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Proximal Femoral Neck and intertrochanteric fractures
1. Proximal femoral neck &
inter trochanteric fracture
Presented by final year
medical student
Ali Kareem
5/2/2017 1
Orthopedic branch – Surgery department - MUCOM
2. • The structure of the head and neck of femur is developed
for the transmission of body weight efficiently, with
minimum bone mass, by appropriate distribution of the
bony trabeculae in the neck.
• Femoral neck fracture is one of the most common injuries
observed in the elderly leading to morbidity and
mortality.
• commonly seen in the women (femalemale ratio is 31
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4. Blood supply
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A. extracapsular arterial ring
❖ lateral &medial femoral circumflex artery
B. ascending cervical branches ( Retinacular arteries)
C. the arteries of the ligamentum teres (foveal artery).
9. 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
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10. ⮚ 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.
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11. • This case is very common in elderly women nearly
80% who have tripped and fallen while walking.
• Main symptoms : pain in the region, eccomyosis
inner side of the thigh.
• Difficulty & inability in walking
• Dx is confirmed by X-Ray of the hip loint in both
anterior & lateral position
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14. 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.
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15. ⮚Multiple fractures-patient with a femoral shaft
fracture may also have a hip fracture which is easily
missed unless the pelvis is x- rayed.
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16. Treatment
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• Conservative Treatment
Fractures at this level have a poor capacity for
union due to the following factors.
• Interference with the blood supply to the proximal
fragment.
• Difficulty in controlling the small proximal fragment.
• The lack of organisation of the fracture
haematoma due to the presence of the
synovial fluid.
17. Treatment
Surgically:-
1. the fracture can be fixed by multiple cancellous
screws, pin plate, dynamic hip screw.
2. a prosthesis can be used to replace the head and
the neck of the femur, in complete transverse
fracture the replacement is said to be complete
(total hip replacement).
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18. Complications
1. Non union
2. Avascular necrosis
3. Osteo-arthritis
4. Dislocation (in replacement method)
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20. Pathoanatomy
❖ The distal fragment rides up
so that the femoral neck-shaft
angle is reduced (Coxa vera).
❖ The fracture is generally
comminuted and displaced.
❖ Rarely it can be
undisplaced fracture.
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21. Diagnosis
Clinical features:-
• History of a fall or RTA.
• Pain in the region of the groin and inability to
move the leg.
• Swelling in the region of the hip, and the leg will
be short and externally rotated.
• Tenderness over the greater trochanter.
• Physical findings are more marked.
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22. Radiological features:-
• X-ray- presence of comminution
of the medial cortex of the neck
• avulsion of the lesser trochanter
• extension of the fracture to the
subtrochanteric region indicate
an unstable fracture.
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24. Treatment
Conservative in :-
• Poor medical and surgical risk patients
• Terminally ill patients
• Very old patients
Methods
1. Simple support with pillows
2. Buck’s traction
3. Plaster spica
4. Skin or Skeletal traction through distal femur or tibia
for 10 – 12 weeks
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28. Operative methods:-
• The fracture is reduced under x-ray control and
fixed with internal fixation devices.
Most commonly used are,
• Dynamic hip screw (DHS).
• Nails such as Proximal Femoral Nail (PFN).
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