Proximal femoral fractures

neck of femur, intertrochanteric,subtrochanteric fractures

1. Proximal femoral fractures Presenter : DR. SOUVIK PAUL

2. ANATOMY OF PROXIMAL FEMUR Physeal closure age 16 Neck-shaft angle : 130° ± 7° Anteversion : 10° ± 7° Minimal periosteum about the femoral neck Calcar Femorale (cantilever of femur): dense vertical plate of bone extending from postero -medial portion of femoral shaft and radiating lateral to the greater trochanter , thicker medially

3. BLOOD SUPPLY OF PROXIMAL FEMUR

4. TRABECULAR PATTERN OF PROXIMAL FEMUR

5. AO PROXIMAL FEMUR # CLASSIFICATION

6. Classification Femoral head fracture Femoral neck fracture Intertrochanteric fracture Subtrochanteric fracture

7. FEMORAL HEAD FRACTURE Almost all a/w hip dislocations. A/w 10% of posterior hip dislocations. Impaction fractures a/w anterior hip dislocations (25% to 75%).

8. Pipkin Classification Type I : Posterior dislocation with femoral head # caudad to the fovea Type II : Posterior dislocation with femoral head # cephalad to the fovea Type III : Femoral head # with associated femoral neck # Type IV : Type I, II, or III a/w acetabular fracture

9. TREATMENT Pipkin Type I :CRIF if fails ORIF with small subarticular screws Pipkin Type II : ORIF Pipkin Type III : ■ Younger age : emergency ORIF ■ Older age : prosthetic replacement Pipkin Type IV : Treated in tandem with associated acetabular fracture.

10. F emoral neck fracture 80 % in women. ( Women: male 2.5: 1) Incidence doubles every 5 to 6 years in women age >30 years. RISK FACTORS: female sex, white race, increasing age, tobacco and alcohol use, previous fracture, low estrogen level.

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

12. Anatomical classification .

13. Pauwels Classification Less stable Less stable unstable

14. Ao classification

15. Mechanism of injury Low-energy trauma: older patients. ■ Direct: fall onto the greater trochanter ( valgus impaction) or forced ER of LL impinges neck onto post lip of acetabulum ( posterior comminution ) ■ Indirect: By muscle forces 2. High-energy trauma: younger and older patients 3. Cyclical loading : athletes, military recruits and ballet dancers

16. DIAGNOSIS Accurate history Pain in the groin or referred pain along the medial side of the knee may be able to walk with a limp Displaced fractures are non-ambulatory with shortening and external rotation of the LL Impacted or stress fractures lack deformity and may bear weight. Tenderness to palpation of ant. hip joint line or deep tenderness over GT X RAY (Break in shenton line ,proximal migration of femur) CT , MRI

17. Treatment Goals: Young Patients Spare femoral head Avoid deformity Improves union rate Optimal functional outcome Minimize vascular injury Avoid AVN

18. Treatment Goals: Geriatric Patients Mobilize Weight bearing as tolerated Minimize period of bed rest Minimize surgical morbidity Safest operation Decrease chance of reoperation

19. TREATMENT OF IMPACTED AND NONDISPLACED FRACTURES (GARDEN I AND II) Internal fixation with multiple cancellous lag screws.

20. DISPLACED FEMORAL NECK FRACTURES Parallel cancellous lag screws Austin-Moore hemiarthroplasty Bipolar or unipolar modular hemiarthroplasty Total hip replacement.

21. Closed Reduction Whitman technique : applying traction to the abducted, extended, externally rotated hip with subsequent internal rotation. Leadbetter technique :when Whitman technique is unsuccessful. flexed at the hip to 90 degrees, and the thigh is slightly internally rotated; traction is applied in line with femur. limb is circumducted into abduction, maintaining the internal rotation, brought down to table level in extension evaluated the reduction with a “heel-palm” test

22. Open approach Smith-Peterson Direct access to fracture Between TFL and sartorius Watson-Jones anterolateral Between TFL&gluteus medius Best for basicevical

23. Fixation Concepts Reduction makes it stable Avoid ANY varus Avoid inferior offset Malreduction likely to fail Tip to apex distance measured on both AP and lateral views should total < 2.5 cm Screws parallel to each other

24. Fixation Concepts Screw position Inferior : within 3 mm of cortex Posterior: within 3 mm of cortex Avoid posterior/superior To avoid iatrogenic vascular damage To avoid screw cutout Good Bad

25. Garden’s index Assessing reduction in subcapital fractures on AP view. Medial femoral shaft and axis of trabecular markings over the medial aspect of the femoral neck lie at 160° to 180° in acceptable reduction In lateral view trabecular markings in line acceptable reduction is within 20° of this ideal.

26. COMPLICATIONS Nonunion (In ORIF ): 5% of nondisplaced # , 25% of displaced # t/t: Proximal femoral osteotomy. Cancellous bone grafting Muscle pedicle grafting Osteonecrosis (ORIF): 10% of nondisplaced # , 30% of displaced # t/t: Early without x-ray changes: protected weight bearing core decompression. Late with x-ray changes : arthroplasty Fixation failure (ORIF) DVT/PE Dislocation (replacement): THR > hemiarthroplasty . Overall 1% to 2%.

27. Internal Screw Fixation Compared with Bipolar Hemiarthroplasty for Treatment of Displaced Femoral Neck Fractures in Elderly Patients J.-E. Gjertsen , T Vinje , L.B. Engesæter et al. J Bone Joint Surg Am. 2010;92:619-628. Prospective study Level of Evidence: Therapeutic Level III. n =4335 patients >70 yr age IF:1823 patients Hemiarthroplasty : 2512 patients Follow-up 12 months.

28. . 1 year mortality, no of reoperations, and patient self-assessment of pain, satisfaction, and quality of life at 4 & 12 months were analyzed mortality : 27% - osteosynthesis group 25% -arthroplasty group; (p = 0.76). reoperations : 412 - osteosynthesis group 72 -arthroplasty group (p =0.02) pain : mean score: 29.9 - osteosynthesis group (p < 0.001 ) 19.2 -arthroplasty group higher dissatisfaction : mean score 38.9 - osteosynthesis group 25.7 -arthroplasty group (p < 0.001 ) lower quality of life :mean score, 0.51 : osteosynthesis group 0.60: arthroplasty group (p < 0.001 ) Scored By : EuroQol visual analog scale Reseachers found Bipolar HA better than screw fixation in elderly

29. Intertrochanteric Fractures 50% of all fractures of the proximal femur. Women: men ranges from 2:1 to 8:1 Risk factors: same as femoral neck fractures

30. Anatomy & biomechanics Extracapsular # cancellous bone with an abundant blood supply . Deforming muscle forces produce shortening, external rotation, and varus at # site Fracture stability : Integrity of posteromedial corte ,lateral cortex Reverse fracture is more unstable

31. Diagnosis H/o High-energy injury or rarely simple fall in old age Usually Non ambulatory ,shortened and externally rotated LL. Tenderness to palpation in GT Ecchymosis ROM testing of the hip :very painful and avoided

32. AO classification trochanteric # Group A1, simple two-part fracture; group A2, fracture extends over two or more levels of medial cortex; group A3, fracture extends through lateral cortex of femur.

33. Boyd & Griffin Classification    Stable fractures Type I: Nondisplaced fracture Type II: Displaced fracture Unstable fractures Type III: Reverse,subtrochanteric,or posteromedial comminution fracture Type IV: Intertrochanteric fracture with subtrochanteric fracture

34. Nonoperative Treatment Prolonged bedrest in traction (usually 10 to 12 weeks), f/b program of ambulation training indicated for the most infirm, moribund patients where surgical intervention is impossible A/W high complication rates : D ecubitus ulcer, UTI Joint contractures Pneumonia DVT & PE Varus deformity and shortening

35. Operative Treatment Sling Hip Screw Intramedullary Devices: Proximal femoral nail (PFN) Gamma 2 Gamma 3 Rehabilitation ■ Early patient mobilization with weight bearing as tolerated is indicated.

36. COMPLICATIONS Malunion Implant failure Nonunion : <2% mainly in unstable fracture Osteonecrosis of the femoral head :rare Neurovascular injury

37. . Proximal femoral nail vs. dynamic hip screw in treatment of intertrochanteric  fractures: a meta-analysis. Zhang K ,  Zhang S ,  Yang J , Med Sci Monit . 2014 Sep 12;20:1628-33 Meta-analysis RCT comparing the effects of PFN and DHS were searched for following the requirements of the Cochrane Library Handbook. Six eligible studies involving 669 unstable fractures

38. , PFN :less operative time (WMD: -21.15, 95% CI: -34.91 - -7.39, P=0.003) intraoperative blood loss (WMD: -139.81, 95% CI: -210.39 - -69.22, P=0.0001) length of incision (WMD: -6.97, 95% CI: -9.19 - -4.74, P<0.00001) than the DHS group. No significant differences regarding postoperative infection rate, lag screw cut-out rate, or reoperation rate. Researchers recommend PFN as the first option in treating IT# .

39. Subtrochanteric fractures 10% to 30% of all hip fractures Bimodal distribution in individuals 20 to 40 years of age and >60 years of age

40. Anatomy and biomechanics # between lesser trochanter and a point 5 cm distal Medial and posteromedial cortices : high compressive forces Lateral cortex : high tensile forces Kochs diagram on stress over femur

41. Symptoms and Signs Swelling Shortening ER of LL Hypovolemic shock in high velocity trauma

42. Fielding classification Anatomical classification describing the position of the major fracture line with respect to the lesser trochanter

43. Russell-Taylor classification Type I: Fractures do not extend into the piriformis fossa . IA: Lesser trochanter is intact. IB: Lesser trochanter is not intact. Type II: Fractures extend into the piriformis fossa . IIA: Lesser trochanter is intact. IIB: Lesser trochanter is not intact

44. AO classification .

45. Nonoperative treatment Skeletal traction f/b hip spica or cast Only for those elderly individuals with severe co morbidities & children. Complication: : Nonunion Delayed union Malunion with varus angulation , Rotational deformity Shortening.

46. Operative Implants : 1.Intramedullary Nail: ■ First-generation ( centromedullary ) nails: both trochanters intact. ■ Second-generation( cephalomedullary )nails : ( Use: loss of the posteromedial cortex , #extending into the piriformis fossae ) 2.Ninety-Five Degree Fixed Angle Device : # involving both trochanters 3.Sliding Hip Screw

47. COMPLICATION Non union Malunion Implant failure

48. Paediatric proximal femur # Cause: Severe high-energy trauma ( fall from height, motor vehicle accident, or fall from bicycle) Trivial trauma with preexisting conditions like Unicameral bone cyst, Osteogenesis imperfecta , Fibrous dysplasia, Myelomeningocele , and Osteopenia from previous polio Child abuse

49. Classification 4 types on anatomic location of # by Delbet Type I: Transepiphyseal : acute traumatic separation of a previously normal physis Type II: Transcervical —fracture through mid-portion of the femoral neck. Usually from severe trauma & displaced Most common complication is AVN Type III: Cervicotrochanteric —fracture through the base of the femoral neck Type IV : Pertrochanteric or intertrochanteric —fracture between the greater and lesser trochanters

50. Clinical features severe pain unable to actively move the limb If dislocation is present: LL in flexion, adduction, and internal rotation

51. Treatment Type I: Transepiphyseal - anatomic reduction with rigid IF f/b cast immobilization Type II: Transcervical Fractures – CRIF to avoid loss of reduction and subsequent malunion , delayed union, or nonunion . Type III: Cervicotrochanteric : CRIF Type IV : Pertrochanteric : nonoperatively in <6 years CRIF :displaced fracture in any age group nondisplaced fracture in an older child >6 yr

52. Conclusion Goal of proximal femur # management: maintaining neck shaft angle & whole abductor mechanism . Achieve union Posteromedial cortex ,lateral cortex , Calcar femorale play a crucial role