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FRACTURE OF NECKOF THE FEMUR          Dr. Prateek Singh (intern)           Department Of Orthopedics    B.P. Koirala Insti...
INTRODUCTION     The structure of the head and neck of femur isdeveloped for the transmission of body weightefficiently, w...
10/16/2012   3
ANATOMY OF NECK OF FEMUR Neck connects head with shaft and is about  3.7 cm long. It makes angle with the shaft 130+/- 7...
 2 borders and 2 surfaces  -upper border –concave and horizontal meets the  shaft at greater trochanter.  -lower border –...
 Blood sypplyCrock described the arteries of the proximal end of   the femur in three groups (a) an extracapsular arteria...
a) The extracapsular arterial ring is formed  posteriorly by a large branch of the medial femoral  circumflex artery and a...
c) The artery of the ligamentum teres is a branch of   the obturator or the medial femoral circumflex   artery    only sma...
Vascular anatomy of the femoral head and neck                                     10/16/2012   9
Anterior aspect                  10/16/2012   10
PATHO-ANATOMY Most fracture are displaced with    distal fragment – externally rotated, adducted,                       a...
 Displacement of the lower bone fragment  caused by the pull of the powerful muscles. In particular the outward rotation...
10/16/2012   13
ETIOLOGY Commonest site of # in elderly(7th /8th decade). Post menopausal  women, osteomalacia, diabetes, stroke, alcoho...
CLASSIFICATION -ANATOMICAL LOCATION       -subcapital       -transcervical        -basicervical (base of the neck fractur...
 -PAUWELThis is based on the angle of fracture from the horizontal Type I: 30 degrees Type II: 50 degrees Type III: 70...
As the fracture progresses from type 1 to type 3, the obliquity ofthe fracture fracture line increases, thus the shear for...
 -GARDEN     This is based on the degree of valgus displacement   Type I: Incomplete/valgus impacted    Type II: Comple...
copyright (your organization) 2003   10/16/2012   19
copyright (your organization) 2003   10/16/2012   20
 -Orthopaedic Trauma Association (OTA)  Classification B1 group fracture is nondisplaced to minimally  displaced subcapi...
10/16/2012   22
MECHANISM OF INJURY Low-energy trauma (most common in older patients)  - Direct: A fall onto the greater trochanter (valg...
 High-energy trauma- accounts for femoral neck  fractures in both younger and older  patients, such as motor-vehicle acci...
CLINICAL PRESENTATIONS H/O fall from height. nonambulatory on presentation (EXCEPT  impacted fracture patient may still ...
10/16/2012   26
CLINICAL EVALUATION Pain is evident on range of hip motion, with  possible pain on axial compression and  tenderness to p...
DIAGNOSIS  Situations in which femoral neck fracture may be  missed- Stress fractures- elderly patient with  unexplained ...
 Multiple fractures-patient with a femoral  shaft fracture may also have a hip fracture  which is easily missed unless th...
RADIOGRAPHIC EVALUATION An anteroposterior (AP) view of the pelvis both  hip in 15 internal rotation and a cross-table  l...
10/16/2012   31
The Importance of a True AP Hip Position                            10/16/2012   32
Cross table view                   10/16/2012   33
Modified Rolled Lateral HipIII(ModifiedFriedman Method)                  copyright (your organization) 2003   10/16/2012  ...
 The patient is  positioned as shown  above with a slightly  raised knee (15-20  degrees) and a  smaller cephalic  tube a...
Shentons Line Shentons line is a line formed by the inferior  aspect of the superior pubic ramus and the  medial aspect o...
10/16/2012   37
TREATMENT    Goals of treatment are to minimize patient discomfort, restore hip function, allow rapid mobilization by o...
 In children- close reduction and Hip spica.If not reduced then ORIF with Moore`s pins. Adults          impacted or gard...
Operative Treatment- include the following- Internal fixation with multiple cancellous lag  screws.(preffered treatment)- ...
Disadvantages-    1) stabilization include a larger surgicalexposure    2) potential to create rotational malalignmentof t...
10/16/2012   42
displaced or garden type 3& 4 age less than 60 years-   internal fixation by1)Multiple cancellous screw-most commonly use...
 age more than 60 years normal hip- Hemiarthroplasty with Austin-Moore              prosthesis.                          ...
 Indications for hemiarthroplasty     Comminuted, displaced femoral neck      fracture in the elderly     Pathologic fr...
Advantages of Hemiarthroplasty over open  reduction and internal fixation :1) It may allow faster full weight bearing2) It...
10/16/2012   47
preexisting degenerative condition -total hip  replacement          Indications osteoarthritis, rheumatoid arthritis, s...
copyright (your organization) 2003   10/16/2012   49
COMPLICATIONS General-1. Deep vein thrombosis2. Pulmonary embolism3. Pmeumonia4. Bed sores Osteoarthritis Avascular nec...
cause of AVN and non-union Tearing the capsular vessels the injury  deprives the head its main blood supply Intra articu...
refrences Essential orthopaedics – J. Maheshwari Handbook of Fractures- Kenneth J. Koval M.D                 & Joseph D....
 GREY’S ANATOMY B.D. chaurasia’s human anatomy                                   10/16/2012   53
copyright (your organization) 2003   10/16/2012   54
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Fracture neck of femur

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  1. 1. FRACTURE OF NECKOF THE FEMUR Dr. Prateek Singh (intern) Department Of Orthopedics B.P. Koirala Institute of Health Sciences
  2. 2. INTRODUCTION The structure of the head and neck of femur isdeveloped for the transmission of body weightefficiently, with minimum bone mass, byappropriate distribution of the bony trabeculae inthe neck. The tension trabeculae and compressiontrabeculae along with the strong calcar femorale onthe medial cortex of the neck of the femur form anefficient system to withstand load bearing andtorsion under normal stresses of locomotion andweight bearing. 10/16/2012 2
  3. 3. 10/16/2012 3
  4. 4. ANATOMY OF NECK OF FEMUR Neck connects head with shaft and is about 3.7 cm long. It makes angle with the shaft 130+/- 7 degree ( less in female due to their wider pelvis). It facilitate movements of hip joint. It is strengthened by calcar femorale (bony thickening along its concavity). 10/16/2012 4
  5. 5.  2 borders and 2 surfaces -upper border –concave and horizontal meets the shaft at greater trochanter. -lower border – straight and oblique meet the shaft at lesser trochanter. -anterior surface- flat .meet shaft at intertrochanteric line . Entirely intra capsular. -posterior surface- convex from above downwards and concave from side to side.meets shaft at intertrochanteric crest.it is crossed by horizontal groove for tendon of obturator externus. 10/16/2012 5
  6. 6.  Blood sypplyCrock described the arteries of the proximal end of the femur in three groups (a) an extracapsular arterial ring located at the base of the femoral neck;(b) ascending cervical branches of the extracapsular arterial ring on the surface of the femoral neck (known as retinacular arteries)(c) the arteries of the ligamentum teres 10/16/2012 6
  7. 7. a) The extracapsular arterial ring is formed posteriorly by a large branch of the medial femoral circumflex artery and anteriorly by branches of the lateral femoral circumflex artery . The superior and inferior gluteal arteries also have minor contributions to this ringb) The ascending cervical arteries can be divided into four groups (anterior, medial, posterior, and lateral) based on their relationship to the femoral neck. lateral group provides most of the blood supply to the femoral head and neck. 10/16/2012 7
  8. 8. c) The artery of the ligamentum teres is a branch of the obturator or the medial femoral circumflex artery only small & variable amount of femoral head is nourished by artery of ligamentum teres. 10/16/2012 8
  9. 9. Vascular anatomy of the femoral head and neck 10/16/2012 9
  10. 10. Anterior aspect 10/16/2012 10
  11. 11. PATHO-ANATOMY Most fracture are displaced with distal fragment – externally rotated, adducted, and proximally migrated. These displacement are less marked than in intertrochanteric fracture because the capsule of hip joint is attached to distal fragment and prevent extreme rotation and displacement of distal fragment. 10/16/2012 11
  12. 12.  Displacement of the lower bone fragment caused by the pull of the powerful muscles. In particular the outward rotation of the leg so that the foot characteristically points laterally. (GM) gluteus maximus; (PI) piriformis; (OI) obturator internus; (GE) gemelli; (QF) quadratus femoris; (RF) rectus femoris; (AM) adductor muscles; (HS) hamstring muscles 10/16/2012 12
  13. 13. 10/16/2012 13
  14. 14. ETIOLOGY Commonest site of # in elderly(7th /8th decade). Post menopausal women, osteomalacia, diabetes, stroke, alcoholi sm, chronic debilitating disease. Old people– weak muscle, poor balance – increased tendency to fall. Fall directly onto greater trochanter. Fall from height, RTA 10/16/2012 14
  15. 15. CLASSIFICATION -ANATOMICAL LOCATION -subcapital -transcervical -basicervical (base of the neck fracture) 10/16/2012 15
  16. 16.  -PAUWELThis is based on the angle of fracture from the horizontal Type I: 30 degrees Type II: 50 degrees Type III: 70 degrees 10/16/2012 16
  17. 17. As the fracture progresses from type 1 to type 3, the obliquity ofthe fracture fracture line increases, thus the shear force at the fracture site increases 10/16/2012 17
  18. 18.  -GARDEN This is based on the degree of valgus displacement Type I: Incomplete/valgus impacted Type II: Complete and nondisplaced on AP and lateral views Type III: Complete with partial displacement; trabecular pattern of the femoral head does not line up with that of the acetabulum Type IV: Completely displaced; trabecular pattern of the head assumes a parallel orientation with that of the acetabulum 10/16/2012 18
  19. 19. copyright (your organization) 2003 10/16/2012 19
  20. 20. copyright (your organization) 2003 10/16/2012 20
  21. 21.  -Orthopaedic Trauma Association (OTA) Classification B1 group fracture is nondisplaced to minimally displaced subcapital fracture B2 group includes transcervical fractures through the middle or base of the neck B3 group includes all displaced nonimpacted subcapital fractures 10/16/2012 21
  22. 22. 10/16/2012 22
  23. 23. MECHANISM OF INJURY Low-energy trauma (most common in older patients) - Direct: A fall onto the greater trochanter (valgus impaction) or forced external rotation of the lower extremity impinges an osteoporotic neck onto the posterior lip of the acetabulum (resulting in posterior comminution). - Indirect: Muscle forces overwhelm the strength of the femoral neck 10/16/2012 23
  24. 24.  High-energy trauma- accounts for femoral neck fractures in both younger and older patients, such as motor-vehicle accident or fall from a significant height. Cyclical loading-stress fractures: These are seen in athletes, military recruits, ballet dancers; patients with osteoporosis and osteopenia are at particular risk. 10/16/2012 24
  25. 25. CLINICAL PRESENTATIONS H/O fall from height. nonambulatory on presentation (EXCEPT impacted fracture patient may still be able to walk) shortening and external rotation of the lower extremity. 10/16/2012 25
  26. 26. 10/16/2012 26
  27. 27. CLINICAL EVALUATION Pain is evident on range of hip motion, with possible pain on axial compression and tenderness to palpation of the groin. Tenderness over Scarpa`s triangle Active SLR not possible 10/16/2012 27
  28. 28. DIAGNOSIS Situations in which femoral neck fracture may be missed- Stress fractures- elderly patient with unexplained pain in the hip should be considered to have stress fracture until proven otherwise. Undisplaced fracture-impacted fracture may be difficult to visualise on plain x-ray. Painless fracture-a bed ridden patient may develop a silent fracture. 10/16/2012 28
  29. 29.  Multiple fractures-patient with a femoral shaft fracture may also have a hip fracture which is easily missed unless the pelvis is x rayed. 10/16/2012 29
  30. 30. RADIOGRAPHIC EVALUATION An anteroposterior (AP) view of the pelvis both hip in 15 internal rotation and a cross-table lateral view of the involved proximal femur are indicated Technetium bone scan or preferably magnetic resonance imaging may be of clinical utility in delineating nondisplaced or occult fractures that are not apparent on plain radiographs. 10/16/2012 30
  31. 31. 10/16/2012 31
  32. 32. The Importance of a True AP Hip Position 10/16/2012 32
  33. 33. Cross table view 10/16/2012 33
  34. 34. Modified Rolled Lateral HipIII(ModifiedFriedman Method) copyright (your organization) 2003 10/16/2012 34
  35. 35.  The patient is positioned as shown above with a slightly raised knee (15-20 degrees) and a smaller cephalic tube angle (15-20 degrees). 10/16/2012 35
  36. 36. Shentons Line Shentons line is a line formed by the inferior aspect of the superior pubic ramus and the medial aspect of the upper femur. Shentons line should describe a smooth curve. If there is any sharp angulation of Shentons line the patient could have a neck of femur fracture. An abnormal Shentons line can be the most obvious indicator of a patients fractured neck of femur demonstrated on an AP pelvis /hip image. 10/16/2012 36
  37. 37. 10/16/2012 37
  38. 38. TREATMENT Goals of treatment are to minimize patient discomfort, restore hip function, allow rapid mobilization by obtaining early anatomic reduction and stable internal fixation or prosthetic replacement. 10/16/2012 38
  39. 39.  In children- close reduction and Hip spica.If not reduced then ORIF with Moore`s pins. Adults impacted or garden type 1 & 2 Non-operative Treatment- bed rest for elderly person whose medical condition carries an excessively high risk of mortality from anesthesia and surgery 10/16/2012 39
  40. 40. Operative Treatment- include the following- Internal fixation with multiple cancellous lag screws.(preffered treatment)- Sliding hip screw – advantages- 1) biomechanical strength greater than multiple cancellous screws. 2) minimization of risk of subsequent subtrochanteric fracture secondary to a stress riser effect. 3) placement of compression across the fracture at the time of reduction 10/16/2012 40
  41. 41. Disadvantages- 1) stabilization include a larger surgicalexposure 2) potential to create rotational malalignmentof the femoral head at the time of screw insertion. Fracture of the femoral neck stabilized with three well- placed, 6.5-mm, short threaded cancellous lag screws. 10/16/2012 41
  42. 42. 10/16/2012 42
  43. 43. displaced or garden type 3& 4 age less than 60 years- internal fixation by1)Multiple cancellous screw-most commonly used.2)Dynamic hip screw (DHS)3)smith peterson nail (S.P. nail) 10/16/2012 43
  44. 44.  age more than 60 years normal hip- Hemiarthroplasty with Austin-Moore prosthesis. 10/16/2012 44
  45. 45.  Indications for hemiarthroplasty  Comminuted, displaced femoral neck fracture in the elderly  Pathologic fracture  Poor medical condition  Poorer ambulatory status before fracture  Neurologic condition (dementia, ataxia, hemiplegia, parkinsonism) 10/16/2012 45
  46. 46. Advantages of Hemiarthroplasty over open reduction and internal fixation :1) It may allow faster full weight bearing2) It eliminates nonunion, osteonecrosis, failure of fixation risks .Disadvantages:1) It is a more extensive procedure with greater blood loss2) A risk of acetabular erosion exists in active individuals 10/16/2012 46
  47. 47. 10/16/2012 47
  48. 48. preexisting degenerative condition -total hip replacement Indications osteoarthritis, rheumatoid arthritis, severe osteoporosis pathologic conditions with acetabular involvement such as Pagets disease 10/16/2012 48
  49. 49. copyright (your organization) 2003 10/16/2012 49
  50. 50. COMPLICATIONS General-1. Deep vein thrombosis2. Pulmonary embolism3. Pmeumonia4. Bed sores Osteoarthritis Avascular necrosis Non-union 10/16/2012 50
  51. 51. cause of AVN and non-union Tearing the capsular vessels the injury deprives the head its main blood supply Intra articular bone has only flimsy periosteum and no contact with soft tissue which could promote callus formation Synovial fluid prevents clotting of the fracture hematoma 10/16/2012 51
  52. 52. refrences Essential orthopaedics – J. Maheshwari Handbook of Fractures- Kenneth J. Koval M.D & Joseph D. Zuckerman M.D Rockwood & Greens Fractures in Adults- Robert W. Bucholz MD, James D. Heckman MD, Charles M. Court-Brown MD. Apleys System of orthopaedics and fractures David Warwick MD. 10/16/2012 52
  53. 53.  GREY’S ANATOMY B.D. chaurasia’s human anatomy 10/16/2012 53
  54. 54. copyright (your organization) 2003 10/16/2012 54
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