1 femoral neck fractures dnbid lecture note
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1 femoral neck fractures dnbid lecture note

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1 femoral neck fractures dnbid lecture note 1 femoral neck fractures dnbid lecture note Presentation Transcript

  • Dr. D. N. BID FEMORAL NECK FRACTURES
  • Definition
    • A Femoral Neck # is a # occurring proximal to the intertrochanteric line in the intracapsular region of the hip.
  • Classification
    • Pauwels [1935]
      • Angle describes vertical shear vector
  • Classification
    • Garden [1961]
    • I Valgus impacted or
    • incomplete
    • II Complete
    • Non-displaced
    • III Complete
    • Partial displacement
    • IV Complete
    • Full displacement
    • ** Portends risk of AVN and Nonunion
    I II III IV
  • Classification
    • Functional Classification
      • Stable
        • Impacted (Garden I)
        • Non-displaced (Garden II)
      • Unstable
        • Displaced (Garden III and IV)
    • Femoral neck # classified as Garden’s type 1: an incomplete impacted femoral neck # in valgus position. All femoral neck #s are intracapsular.
    • Garden’s type 2: nondisplaced complete femoral neck #.
    • Garden’s type 3: displaced femoral neck # in varus position. There is often disruption of the joint capsule.
    • Garden’s type 4: completely displaced femoral neck #. It has the poorest prognosis. The femoral head may go on to AVN. In older patients, this # is usually treated with a endoprosthesis.
  • Subcapital femoral neck # at the proximal end of the neck. This # is displaced and in varus position (Garden’s type 3)
  • Subcapital # of the femoral neck impacted and in valgus position (Garden’s type 1).
  • Mechanism of Injury
    • Most femoral neck # in the elderly are spontaneous or caused by low energy trauma.
    • This population is subject to senile osteoporosis (type II), which causes weakness in both the cortical and trabecular bone of the femoral neck and predisposes it to #.
    • In younger patients, high energy trauma is necessary to cause a femoral neck # , and therefore displacement of the # and damage to the blood supply is usually greater in those cases.
  • HIGH-ENERGY INJURY
  • LOW ENERGY INJURY
  • Treatment Goals
    • Orthopaedic Objectives
        • Alignment
        • Stability
    • Rehabilitation Objectives
        • Range of Motion
        • Muscle Strength
        • Functional Goals
    • Orthopaedic Objectives
        • Alignment
          • Restore fragments to their correct anatomic position for unstable hip #s.
          • Maintain alignment in nondisplaced or impacted stable #s.
          • Satisfactory alignment after reduction of an unstable # should have no more than 15 degrees of valgus and 10 degrees of anterior posterior angulation.
    • Orthopaedic Objectives
        • Stability
          • Compress the # fragments with lag screws to restore cortical and cancellous contact.
          • Replace the femoral head in the elderly patient with an unstable# to achieve immediate stability.
  • Subcapital # of the femoral neck.
  • Fracture fixed with a screw and side plate to compress the # in an attempt to restore cortical and cancellous contact.
  • To achieve immediate stability, the femoral head and neck are replaced in an elderly patient with an unstable #.
    • Rehabilitation Objectives
        • Range of Motion: Improve and restore ROM of the knee and hip.
        • ROM of Hip & Knee
    Motion Normal Functional Knee Flexion 130-140 ° 110 ° Extension 0 ° 0 ° Hip Flexion 125-128 ° 90-110 ° Extension 0-20 ° 0-5 ° Abduction 45-48 ° 0-20 ° Adduction 40-45 ° 0-20 ° Internal Rotation 40-45 ° 0-20 ° External Rotation 45 ° 0-15 °
    • Rehabilitation Objectives
        • Muscle Strength:
        • Improve the strength of the muscles that are affected by the #.
            • Gluteus medius
            • Iliopsoas
            • Gluteus maximus
            • Adductor longus, magnus, brevis
            • Quadriceps
            • hamstrings
    • Rehabilitation Objectives
        • Functional Goals:
        • Normalize the patient’s gait pattern.
        • Achieve 90 degree hip flexion for proper sitting position.
    • Expected time of Bone Healing
    • 12-16 weeks.
    • Expected Duration of Rehabilitation
    • 15-30 weeks.
  • Methods of Treatment
    • Closed or Open Reduction and Internal Fixation
      • Biomechanics: Stress sharing device
      • Mode of Bone Healing: Primary in non-displaced, impacted, or anatomically reduced #s.
      • Indications:
        • #s that are impacted, nondisplaced, or adequately reduced in patients younger than 65 years of age should be internally fixed with multiple parallel cannulated screws or pins.
        • A compression screw and side plate and an additional antirotation screw may be used for basicervical #s ( to prevent the loose head from spinning on the screw) that have a comminuted lateral cortex or severe osteoporosis.
    • Multiple parallel cannulated screw for internal fixation of a Garden’s type 1 #. Fractures that are adequately reduced in patients younger than 65 years of age are treated with internal fixation in situ.
    • Compression screw and slide fixation. This is an alternative to multiple parallel cannulated screws. An additional proximal antirotational screw may be used to prevent the loose head from spinning on the screw.
  • Methods of Treatment
    • Prosthetic Replacement of Femoral Head
      • Biomechanics: Stress bearing device.
      • Mode of bone healing : None
      • Indications: A fixed unipolar (Austin-Moore or Thompson type) or bipolar endoprosthesis may be used to treat an unstable displaced # when a satisfactory reduction cannot be achieved and the patient is older that 65 years of age. Other indication include cases in which rheumatoid, degenerative, or malignant disease has caused preexisting articular damage.
  • Bipolar endoprosthesis for treatment of an unstable displaced femoral neck #. This is frequently used in patients older than 65 years of age when satisfactory reduction cannot be achieved.
  • Garden’s type 4: femoral neck #, completely displaced, in an older patient.
  • Bipolar endoprosthesis replacement of the #ed femoral neck during the immediate postoperative period. Note the drains and staples in place.
  • Treatment
    • Early to Immediate (Day of Injury to One Week)
    • Two Weeks
    • Four to Six Weeks
    • Eight to Twelve Weeks
    • Twelve to Sixteen Weeks
  • Long term considerations and problems
    • Avascular necrosis of the femoral head may require prosthetic replacement if it becomes symptomatic and causes pain.
    • Nonunion may require prosthetic replacement of the femoral head and neck.
    • Leg length discrepancy is rare, but may be a long term problem requiring a shoe lift.
    • Prominent and painful screws, pins, and plates may require removal.
  • The End