Absence of cambium layer of periosteum Intracapsular Vascular anatomy Inaccurate reduction Loss of fixation

This layer produces peripheral callus The portion of the neck which is within

capsules has essentially no cambium layer Therefore healing in the femoral neck area

is completely dependent on endosteal union alone.

The lack of callus also reduces the rate of union.

Unless the fracture fragments are impacted the synovial fluid can lyse blood clot formation and thereby destroy another mode of the fracture healing by preventing the formation of cells and scaffoldings that would allow vascular invasion of the femoral head.

An Extracapsular arterial ring located at the base of the femoral neck

Artery of the ligamentum teres Epiphyseal blood supply Metaphyseal blood supply

Base of the femoral Neck. Formed by Medial Femoral circumflex artery

and Lateral circumflex femoral artery. Superior and inferior gluteal arteries also

contribute

The ascending cervical branches are given by extracapsular arterial ring

Derived From The Obturator and Medial circumflex Femoral Artery

inadequate to supply femoral head with displaced fractures

Can be divided into four groups as anterior, posterior, medial, lateral.

Of these lateral group provides most of the blood supply to neck and head.

These arteries form subsynovial intra- articular arterial ring.

Once branches of these arteries penetrate the femoral head they are termed as epiphyseal arteries

Prompt reduction and stable fracture fixation in the treatment of fracture neck of femur with the hope that the metaphyseal vessels will promptly reestablish and restore the circulation may help to reduce the chances of nonunion and AVN.

Type Description Presentation I Inadequate fixation Relatively early or nonanatomic reduction

II Loss of fixation with Later, Fracture displacement into varus

III Fibrous nonunion Usually late with no displacement Activity related & intact Fixation pain

Femoral neck fracture should unite by six month

If there is no evidence of healing or patient continued to have pain nonunion should be suspected.

Bone scan has to be done to rule out AVN Followed by that CT scan

Elderly Patients Replacement arthroplasty Hemiarthroplasty THR

To improve the mechanical environment at the fracture site

To improve the biologic environment of the nonunion site by bone grafting (nonvascularized,free vascularized, or muscle pedicle–type grafts)

Removal of fixation Osteotomy through fracture site Realignment of femoral head on neck Reinsertion of more stable fixation Muscle pedicle graft may be used

Deformity is usually varus Postero-inferior displacement of femoral

head on neck.

Initial fixation must be removed Valgus osteotomy using osteotomy plate

with compression device

McMurray’s osteotomy-Just proximal to lesser trochanter.

Schantz osteotomy-Made through just distal to lesser trochanter.

The goal of the procedure is to change a shear force on the neck fracture into a compression force.

Preoperative planning is very important

To drill out or open the endosteal canal to allow revascularisation and endosteal healing of previous fibrous nonunion.

A vascularised graft should be added to stimulate the bone union.

Fracture can be stabilized with blade plate or sliding hip screw.