fracture neck femur. could be intracapsular or extracapsular intracapsular # neck femur is...
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Fracture neck Femur
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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
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Clinical significance of vascular anatomy
Common complication of intracapsular # neck femur : – Avascular necrosis of femoral head and– Nonunion # neck femur
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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.
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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
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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.
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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.
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Classification (Garden).– Stage I : incomplete fracture of the neck
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stage II : complete fracture but undisplaced
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stage III: complete with partial displacementFig : -
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stage IV : complete femoral neck fracture with full displacement:
Fig : -
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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.
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Pauwels classification however refers to the angle the
fracture line makes with the horizontal
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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
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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
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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)
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.
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)
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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.
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Other Investigations
– To show avascular changes : - – Venography – Intraosseous pressure recording – Isotope scanning – Bone scan with technetium – 99m ,sulphur
colloid
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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
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Broad treatment guidelines
• 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
Multiple Moore`s pinning
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Dynamic Hip Screw
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Dynamic hip screw- DHSDynamic 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.
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Austin Moore's prosthesis.
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Total Hip Replacement
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Hip spica plaster
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Arthrodesis (joint fusion )
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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
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Fracture treated with A.O cannulated screws
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Skin Traction set
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Skeletal traction
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Skeletal traction
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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
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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 .
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Other treatment options
• After 70 years ,in Displaced # of femoral neck , treatment options : - – Hemireplacement arthroplasty ( displaced
intracapsular # neck of femur )– Osteotomy – THR
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Complications
• Thromboembolism : - leading cause of death within first 7 days ( 40 % )
• Nonunion
• Avascular necrosis
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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
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Radiology
– X – ray of the hip shows ununited # neck of femur and avascular changes in the head.
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Treatment
Head viable
• Osteotomy + bone grafting
Head not viable
1. acetabular cartilage viable : -
- hemireplacement arthroplasty by using a prosthesis
- bipolar arthtroplasty
2. acetabular cartilage not viable:
- total hip replacement
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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
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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 )
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Prosthesis for hemiarthroplasty of the hip joint
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bipolar hemiprosthesis
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Bipolar hip prosthesis