Transcript Fracture Neck Femur - Al-Kindy College of Medicine

Fracture Neck Femur
Dr.Sadeq Al-Mukhtar
Consultant Orthopaedic Surgeon
Epidemiology
97% occurs in patients more than 50 years •
old. The incidence increases with age.
3% occurs in under 50 years age(20-40) due •
to high energy trauma, sports, industrial &
motor vehicle accidents. In 20-40 years most
hip fractures are subtrochanteric or basicervical. Fractures in elderly are serious
injuries, about 250,000 fractures per year in
USA & the number is projected to double by
the year 2050 & the cost exceeds 6 billion $
per year
Anatomy
The femoral side of the hip is made of •
the femoral head with its articular
cartilage & the femoral neck which
connects the head to the shaft in the
region of intertrochanteric area. The
synovial membrane incorporates the
entire head &the anterior neck but only
the middle part of the neck posterior
.The neck shaft angle is 130(+_7)
degree. The Ante version is 10(+_7).
The diameter of femoral head ranges from •
40-60 mm. The thickness of the articular
cartilage ranges from 4mm in the apex to
1mm in the periphery.
Blood supply of the head from: •
1- Artery of ligamentum teres that usually •
originates from anterior obturator artery but
it supplies only small area of the head near
the attachment of the ligament.
2- Lateral, medial, anterior & posterior •
Capital vessels.
3- Lateral, medial, anterior &posterior •
cervical vessels.
All these 2&3 vessels groups comes from •
intertrochanteric ring.
Accumulation of intracapsular hematoma •
interferes with the venous outflow &perhaps
the vascular inflow. After 12 hours necrosis
of the head starts.
Biomechanics
Falling from standing position leads to direct blow •
on the greater trochanter. Osteoporosis is the
precipitating factor.
In young& middle aged high velocity trauma is •
needed to induce fracture.
Postmenopausal& senile osteoporosis predisposes •
to fracture .By the age of 65 years, 50% of women
show bone mineral content below the threshold for
fracture. By the age of 85 year this will reaches 100%
In elderly it can occur with minor trauma on an •
externally rotated thigh or the bone is so weak that
powerful muscle contraction can lead to fracture.
Classifications
1- Anatomical classification: •
A- Intracapsular: •
Subcapital (high risk) •
Tran cervical (moderate risk) •
Basal (less risk) intracapsular anteriorly, extra •
capsular posteriorly.
Sometimes, high energy fracture occur in young •
which involve the shaft of femur then to the base
of the neck then to the sub capital area. Usually
these are undisplaced.
B- Extra-capsular: •
Inter-trochanteric fractures •
Per-trochanteric •
Notes:Intracapsular fractures carry poor •
prognosis because of poor blood supply
which lead to avascular necrosis & nonunion while extracapsular fractures carry
good prognosis due to the good blood
supply
2- Gardens classification: •
They are classified according to the degree of
displacement of the fracture fragment.
1- Incomplete fracture(abduction& impacted)
making the neck in valgus.
2- Complete fracture without displacement; the neck
alignment looks normal.
3- Complete fractures with partial displacement.
4- Complete fractures with complete displacement.
1&2 are considered as undisplaced •
fractures& have good prognosis while
3&4 are displaced fracture& have poor
prognosis. Stage 1 can slowly progress
to stage 4 if untreated.
Pauwels classification:
They are classified according to the •
direction of the fracture:
Pauwel s 1: The angle from the •
horizontal line is 30-49 degree.
Pauwel s 2: The angle from the •
horizontal line is 50-69 degree
.
Pauwel s 3: The angle is 70& more.
All the available classifications can not •
determine the exact displacement that
occurred at the time of accident, the
degree of vascular damage & the
condition of the posterior femoral
neck.
Clinical features
Patient is usually old with history of •
trauma. The patient is unable to stand
or walk. On examination the limb is
shorter, externally rotated & he is
unable to move it. Movement of the hip
is tender &limited.
Diagnosis
It is achieved by history,Examination, & •
X-Ray of the hip, A.P& Lateral views are
required.
Differential diagnosis: •
Non-traumatic fractures of the neck of •
femur:Pathological fractures: Multiple •
myeloma, Secondary bone tumors.
Post-irradiation fractures. •
Stress fractures: Hair-line •
fracture with no
shortening or deformity.
Treatment
According to the treatment required, •
the complications likely to occur & the
prognosis; patient are divided into
three age groups;
Fractures in elderly; over 70 years. •
Fractures in young & middle aged. •
Fractures in children. •
Each group has its own problems but there is one •
common factor to them ( the danger of injury to the
retinacular vessels with end result of avascular
necrosis).
This can sometimes be the cause of non-union •
whatever the method used for immobilization &even
in cases where union has occurred late avascular
necrosis. Changes in the weight bearing segment of
the head can result in a stiff& painful joint .IT IS NOT
WITHOUT REASON THAT THE INJURY HAS BEEN
LABELLEDE THE UNSOLVED FRACTURE.
There must be rigid lines of demarcation, each •
fracture must be carefully& individually assessed.
The Aim of treatment
Accurate reduction. •
Rigid fixation •
Early mobilization to avoid •
complications.
Causes of avascular necrosis
Interference with blood supply of the head. •
No periosteum( some believe there is very •
thin one) so only endosteal healing will
occur resulting in poor callus.
Dissolution of the fracture hematoma by •
synovial fluid.
Treatment of patients above 70
years
Because of high incidence of AVN &non- •
union& complications of prolonged
immobilization, the treatment is Arthroplasty.
Partial Arthroplasty: Using Austen Moore or •
Thompson's prosthesis.
Total hip replacement (THR): Indications •
includes delayed union &secondary
osteoarthritis involve acetabulum.
Treatment of young &middle
aged patients
Accurate reduction by:- •
Closed reduction under anesthesia.or •
Open reduction) •
Rigid fixation by screws( at least 3 •
screws), using DHS(dynamic hip
screws), or Smith-Petersons nail…..ect.
Treatment in Children
Some prefer conservative but the best •
method of fixation by multiple pins
&immobilization by hip spica for 6
weeks &weight bearing after 8-12
weeks.
Notes: Even undisplaced fractures are •
not immune from complications like
AVN.
Complications
General: •
1- DVT& Pulmonary embolism: It is due to prolonged •
immoblication, treated by prophylactic early
mobilization, if happens give Anticoagulants.
2- Bed sores: It is due to prolonged immobilization, •
bad nursing &pressure on the skin& bony
prominence leading to necrosis that may be followed
by infection. It is treated by prophylactic frequent
turning of the patient, talk powder& pneumatic
bedes.
3- Pneumonia, chronic UTI. •
4- Psychological trauma.. •
Local complications
Avascular necrosis AVN: •
Incidence is 10-30% ( 10% in undisplaced •
fractures, &30% in displaced fractures). It
may be partial or complete with consequent
collapse of the bone structure leading to
fragmentation. It takes months or even 2-3
years to occur. If involved the fracture site it
may lead to failure to union whereas collapse
at the articular surface leads to O.A & the
patient complains of hip pain & inability to
walk X-Rays reveal increased bone density,
collapse & later an O.A changes.
2- NON UNION
Causes are:- •
1- Interference with blood supply. •
2- Inadequate immobilization& early •
mobilization.
3- Dissolution of the hematoma by synovial •
fluid.
Pathology of non-union: •
When there is failure to unite, the fracture •
undergoes absorption& if it is associated
with AVN the head will collapse.
Clinical features: Hip pain, lateral rotation of
the limb& inability to walk with shortening.
Treatment:In young patient: If the head is viable to make
the fracture line horizontal, the treatment is:
Subtrochanteric valgus osteotomy.
Rigid fixation &bone graft.
In elderly, Arthroplasty.
3- Osteoarthritis.
Fractures of the Trochanteric
region
These fractures occur in the region between the •
greater &lesser trochanters. They are common in
elderly especially in women, more than the fracture
of neck femur.
Compared to patients with fractured femoral neck, •
patients with intertrochanteric fractures are
significantly older, more likely to be limited to home
ambulation& more dependant in their activities of
daily living: therefore they tend to have overall
poorer prognosis .Because the region is a vascular
area so we note blood supply is excessive & AVN is
less than 1%.
Classification
1- Stable fracture:-The the postero- •
medial buttress remains intact or
minimally comminuted& therefore
collapse of the fracture fragment is
unlikely.
2- Unstable fracture: The large segment •
of postero-medial wall is fractured
free& comminuted& therefore tends to
collapse in varus.
KYLE Classification
1- Non-displaced stable fracture: without •
comminution (stable) 21%
2- Minimal comminution but displaced •
fracture: once reduced become (stable) 36%
3- Large postero-medial comminuted area •
.This is a problem fracture (unstable) 28%
4- Intertrochanteric & subtrochanteric •
fracture: It is uncommon (unstable) 15%
Treatment
Types; •
1- Conservative; Traction for 6-8 weeks. •
2- Surgical; Because patients are elderly& •
complications of such fractures are high so
surgery is indicated.
Principles:- •
Reduction either closed under screen or •
open reduction.
Rigid fixation by pin& plate, DHS ,angled •
plate …etc.
Complications
General; The same as complications of •
fracture neck femur .
Local; •
1- Malunion; Varus deformity or external •
rotation which is treated by corrective
osteotomy& fixation.
2- Non-union; rare due to soft tissue •
interposition, treated by ORIF & bone graft.
Subtrochanteric fracture
These are fractures in the area between •
lesser trochanter & the junction between
proximal and middle 3rd of femur. It occur in
all age groups but there are two peak ages of
incidence;
1- Late adolescence & early adulthood; here •
high energy trauma is needed.
2-Geriatric; minor trauma to bone lesion like •
metastatic tumor lung, breast cancer)
causing pathological subtrochanteric
fracture.
The upper fragment is flexed due to •
spasm of the iliopsoas& abducted by
gluteal muscle while the distal segment
is adducted by adductor muscles
•
Thank you
•