Lecture On Fracture Neck Femur MBBS

1. DR ABHISHEK PATHAK
ASSOCIATE PROFESSOR
ORTHOPAEDICS

2. ANATOMY
NORMAL
NECK SHAFT
ANGLE IS 135
DEGREE

3. ANTEVERSION = 10 ± 7º

4. CALCAR FEMORALE
• Calcar femorale is a
Condensed plate of
bone extending from
lesser trochanter to
greater trochanter
posteromedially

5. TRABECULAR SYSTEM

6. Figure 2 Computer-generated image demonstrates the orientation of the load-bearing trabeculae of the proximal femur, including the vertically oriented
primary compressive trabeculae (red lines), the more horizontally oriented primary tensile trabeculae (black lines), and obliquely oriented secondary
compressive trabeculae (yellow lines). The intervening trabecular bone between the medially converging compressive trabeculae is known as the Ward
triangle (yellow triangle), a site of relative weakness.
Sheehan SE. Published Online: July 17, 2015
https://doi.org/10.1148/rg.2015140301

7. FRACTURE NECK OF FEMUR
Variously called as
• The unsolved fracture
• Fracture of necessity
WHY

8. • EVEN WITH A GOOD REDUCTION AND FIXATION
ABOUT 30% GO INTO NON-UNION / AVN
• SURGEON HAS SOME CONTROL OVER NON-UNION
BUT NOT OVER AVN
• INCIDENCE OF NON-UNION CAN BE GREATLY
REDUCED BY EARLY REDUCTION AND INTERNAL
FIXATION
• AVN DEPENDS ON THE INITIAL TRAUMA AND
DISPLACEMENT OF THE FRACTURE

9. REASONS FOR NON UNION
1. INTRA-ARTICULAR FRACTURE THUS SYNOVIAL
FLUID A DETERRENT TO # UNION
2. VASCULARITY PRECARIOUS
3. PERIOSTEUM IS LACKING THUS THE UNION IS
ENDOSTEAL
4. # SUBJECTED TO HIGH SHEARING FORCES
5. BONE QUALITY MAY NOT BE GOOD

10. BLOOD SUPPLY
• Lateral epiphysel artery
– terminal branch MFC artery
– predominant blood supply
to weight bearing dome of
head
• Artery of ligamentum
teres
– from obturator artery
– supplies anteroinferior
head
• Lateral femoral circumflex
a.
– less contribution than MFC

11. Figure 3 Computer-generated image demonstrates the vascular anatomy of the proximal femur. Blood flow to the proximal femur is supplied primarily by the
branches of the medial and lateral circumflex femoral arteries. Supplemental flow to the femoral head is supplied by the artery of the ligamentum teres, a
branch of the obturator artery. Green oval = transition point between the extracapsular and intracapsular portions of the ascending cervical retinacular
arteries; yellow circle = lateral aspect of the femoral head-neck junction, a vulnerable zone where injury poses a substantial risk of clinically significant
vascular compromise.

13. • Three ligaments in this region
1) Ileofemoral
2) Pubofemoral
3) Ischiofemoral

16. • 1575- Ambroise Pare described I/C # neck
femur
• 1850- Lagenbeck nails a hip
• 1904- Whitman’s reduction and spica cast
• 1931- Smith-Peterson used his triflanged
nail
• 1936- Moore’s pin and Knowle’s pin
• 1943- Moore’s prosthesis
• 1952- Thompson’s prosthesis
• 1960- Charnley’s Total Hip Arthroplasty

17. EPIDEMOLOGY
• Common fracture to occur in old female
usually due to post menopausal osteoporosis
• Average year of occurrence is 60-70
• Young adults are involved in high energy
trauma

18. Risk factors include
1. Female sex
2. Alcohol and tobacco use
3. Previous #
4. Low estrogen level

19. MECHANISM
• Low energy trauma in elderly patients
–Direct: Fall on GT or forced ext.
Rotation
–Indirect : Muscle forces overwhelming
bone strength
• High energy trauma : RTA, Fall from
height
• Cyclical loading can cause stress fractures

20. Clinical evaluation
• H/o trivial trauma after which the patient is non
ambulatory
• Pt. with impacted fracture may bear weight
• ½ to 1 cm of shortening
• Limb in mild ext. rotation as compared to normal
limb
• Pain in groin
• Tenderness at the base of Scarpa’s Triangle
• Pain on hip movt.
• Axial tenderness

21. Inguinal
Ligament
Medial border of
adductor longus
Medial border of
sartorius

22. IMAGING
• X-ray pelvis with both hips AP view
• X-ray of affected hip AP and Lateral
view
• Internal rotation AP views
• Tech. Bone Scan
• MRI

23. ANATOMICAL CLASSIFICATION

24. PAUWELS CLASSIFICATION
• ANGLE THAT FRACTURE LINE SUBSTANDS
WITH THE HORIZONTAL

25. Garden Classification
I - Incomplete or Impacted
II - Complete no displacement
III - Complete with partial displacement
IV- Complete with total displacement

26. GARDENS CLASSIFICATION
• GARDEN’S TYPE I

27. • GARDEN’S TYPE II

28. • GARDEN’S TYPE III

29. • GARDEN’S TYPE IV

30. Gardens Classification

31. SHENTON’S LINE

32. SHENTON’S LINE

33. Goals of treatment

34. • Minimize patient’s discomfort
• Restore hip function
• Allow rapid mobilization by early
reduction and internal fixation so as
to avoid problems of long term
recumbency

35. NON OPERATIVE
TREATMENT
• No place in todays time
• Recommended only for patients who are
at extreme medical risk, moribund or
demented nonambulators

36. TREATMENT
OPTIONS

37. DISPLACED FRACTURE IN
YOUNG ADULTS
• # LESS THAN 3 WEEKS OLD
• OPEN OR CLOSED ANATOMIC
REDUCTION WITH STABLE INTERNAL
FIXATION WITH
a) 6.5 mm CCS, optimum 3 in number
b) DHS with a derotation screw

38. DHS with a derotation screw

39. 6.5 mm CCS, optimum 3 in number

40. FRACTURES IN CHILDREN
• Closed reduction and internal fixation
with
a) Moore’s pin
b) Knowles pin
Followed by spica cast immobilization

42. CRITERIA FOR ANATOMIC
REDUCTION
• Garden’s criteria : Trebacular angle
on AP and Lat. view should be within
the range of 160-180 deg.
• Lovetts “LAZY S” criteria

44. FRACTURE > 3 WK. OLD
• OSTEOTOMIES:
McMurray’s
Valgus angulation
Provide arm chair
effect

45. 1. MUSCLE PEDICLE GRAFT
1. Meyer’s quadratus femoris pedicle
2. Bakshi’s TFL pedicle graft
2. GIRDLESTONE EXCISION
ARTHROPLASTY
3. ARTHRODESIS
4. ORIF WITH FIBULAR GRAFT

46. # N/F IN ELDERLY > 60 YRS
• Physiological age is important.
• HEMIARTHROPLASTY
UNIPOLAR : 1) Austin Moore prosthesis
2) Thompson prosthesis
BIPOLAR PROSTHESIS
• THR- when acetabular erosion is present

47. Austin Moore prosthesis

48. BIPOLAR PROSTHESIS

49. THR

50. STRESS FRACTURE

51. COMPLICATIONS
• Non union
• AVN
• Limb length dicrepency