Fracture Neck of Femur-in details

1. FRACTURE
NECK OF
FEMUR
Dr Chinmoy Mazumder
Indoor Medical Officer
Department of Orthopaedics
EMCH

2. Index
Anatomy of Hip Joint
Fracture femur neck
 Aetiology
 Mechanism of Injury
 Classification
 Clinical features
 Investigations
 Treatment
 Complications
 Conclusions

3. What is a femoral neck
fracture?
A fracture through the intra articular part of the femoral neck is
usually referred to by the term femoral neck fracture.
 Another term is intracapsular proximal femoral fracture. About
80% of these fractures are displaced.
 Hip fractures comprise 20% of the operative workload of an
orthopedic trauma unit.
 Intracapsular femoral neck fractures account for 50% of all hip
fractures
 The lifetime risk
women 40% to 50%
men 13% to 22%
 Age
occur most frequently in elderly female patients
They are uncommon in patients younger than 60 years

4. Anatomy -Femur

5. 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).

6. ANATOMY OF NECK OF
FEMUR
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.

7. Anatomical factors
 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.
 The tension trabeculae and compression trabeculae
along with the strong calcar femorale on the medial
cortex of the neck of the femur form an efficient system
to withstand load bearing and torsion under normal
stresses of locomotion and weight bearing.
 In old age, osteoporosis of the region occurs. The
incidence of fracture neck of femur is higher in old age.

8. Trabecular Pattern of proximal
Hip

9. Anatomy of Hip Joint
 The hip is a synovial joint with wide range of rotational motion
and stability
 Stability is conferred by its ball and deep socket configuration,
acetabular labrum, a strong joint capsule, articular cartilage,
and surrounding muscle

10. Surgical Anatomy : Skeletal
Anatomy

11. Anatomy : Ligaments

12. Blood supply Of NOF
Crock 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

13. Blood supply Of NOF
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 ring
b) 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.

14. Blood supply Of NOF

15. Blood supply Of NOF
 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.

16. Blood supply Of NOF

17. Developmental anatomy
 Proximal femur has single physis at birth
 Separates into two distinct centers of ossification
capital ephiphysis
trochantric apophysis
 Ossification of femoral ephiphysis between 4 to 6 months
 Ossific nucleus of greater trochanter appears at 4 years

18. Developmental anatomy
 Lesser trochanter at 10 years
 Trochanteric physis growth arrest at 16-18 years
 Proximal femoral physis at 18 years
 Neck shaft angle is 135 degree at birth, 145
degree at 1 to 3 years
 Gradually matures to 130 degrees at skeletal
maturity
 Femoral anteversion is 30 degrees at birth and
ranges to 10.4 degrees at skeletal maturity

19. Risk Factors for Hip Fractures

20. 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

21. MECHANISM OF INJURY
 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.

24. CLASSIFICATION
 ANATOMICAL LOCATION
-subcapital
-transcervical
-basicervical (base of the neck fracture)

25. CLASSIFICATION
PAUWEL
This is based on the angle of fracture from the
horizontal
 Type I: 30 degrees
 Type II: 50 degrees
 Type III: 70 degrees

26. CLASSIFICATION
As the fracture progresses from type 1 to type 3, the obliquity of
the fracture fracture line increases, thus the shear force at the
fracture site increases

27. CLASSIFICATION
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

31. OrthopaedicTrauma 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

33. PAEDIATRIC NECK FEMUR #
(PROXIMAL FEMUR)
DELBET’S CLASSIFICATION
 TYPE 1: TRANSEPIPHYSEAL
1A : HEAD WITHIN ACETABULUM
I B : HEAD OUTSIDE ACETABULUM
 TYPE 2 : TRANSCERVICAL
 TYPE 3 : CERVICOTRONCHANTERIC
 TYPE 4: PERTROCHANTERIC

35. Diagnosis
History
Most patients will have a history of a simple, low-
energy fall
 2% to 3% of cases, there is no history of trauma
 25% to 30% of older patients there is cognitive
impairment and there may be an unreliable history
 An acute medical event or deterioration of a
preexisting condition may have contributed to the
fall causing the hip fracture, and this possibility
should always be considered

37. PATHO-ANATOMY
Most fracture are displaced with distal fragment
 Externally rotated,
 Adducted, and
 Proximal migrated.
 THIS IS MAINLY DUE TO GLUTEUS MAXIMUS, SHORT
EXT. ROTATORS AND ADDUCTORS
 Displacement are less marked than intertrochanteric
fracture because the capsule of hip joint is attached to distal
fragment

38.  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

40. 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.
 Multiple fractures-patient with a femoral shaft fracture may
also have a hip fracture which is easily missed unless the
pelvis is x rayed.

41. 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.

42. The Importance of a True AP
Hip Position

43. Modified Rolled Lateral Hip
 The patient is positioned
as shown above with a
slightly raised knee (15-20
degrees) and a smaller
cephalic tube angle (15-20
degrees).

45. Shenton's Line
 Shenton's line is a line formed by the inferior
aspect of the superior pubic ramus and the medial
aspect of the upper femur. Shenton's line should
describe a smooth curve. If there is any sharp
angulation of Shenton's line the patient could have
a neck of femur fracture. An abnormal Shenton's
line can be the most obvious indicator of a
patient's fractured neck of femur demonstrated on
an AP pelvis /hip image.

47. COMPUTED TOMOGRAPHY
 Because of its superior resolution, cross-
sectional capabilities, and amenability to
image reconstruction in the coronal and
saggittal planes,
 Useful for assessing fracture comminution
preoperatively and in determining the extent
of union (or lack there of) postoperatively.

48. MRI
 In cases of doubtful diagnosis
MRI may be useful additional
modality.
 Can also show soft tissue
problems associated with hip
pain in absence of fracture.
Limitations
 Relative lack of widespread
availability
 Its higher costs
 Exclusion of patients with
cardiac pacemakers

49. Nuclear Medicine
 In past technititium bone scan was used in
situations when plane radiography not able to
show fracture.
 Usually show positive result in fracture neck
femur.
 False negative results in osteopenic bone if
carried out within 48-72 hrs of injury.
 Sensitive but not specific
 CT scan is more accurate

50. 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.

51. METHODS OF FIXATION
 CANNULATED SCREW FIXATION
 DYNAMIC HIP SCREW
 HEMIARTHROPLASTY
 TOTAL HIP ARTHROPLASTY

52. DECISION MAKING
 Undisplaced Fractures :
CC Screw fixation
 Displaced Fractures :
ORIF with CC Screws , Dynamic Hip
Screw , Hemiarthroplasty
 Age
Less than 65 years : preserve head with
ORIF
More than 65 years : Hemiarthroplasty.

53. TREATMENT
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

54.  Operative Treatment-
include the following
- Internal fixation with
multiple cancellous
cannulated screws.(preffered
treatment)
- Sliding hip screw

56.  Advantages of DHS-
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

57.  Disadvantages-
1) stabilization include a larger surgical
exposure
2) potential to create rotational
malalignment of the femoral head at the time of
screw insertion.

58.  age more than 60 years
normal hip Hemiarthroplasty
 HEMIARTHROPLASTY
1.Austin moore prosthesis
2.Thompson prosthesis
3.Bipolar

59. 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)

60. THOMPSON PROSTHESIS
Indications
1.Non union
2.Age - > 60yrs
3.Inadequate femoral calcar
4.Pathological fracture
5.Osteoporosis

61. AUSTIN MOORE
PROSTHESIS
 Indications:
 1.Non union
 2.Age - > 60yrs
 3.Adequate femoral calcar

62. BIPOLAR HEMIARTHROPLASTY
 Indications
1.Non union
2.Young patient(50-55yrs)
acetabular erosion is
less,compared to unipolar
hemiarthroplasty

63.  Advantages of Hemiarthroplasty over open
reduction and internal fixation :
1) It may allow faster full weight bearing
2) It eliminates nonunion, osteonecrosis,
failure of fixation risks .
 Disadvantages:
1) It is a more extensive procedure with
greater blood loss
2) A risk of acetabular erosion exists in active
individuals

65. Total hip replacement
Indications
1.Pre existing acetabular disease
 osteoarthritis,
 rheumatoid arthritis,
 severe osteoporosis
 pathologic conditions with
acetabular involvement such as
Paget's disease
2.Displaced fracture in old age
>60yrs
3.Avasular necrosis of femoral head
4.Neglected fracture

67. COMPLICATIONS OF
PROSTHETIC REPLACEMENT

68. COMPLICATIONS
General-
1. Deep vein thrombosis
2. Pulmonary embolism
3. Pmeumonia
4. Bed sores
Osteoarthritis
Avascular necrosis
Non-union

69. NON UNION
 Absence of cambium layer of periosteum.
fracture heals through endosteal callus
 Diminished blood flow
 Synovial fluid washes away the hematoma
formation
 Shearing and distraction forces

70. TREATMENT OF NON
UNION
 YOUNG AGE:
1.Mc-murray’s osteotomy
2.Pauwel’s Y osteotomy
3.Valgus osteotomy
 OLD AGE:
1.Prosthetic replacement

71. MC-MURRAY’S
OSTEOTOMY
 Oblique medial
displacement
intertrochanteric
abduction osteotomy
 Proximal fragment
rotated externally
 Distal fragment
displaced medially

72. PAUWEL’S Y OSTEOTOMY
 PRINCIPLE
Vascular proximal end of shaft displaced medially to
bridge the non union site

73. VALGUS OSTEOTOMY
 PRINCIPLE
Converts the mechanical
loading of non union site
from shear force into
compressive force