ppt.pptx neck of femur fracture without dnvd

neck of femur fracture without dnvd

1. FRACTURE NECK OF FEMUR Dr.Sasidhar DEPT OF ORTHOPAEDICS

2. Case A 36yr old Patient brought to causality on stretcher with Chief complaints of right hip pain since 2 days developed after sustaining injury after A/H/O fall from Bed 2 days back. No Head injury, LOC, ENT bleed, vomitings,loose stools. No H/o fever, vomiting, loose stools. H/O PRESENT ILLNESS: Patient was apparently asymptomatic 2 days back then his attendant found him fell on floor bedside at night after which he started complaining of right hip pain, inability to bear weight and difficulty in the moving the right lower limb.

3. Past history H/o accidental fall and right clavicle fracture which was left untreated 2yrs back. Left Hemi-arthroplasty surgery done 2yrs back. Treated as in-patient for alcohol and tobacco dependence syndrome in De-addiction center for about 2 months duration 1year back. Not a k/c/o DM/HTN/ASTHMA/EPILEPSY/CVA/CAD

4. PERSONAL HISTORY MARRIED APPETITE: NORMAL DIET: MIXED BOWEL AND BLADDER: REGULAR KNOWN ALLERGIES: NO ADDICTIONS: - ALCOHOLIC since 15 yrs - TOBACCO-SMOKING since 15 yrs

5. General examination Patient conscious, coherent and co-operative Thin built and looks malnourished BP: 100/90 mm Hg PR: 82 bpm RR : 21/ min SPO2: 97% at room air TEMP 98.3 ⁰F PALLOR ICTERUS CYANOSIS CLUBBING LYMPHEDINOPATHY EDEMA PRESENT ABSENT ABSENT ABSENT ABSENT ABSENT

6. LOCAL EXAMINATION OF RIGHT HIP INSPECTION: ATTITUDE: Patient in supine, both ASIS at same level , externally rotated. Diffuse swelling present around the groin region. Skin : normal, no sinuses and scars PALPATION No local rise of temperature Tenderness + over the GT and groin region. ROM : restricted and painful Abnormal mobility present Sensations intact Distal pulses present.

7. PROVISIONAL DIAGNOSIS : Closed displaced Right fracture neck of femur ? ICNF/INTERTROCHANTERIC Fracture

8. On the day of admission HAEMOGLOBIN 9.0 gm/dl TOTAL COUNT 7,400 cells/ cumm NEUTROPHILS 66 % LYMPHOCYTES 23 % EOSINOPHILS 01 % MONOCYTES 10 % BASOPHILS 00 % PLATELET COUNT 1.3 laks /cu.mm SMEAR- Normocytic , normochromic anemia with thrombocytopenia Total Bilurubin 1.19 mg/dl Direct Bilurubin 0.38 mg/dl SGOT(AST) 24 IU/L SGPT(ALT) 12 IU/L ALKALINE PHOSPHATASE 127 IU/L TOTAL PROTEINS 4.9 gm /dl ALBUMIN 2.3 gm/dl A/G RATIO 0.94 CBP LFT

9. UREA 18 mg/dl CREATININE 0.8 mg/dl URIC ACID 3.3 mmol /L CALCIUM 8.9 mg/dl PHOSPHOROUS 2.7 mg/dl SODIUM 137 mmol /L POTASSIUM 3.2 mmol /L. CHLORIDE 105 On the day of admission RFT E S R 30 mm/ 1st hour C-Reactive Protein : Positive(2.4 mg/dl)

10. RADIOLOGICAL FINDINGS NORMAL SHENTON’S LINE Shenton’s line  disruption BREAK IN NECK OF FEMUR 1. Shenton’s line   disruption: loss of contour between normally continuous line from medial border of femoral neck and inferior border of the superior pubic ramus. 2. Transverse Fracture line seen along neck of femur. INTRACAPSULAR NECK OF FEMUR FRACTURE

11. DIAGNOSIS : Closed displaced Right IC neck of femur fracture Left Hemi-arthroplasty 2Yrs back 2yr old malunited right clavicle lateral1/3rd fracture SURGERY DONE : ORIF WITH CC screw fixation for right intracapsular fracture neck of femur.

12. Post op POST OP XRAY CC SCREW FIXATION INSITU HAEMOGLOBIN 10.1 gm/dl TOTAL COUNT 7,800 cells/ cumm NEUTROPHILS 72 % LYMPHOCYTES 18 % EOSINOPHILS 01 % MONOCYTES 09 % BASOPHILS 00 % PLATELET COUNT 1.1 lakhs /cu.mm SMEAR Normocytic normochromic anemia with thrombocytopenia POST-OP CBP

13. INTRODUCTION - ANATOMY

14. INTRODUCTION -ANATOMY Normal Neck-shaft angle =130±7degrees Femoral anteversion

15. INTRODUCTION - ANATOMY

16. INTRODUCTION BLOOD SUPPLY

17. INTRODUCTION BLOOD SUPPLY OF NECK OF FEMUR An extracapsular arterial ring located at the base of femoral neck Ascending cervical branches of the extracapsular arterial ring of the surface of the femoral neck known as retinacular arteries) The arteries of the ligamentum teres

18. INTRODUCTION BLOOD SUPPLY OF NECK OF FEMUR The extracapsular arterial ring is formed posteriorly by a large branch of the medial femoral circumflex artery and anteriorly by branches of the lateral femoral circumflex artery The ascending cervical arteries can be divided into four groups (Anterior, Medial, Posterior, and lateral) based on their relationship with femoral neck. Lateral group provides most of the blood supply to the femoral head and neck The artery of ligamentum teres is a branch of the Obturator or the Medial femoral circumflex artery ( Only a small amount of femoral head is nourished by this)

19. INTRODUCTION FRACTURE NECK OF FEMUR Commonly seen in elderly women – low energy falls Very low incidence in younger patients – high energy trauma Mechanism of injury: Low energy trauma – Direct or Indirect High energy trauma – MVA or fall from heights Cyclical loading-stress fractures Insufficiency fractures – osteoporosis or osteopenia

20. Fracture neck of femur is an unsolved fracture, why?? Elongated position of femoral neck in joint capsule Absence of cambium layer of periosteum , periosteum is replaced by retinaculum, which is a reflected part of capsule Fracture heals without external callus, almost heals entirely from intramedullary endosteal callus Peculiar blood supply of the head of femur Intracapsular callus formed will get washed by synovial fluid. Intracapsular hemorrhage following fracture neck of femur causes tamponade effect and obliterate retinacular vessels and fuerther decrease blood supply to head

21. REVASCULARIZATION OF THE HEAD OCCURS FROM; The areas of the femoral head that remains viable Vascular ingrowth from the distal fragment Capillary ingrowth from distal fragment( It’s a slow process and occurs when the fixation is rigid and stable)

22. CLASSIFICATION Anatomical location SUBCAPITAL BASICERVICAL TRANSCERVICAL

23. CLASSIFICATION – PAUWEL’S Angle subtended by the fracture to the horizontal More the angle, more the shearing forces, more the instability

24. CLASSIFICATION – GARDEN’S

25. CLINICAL FEATURES H/o trauma – High or low energy Non ambulatory (except in impacted and stress fractures) Pain over the groin Deformities – external rotation of the limb with shortening Tenderness – on hip ROM, axial compression and over the groin, Scarpa’s triangle In low energy fracture – h/o LOC, syncopal attacks, chest pain, prior hip pain (pathological #) Preinjury ambulatory status – determinant of treatment

26. CLINICAL FEATURES

27. RADIOLOGICAL EVALUATION Plain radiograph of pelvis with both hip joint – AP view, with 15 deg of internal rotation of the limb Cross table lateral view of proximal femur of fracture side CT scan – undisplaced femoral neck fractures MRI – imaging of choice in delineating non-displaced or occult fractures Bone scans and CT scan is reserved for those who have contraindications for MRI

28. AP VIEW variations

29. Lateral view frog lateral

30. RADIOLOGICAL EVALUATION SHENTON’S LINE IN AN X-RAY

31. RADIOLOGICAL EVALUATION

32. TREATMENT Goals of the treatment are: Minimize patient discomfort Restoration of hip function Early stable fixation of fracture or prosthetic replacement Allow rapid mobilization Early bed to chair mobilization - to avoid risks and complications of prolonged recumbence (Venous stasis, DVT, Pulmonary Embolism, poor pulmonary toilet, atelectasis, pressure sores)

33. TREATMENT Preoperative skin traction – below knee traction Immobilization of limb gives pain relief Reduce the risk of further soft tissue injury Helps to maintain reduction Easier intraoperative fracture reduction Use is contraversial

34. TREATMENT Non-operative treatment – can be employed in undisplaced fractures; in patients with severe medical comorbidities Good results have been reported from some studies Advantage: surgery can be avoided Disadvantage: Greater risk of fracture displacement Hence there is no role of non-operative in treatment of fracture neck of femur

35. TREATMENT - SURGICAL

36. TREATMENT - SURGICAL

37. TREATMENT - SURGICAL Displaced fractures In young patients: urgent reduction and internal fixation and capsulotomy Multiple screw fixation – 3 cannulated cancellous screws in inverted triangular configuration Sliding hip screw or dynamic hip screw Angled blade plates

38. TREATMENT - SURGICAL

39. TREATMENT - SURGICAL Displaced fractures In elderly patients: High functional demand and good bone quality: Total hip replacement Low functional demand and poor bone quality: Hemiarthroplasty Severely ill, demented, bedridden patients: non-operative

40. TREATMENT - SURGICAL

41. COMPLICATIONS Non-union: if the fracture has not united by 3months 5% in undisplaced and 25% in displaced fracture In elderly: arthroplasty In young patients: proximal femoral osteotomy Osteonecrosis : avascular necrosis of femoral head 10% in undisplaced and 30% in displaced fractures Early without x-ray changes: core decompression Late with x-ray changes: arthroplasty in elderly; osteotomy/arthrodesis/arthroplasty in younger patients

42. COMPLICATIONS Fixation failure: poor reduction/fixation; osteoporotic bone Prosthetic dislocation and prosthetic loosening Prominent hardware: due to fracture collapse and screw backout Others: complications of prolonged recumbence, infection

43. Thank you