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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 ?
– 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 II : complete fracture but undisplaced
stage III: complete with partial displacement
Fig : -
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
degrees
Type II : - has an obliquity ranging from 30 to
50 degrees
Type 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
Broad treatment guidelines
• Age group
• More than 70 years
•
•
•
•
undisplaced
DHS
Displaced
•
•
•
•
Prosthesis
THR
Young adults
DHS
DHS
Osteotomy or
prosthesis
• Multiple Moore`s
Children
HIP spica
pinning
Multiple Moore`s pinning • Osteotomy
• arthrodesis
DHS = dynamic hip screws
THR = total hip replacement
Dynamic Hip Screw
hip screwDHS
• Dynamic
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.
Austin Moore's prosthesis.
Total Hip Replacement
Hip spica plaster
Arthrodesis (joint fusion )
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
Fracture treated with A.O
cannulated screws
Skin Traction set
Skeletal traction
Skeletal traction
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.
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
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 )
Prosthesis for hemiarthroplasty
of the hip joint
bipolar hemiprosthesis
Bipolar hip prosthesis