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Fracture neck Femur. Fracture neck Femur. Could be intracapsular or extracapsular Intracapsular # neck femur is notoriously known as an orthopedic enigma (difficult problem) , Problem of healing , why ?
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Fracture neck Femur • Could be intracapsular or extracapsular • Intracapsular # neck femur is notoriously known as an orthopedic enigma (difficult problem) , Problem of healing , why ? • Synovial fluid lyse clot at the # site and thereby destroy another mode of secondary healing • Displaced # leads to avascularity
Clinical significance of vascular anatomy Common complication of intracapsular # neck femur : • Avascular necrosis of femoral head and • Nonunion # neck femur
Aetiology : - • Common in older patients with osteoporosis or osteomalacia Mechanism of injury : • Due to trivial fall , as a result of direct blow over the greater trochanter • Lateral rotation of the extremity • Major trauma in young adults like RTA , fall etc. • Cyclical loading due to muscle force and torsion.
Classification • Garden`s and Pauwel`s in adults and Delbet`s classification in children are used. • Broad classification • Intracapsular – from subcapital area to the middle of the neck. • Extracapsular – from base of the neck to the pertrochanteric region
Classification:- • Intracapsular Fractures This is divided according to the level of the fracture line in the neck as follows. • 1) Subcapital 2) Transcervical 3) Basal (at the junction of neck and shaft ) • Extracapsular Fractures - grouped as Trochanteric fractures of various types.
Gardens classification • grade1: incomplete fracture of the femoral neck. • grade 2: complete fracture but undisplaced. • grade 3: complete fracture with partial displacement. • grade 4: complete fracture with total displacement.
Classification (Garden). • Stage I : incomplete fracture of the neck
stage IV : complete femoral neck fracture with full displacement: Fig : -
Subcapital fractures are classified by : - • Pauwels Classification:Type I : - has an obliquity ranging from 0 to 30 degreesType II : - has an obliquity ranging from 30 to 50 degreesType III : - has an obliquity of 70 or more degrees - The greater the obliquity in the fracture, the higher the chances of either delayed or nonunion.
Pauwels classification however refers to the angle the fracture line makes with the horizontal
Delbet`s classification • Transepiphyseal : - at the junction of the head and neck • Transcervical : - through the middle of the neck • Basal : - at the junction of neck and shaft • Intertrochanteric : - in between the greater and lesser trochanters • Pertrochanteric : - at the level of the trochanteric
Clinical features • Pain • Restriction of movements of the affected hip • On examination : - • Tenderness over the anterior hip joint line • Minimal shortening and external rotational deformity of the affected limb due to the fracture being intracasular • Active straight leg raising is difficult • In impacted # complains : - • Groin pain , restriction of hip movement
Investigations • X – ray AP and lateral view of the hip joint. Following points are noted : - • The extent of fracture line whether complete or incomplete • The fracture angle • Break in the shenton`s line • Prominent lesser trochanter • the degree of osteoporosis (Singh`s index)
. Shenton's line is an imaginary line drawn along the inferior border of the superior pubic ramus (superior border of the obturator foramen) and along the inferomedial border of the neck of femur. This line should be continuous and smooth. Interruption of Shenton's line can indicate fractured neck of femur - named after the English radiologist Edward Warren Hine Shenton (1872-1955)
Singh`s index- it measures the degree of osteoporosis in the proximal femur based on radiographic evaluation of the trabecular pattern and helps to decide the choice of implants.
Other Investigations • To show avascular changes : - • Venography • Intraosseous pressure recording • Isotope scanning • Bone scan with technetium – 99m ,sulphur colloid
Treatment • Emergency condition and should be reduced and fixed within 24 hours to get an optimum result. Aims of treatment : - • Early anatomical reduction which helps prevent further vascular damage . • Impaction of the # fragments. • Rigid internal fixation
Age group undisplaced More than 70 years DHS Young adults DHS Children HIP spica DHS = dynamic hip screws THR = total hip replacement Displaced Prosthesis THR DHS Osteotomy or prosthesis Multiple Moore`s pinning Osteotomy arthrodesis Broad treatment guidelines Multiple Moore`s pinning
Dynamic hip screw- DHS Most commonly used device for both stable and unstable fracture patterns. Plate angle is variable 130 to 150 degrees. Has to be positioned centrally in the femoral head. Use of radiological views to know the exact position.
Treatment plans as per garden`s classification : - Garden 1 : - • Conservative : - Hip spica ( old # , unfit for surgery ) • Surgery : - multiple Moore`s pinning Grade 2 : - (# complete ) • DHS or multiple cannulated AO screws Grade 3 / 4 : - • Conservative : - Hip spica , leg traction • Surgery : - • Anatomical reduction , impaction and stable internal fixation
Reduction techniques Closed reduction with hip in extension : - Whitmann`s method : - • Extension + internal rotation +abduction movements of the hip Massie: - • Forceful internal rotation of the limb Mc Elevenny : - • Extension + external rotation + internal rotation +adduction movement. Deyerle : - • Traction with extension + foot is internally rotated +force applied on greater trochanter from anterior to posterior direction
Closed reduction with hip in flexion Lead better method : - • Flexion of hip , traction along long axis of femur , thigh internally rotated and abducted. • Evaluate reduction by “ heel palm test “ Heel palm test : • Heel of the affected limb should remain neutral in the palm of the clinician`s hand and not lie externally rotated after reduction. Smith peterson : - • Slight hip flexion +then internal rotation +abduction + extension Flynn : - • Flexon , traction along the femoral neck .
Other treatment options • After 70 years ,in Displaced # of femoral neck , treatment options : - • Hemireplacement arthroplasty ( displaced intracapsular # neck of femur ) • Osteotomy • THR
Complications • Thromboembolism : - leading cause of death within first 7 days ( 40 % ) • Nonunion • Avascular necrosis
Nonunion • Nonunion rate 85 – 95 % • If there is no evidence of radiological healing taking place between 6 and 12 months at treatment on a radiograph , it is declared as nonunion. Causes : - • Inaccurate reduction • Poor internal fixation • Avascularity of femoral head Clinical features : - • Unable to bear the weight on the affected side • Wasting of the muscles • Minimal shortening of the affected lower limb
Radiology • X – ray of the hip shows ununited # neck of femur and avascular changes in the head.
Head viable Osteotomy + bone grafting Head not viable acetabular cartilage viable : - - hemireplacement arthroplasty by using a prosthesis - bipolar arthtroplasty 2. acetabular cartilage not viable: - total hip replacement Treatment
Avascular necrosis Survival of head depends on : - • Uninjuired vascular supply • Revascularisation Vascular injury occurs : - • At the time of # commonly • During reduction or internal fixation • Hence , good anatomical reduction and stable internal fixation is required to preserve the remaining blood supply , which help in revascularisation
Investigation • X – rays shows increased density of the femoral head , and this may take 6 months to 2 years to be seen on radiographs. • Bone scan ( for avascularity ) Treatment : - • Symptomatic treatment ( bed rest , NSAIDs) • Displacement or angulation osteotomy in early stages • Hemireplacement prosthesis ( acetabular cartilage viable) • Total hip replacement (acetabular cartilage is not viable )
