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Neck of Femur Fracture

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22 views28 pages

Neck of Femur Fracture

Uploaded by

sharmasakar08
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Neck of Femur Fracture

Presented By:
Jeeban KC
FEMUR
Neck of Femur Fracture
• Commonest site of fractures in the elderly.
• Risk factors include bone-weakening disorders such as :
 Osteomalacia,
 Diabetes,
 Stroke (Disuse),
 Postmenopausal
 Alcoholism
 Chronic Debilitating Disease.
• Two types of fractures of neck of the
femur:
- Intra-capsular
- Extra-capsular.
• Fracture of neck : Intracapsular fracture of
neck.
• Inter-trochanteric fracture : Extra-capsular
fracture .
- Behave differently in terms of outcome
and uniting.
Mechanism of Injury
• Simple fall with less force in elderly:
- catching a toe in the carpet
- twisting the hip into external rotation.
• Fall from a height or a blow sustained in a RTA in younger
individuals
• Stress fractures of the femoral neck occur in runners or
military personnel
• Uncommon in children
Pathoanatomy
• Most of these fractures are displaced,
with the distal fragment externally
rotated and proximally migrated.
• These displacements also occur in
inter-trochanteric fracture in which
these are more marked because here,
the capsule of the hip joint is attached
to the distal fragment.
Classification

• Anatomical classification
• Pauwel’s classification
• Gardens classification
Anatomical Classification

• Subcapital – a fracture just below the head


• Transcervical – a fracture in the middle of
the neck
• Basal – a fracture at the base of the neck.

The more proximally the fracture is located, the


worse is the prognosis.
Pauwel’s Classification
- Based on the angle of inclination of the fracture in relation to the
horizontal plane (Pauwel’s angle)
- The more the angle, the more unstable is the fracture, and
worse the prognosis.
Garden’s Classification
- Based on the degree of displacement of the fracture (mainly
rotational displacement).
- Stage 1: An incomplete impacted /abduction fracture in which the
femoral head is tilted in postero-lateral direction, with an obtuse
angle laterally at the trabecular stream
- Stage 2: Complete but undisplaced fracture so that there is a break
in the trabecular stream.
- Stage 3: Complete and partially displaced fracture
- Stage 4 : Complete and fully displaced fracture.
Garden’s Classification
Diagnosis

Clinical features:
• Young patient: May arrive walking with complaint of little pain in
the groin
• More often- elderly, brought to the casualty department with
complaints of:
- Pain in the groin
- Inability to move his limb or bear weight on the limb
- Following a ‘trivial’ injury like slipping on the floor, missing a step
etc.
- Pain and swelling
Examination Reveals
• External rotation of the leg, the patella facing outwards.
• Shortening of the leg, usually slight.
• Tenderness in the groin.
• Attempted hip movements painful, and associated with
severe spasm.
• Active straight leg raising not possible.
Radiological Features
- Break in medial cortex of neck
- External rotation of femur with lesser trochanter appear more
prominent
- Overriding of greater trochanter so it lies at the level of femur
- Break in trabecular stream
- Break in the Shenton’s line
- Impacted fracture (undisplaced): only bending of trabeculae
seen
Treatment
Treatment
Termed an ‘unsolved fracture’ because of the high incidence of
complications due to:
- The blood supply to the proximal fragment (head) is cut off
- It is difficult to achieve reduction and maintain it because the
proximal fragment is to small.

( Because of these factors, the fracture invariably needs operative


treatment )
Impacted fracture:
An impacted fracture can be treated in all age groups by
conservative methods.
• Some surgeons fix these fractures internally with screws for
fear of displacement.
- In children : A hip spica,
- In adults : Immobilization in a Thomas splint are preferred
methods.
Un-impacted or displaced fractures:
Aim of treatment in patients up to 60 years : to achieve union
• For this, internal fixation is usually required.
• In the elderly, it is preferable to excise the head of the femur
and replace it by a prosthesis.
• In some younger patients presenting late, to achieve closed
reduction of the fracture difficult, so open reduction of the
fracture is done.
Internal fixation: Any of the following implants may be used for
internal fixation:
• Multiple cancellous screws – most commonly used.
• Dynamic hip screw (DHS) – used sometimes.
• Multiple Knowle’s pins/Moore’s pins used in children.
McMurray’s osteotomy:
• An oblique osteotomy at the inter-trochanteric
region.
• The direction of osteotomy is medially upwards,
beginning at the base of the greater trochanter
and ending just above the lesser trochanter after
which distal fragment is displaced medially and is
abducted.
• The position is held by an external support (hip
spica) or by internal fixation with plate and
screws.
• By this osteotomy the head is supported by the
distal fragment (arm-chair effect) that helps in
limb taking the weight on walking.
Hemiarthroplasty
• Procedure used for elderly patients.
• The head of the femur is excised
and replaced by a prosthesis.
• Two types of prosthesis commonly
in use:
- Unipolar
- Bipolar
1. Unipolar prosthesis
- They have a 'head' with an attached stem.
- The stem is introduced inside the medullary canal of the femur,
and the head sits over the neck of the femur.

2. Bipolar prosthesis
- The head has two parts: a smaller head, and a mobile plastic cup
on top of it.
- When the prosthesis is fitted on the neck, there is movement at
two planes

a. one between the acetabulum and the plastic cup

b. other between the plastic cup and the head.


Meyer’s Procedure
- Here the fracture is reduced by exposing it from
behind.
- It is fixed with multiple screws and supplemented
with a vascularised muscle-pedicle bone graft
taken from the femoral attachment of the
quadratus femoris muscle.
- Used in treating the fractures presenting late /
those with significant comminution at the fracture
site.
- Also used for non-union of the femoral neck
fractures.
Complications
1. General complications: Most of whom are elderly, are prone to:
• Deep vein thrombosis,

• Pulmonary embolism

• Pneumonia

• Bed sores

2. Non-union : approx 30 - 40 % of intra-capsular fractures.


- Complaint is pain and inability to bear weight on the affected limb.
- The limb is short and externally rotated and active straight leg
raising is not possible.
3. Avascular necrosis:
- After a fracture through the neck, all the
medullary blood supply and most of the
capsular blood supply to the head are cut off.
- The viability of the femoral head may therefore
depend almost entirely on the blood supply
through the ligamentum teres.
- If this blood supply is insufficient, avascular
necrosis of a segment or whole of the head
occurs.
Section : Excised femoral head, showing
the large necrotic segment and splitting
of the articular cartilage.
4. Osteoarthritis
- Develops a few years following fracture of the neck of femur. It
may be because of:
- Avascular deformation of the head
- Union in faulty alignment. The patient presents with pain and
stiffness of the joint.
References
- Essential Orthopaedics, Maheshwari,
- Apley’s System of Orthopaedics and Fractures

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