered -> Why? Even distribution of stress over plate and bone when limb is loaded. Hence, prevent implant breakage and weakening of bone. Mode of action : Sequential collapse at the fracture site when joint is loaded

33. Indication of standard and short barrel DHS plate Minimum length of DHS screw: =Thread length+ optimum sliding distance + standard barrel length =22 + 25 + 38 = 85 mm Standard barrel : When length of DHS screw is 85 mm or more Short barrel : When length of DHS screw is less than 85 mm

34. Hemiarthroplasty Indications Age more than 65yrs Unsatisfactory reduction/ failure of CC screws Loss of fixation post surgery Pathological fracture Old undiagnosed fracture of more than 3weeks Complete dislocation of head Osteoporosis

35. Advantages Immediate weight bearing mobilisation Eliminates complications like AVN, Non union Contraindications Active young patient Severe osteoporosis Pre existing sepsis

36. Surgical approaches

37. There is no true internervous plane. Split the fibers of the gluteus maximus, a procedure that does not cause significant denervation of the muscle. Position of the patient on the operating table for the posterior approach to the hip joint Posterior approach (Moore’s approach- Southern exposure)

38. Retract the gluteus maximus to reveal the fatty layer over the short external rotators of the hip A: Skin incision for the posterior approach to the hip joint. B: Incise the fascia lata

39. A, B: Internally rotate the femur to bring the insertion of the short rotators of the hip as far lateral to the sciatic nerve as possible. C: Detach the short rotator muscles close to their femoral insertion and reflect them backward, laying them over the sciatic nerve to protect it. Push the fat posteromedially to expose the insertions of the short rotators. Note that the sciatic nerve is not visible; it lies within the substance of the fatty tissue. Place your retractors within the substance of the gluteus maximus superficial to the fatty tissue.

40. To gain additional exposure, cut the quadratus femoris and the tendinous insertion of the gluteus maximus. Incise the posterior joint capsule to expose the femoral head and neck.

41. AUSTIN – MOORE PROSTHESIS THOMPSON PROSTHESIS UNIPOLAR HIP PROSTHESIS

42. BIPOLAR PROSTHESIS Parts of prosthesis: Head within head Neck—fixed length Collar—sits over calcar Stem—smooth and tapered Advantages of bipolar prosthesis Increased range of motion Less acetabular wearing.

43. Modular Bipolar Prosthesis Device in between bipolar prosthesis and cemented total hip arthroplasty system. Advantages :– One can preserve his normal acetabulum for long time Option for THA is open (only acetabular component is needed)

44. TOTAL HIP REPLACEMENT Widely performed for neck of femur non union & AVN Indications Degenerative arthritis Active patient with age more than 60yrs Advantages Eliminates potential of acetabular erosion seen with hemiarthroplasty

45. Complications of Femoral neck fractures Avascular necrosis Non union Segmental collapse Degenerative arthritis Thromboembolic events Chondrolysis (rare)

46. Neck of femur non-union Causes of non-union Avascularity of the head of the femur. Lack of cambium layer of the periosteum Unsatisfactory reduction is the most important factor Continuous Synovial bathing Posterior comminution Age and osteoporosis

47. SANDHU CLASSIFICATION STAGE 1 STAGE 2 STAGE 3 Fracture Surfaces Regular Smooth & Sclerosed Smooth Proximal Fragment 2.5cm or more 2.5cm or more <2.5cm Fracture Gap Less than 1cm b/w 1 and 2.5cm >2.5cm Femoral Head No signs of AVN Head of femur still visible Signs of AVN present

48. Leighton’s Classification of Femoral Neck Non union Type 1 - Inadequate fixation or non-anatomic reduction Type 2 - Loss of fixation with fracture displacement Type 3 - Fibrous non-union with no displacement and intact fixation

49. AVN + Non union <50 years : Pedicle grafting / Arthrodesis / Osteotomy >50 years : Arthroplasty Non union + anatomy preserved (No AVN) <65 years : Osteosynthesis - ORIF with Vascularised grafting - ORIF with fibula grafting > 65 years : Arthroplasty Non union with destroyed anatomy < 65 years : Osteotomy ( Pauwel’s ) >65 years : Arthroplasty

50. Salvage procedures If femoral head is viable and adequate neck is remaining non unions can be treated by: Fixation alone Osteotomy+/-fixation Muscle pedicle bone grafting+/-fixation Cortical bone grafting+/-fixation Vascularised fibular grafting Cancellous bone grafting+/-fixation Combination of osteotomy and bone grafting

51. Sacrificing procedures These included the following techniques Unipolar arthroplasty Bipolar arthroplasty Total hip arthroplasty Girdlestone arthroplasty. Arthrodesis

52. Meyers Bone Graft Meyer et al 1974 Useful for delayed presenters and non union Indications Impacted fracture with AVN Late diagnosed fractures Non union

53. Meyers Bone Graft Posterior approach, posterior capsulotomy is performed Femoral neck nonunion is identified, and fibrous tissue is cleared Quadratus femoris insertion on the posterior aspect of the femur is elevated with a length of 4 cm, a width of 1.5 cm and a depth of 1 cm

54. Advantages Fracture stability enhanced in posterior bony comminutions by buttressing effect of posterior bone graft Serves as additional source of blood supply to femoral head Permits accurate reduction since capsule is opened Direct visualization of posterior part of neck helps in assessment of degree of comminution

55. Disadvantages Damage to posterior vascular supply of femoral head Extensive soft tissue dissection Risk of infection with joint involvement

56. Muscle pedicle bone grafting Quadratus femoris ( Judet , Meyers ) Gluteus Medius based ( Hibbs) Tensor Fascia Lata ( Bakshi )

57. Osteotomy Lineal osteotomy : Medial displacement osteotomy first described by Haas revised by McMurray and Leadbetter Angulation osteotomy described by Schanz with modification by Pauwel’s

58. Arm Chair Effect The distal fragment is placed directly under the head so weight is directly transmitted from head to shaft bypassing neck Shearing forces are converted to compressive forces

59. Mc Murray’s Osteotomy Mc Murray 1936 Displacement type of osteotomy Oblique osteotomy at the inter-trochanteric region Direction of osteotomy is medially upwards Beginning at the base of the greater trochanter and ending just above the lesser trochanter Line of weight bearing shifted medially

60. Valgus Osteotomy Defined by Pauwel’s 1927 Non union Neck of femur was due to the high shear forces that increased with the vertical orientation of the fracture Shearing force is converted to compressive force by angulation osteotomy and fixation with blade plate

61.   K-wire over the anterior side of the femoral neck marks the anteversion of the neck . Parallel in the lateral plane to the K-wire in (a) a second intraosseous K-wire (a) is introduced, respecting the calculated valgization The seating chisel is introduced exactly parallel to the second wire and as caudally in the femoral head as possible Lateral wedge is removed and valgization osteotomy is closed with well seated 120° angle blade plate

62. Free fibular bone graft Principle : The use of internal fixation and fibular auto grafting for neglected fractures for revascularization of the femoral head two types of free fibular graft Vascularized free fibular bone grafting Non vascularized free fibular bone graft

63. Triple attack technique for non-union of femoral neck fractures Iliac autogenous bone grafting + valgus subtrochanteric osteotomy + static fixation

64. Fractures of hip in children Extremely rare < 1% Incidence between = 10 to 20 years Secondary to severe trauma Small percentage a/w bone cyst, fibrous dysplasia

65. Treatment Options Type 1 Trans epiphyseal Separation without dislocation = Gentle closed traction & screw fixation Separation with dislocation = Closed reduction or Open reduction with Screw fixation Type 2 Transcervical Closed reduction and screw fixation Avoid crossing epiphyseal plate

66. Type 3 Cervico trochanteric Gentle closed traction with screw fixation Non – displaced : Abduction hip spica cast Type 4 Intertrochanteric Skin traction f/b abduction hip spica cast Internal fixation is necessary if reduction can’t be maintained

67. Complications Osteonecrosis The overall incidence is 40% after pediatric hip fracture Ratliff described three types Type I: Diffuse, complete head involvement, and collapse; poor prognosis (60%) Type II: Localized head involvement only; minimal collapse (22%) Type III: Femoral neck involved only; head sparing (18%)

68. 2. Coxa vara : secondary to inadequate reduction 3. Nonunion : The incidence is 10%, primarily owing to inadequate reduction or Inadequate internal fixation. It may require valgus osteotomy with or without bone graft 4. Premature epiphyseal fusion 5. Shortening of limb : 1 – 3.5cm shortening

69. Ipsilateral Femoral Neck and Shaft Fractures Fixation of the femoral neck fracture with cannulated screws and retrograde intramedullary nailing of the femoral shaft fracture Fixation of the femoral neck fracture with cannulated screws and plating of the femoral shaft fracture Fixation of both fractures with a sliding hip screw with a long plate to allow femoral fixation

70. Pathological fractures Less common than those in the pertrochanteric region History of carcinoma with a predilection for bony spread Minimal or no history of trauma Patients with evidence of a lytic lesion in the femoral neck Favorable prognosis and better function should be considered for THA Limited functional demands or life expectancy, a bipolar hemiarthroplasty

71. Stress fractures Depends on two factors – Degree of force applied Strength of bone involved Young persons – Normal bones subjected to unaccustomed strenuous exercise Old persons – Osteopenic bone with minimal stress

72. Clinical features - progressive hip or groin pain with or without a limp - pain may be perceived in the thigh or knee - it does not significantly limit activities Investigations Early detection – bone scan Late detection – after 2 weeks endosteal or subperiosteal callus formation

73. Classification Stress fracture neck of femur (Fulkerson and Snowdy ) Tension stress fracture : superolateral aspect of neck, increased risk of displacement Compression stress fracture : inferomedial aspect, decreased risk of displacement Completely displaced fracture neck of femur displaced.

74. Treatment options Compression type – Haze of callus in inferior part of neck - Treated with absolute bed rest Distraction type – Fracture line perpendicular to axis of femoral neck - Treated with Muliple pins or AO screws

75. Reference’s Rockwood and green’s 9 th Edition Campbell’s Operative orthopaedics 14 th Edition Skeletal trauma – Browner, Jupiter – 5 th Edition Surgical exposures in orthopaedics – Hoppenfeld 5 th Edition GS Kulkarni textbook of orthopaedic and trauma

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