Structural anatomy, etiology, predisposing factors, classification, various treatment methods

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2. Femoral Neck Fractures
By: Dr. Kalimullah Wardak
5.6.2021 - 17.03.1400

3. 1. GENERAL FACTS
Anatomy:
1. Topography
2. Angle
3. Blood supply
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4. 1. GENERAL FACTS
Anatomical Location:
1. Subcapital
2. Transcervical
3. Basicervical
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5. 1. GENERAL FACTS
Garden Classification (Risk of nonunion and AVN):
• 25% of displaced #  AVN and Nonunion
1. Incomplete (Impacted in valgus)
2. Complete but nondisplaced on at least two planes
3. Complete fracture with partial displacement
4. Complete fracture with complete displacement
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6. 1. GENERAL FACTS
Stages III and IV can be differentiated radiographically by carefully scrutinizing the
trabecular patterns of the femoral head and acetabulum. Stage III femoral neck
fractures maintain contact between the femoral neck and femoral head, and the
trabecular patterns between the head and acetabulum are no longer aligned.
Stage IV fractures do not maintain contact between the femoral neck and femoral
head, and the trabecular patterns between the head and acetabulum have
realigned.
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7. 1. GENERAL FACTS
Pauwell’s Classification (Biomechanical stability):
• Based on the angle of fracture line with horizontal plane.
1. 0˚ - 30˚
2. 30˚ - 50˚
3. >50˚
• High angle ~ shear force ~ high complications
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8. 2. DIAGNOSIS
• History of:
1. Trauma (Except in stress fractures)
2. Concomitant injuries
• Physical examination:
1. External Rotation
2. Shortening
3. Ecchymosis
4. Axial or local tenderness
• Radiographs
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9. 2. DIAGNOSIS
• If X-ray is normal but clinical suspicion of a hip remains high, order:
1. CT-scan (3D image reconstruction) for a thorough evaluation
2. MRI for subtle changes
3. Bone Scan
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10. 2. DIAGNOSIS
• Diagnosis can be missed in:
1. Stress fracture in the elderly
2. Nondisplaced fracture
3. Painless fracture
4. Multiple concomitant fractures
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11. 3. CAUSES:
Weak bone:
a. Mineral density
1. Osteopenia: Osteoporosis, Osteomalacia, Paget’s Disease
2. Osteopetrosis: CAI-II deficiency
b. Cellular component
1. Osteogenesis Imperfecta: Collagen Type-I aberrant production
Excessive applied force:
a. Excessive force/load
b. Awkward direction of applied force
c. Repetition
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12. 3. CAUSES:
• Stress fractures:
Causes:
Overuse. Female Runner with Groin pain: has stress fracture MRI
1. Tension type: upper surface, emergent fixation before it progresses to complete
2. Compression type: lower surface of neck, if less than 50%, you can use protected
crutch ambulation; if more, Do ORIF
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13. 4. TREATMENT
A satisfactory reduction:
Minimizes the complications
For everyone, even those planned for internal fixation
Reduction attempts should not be forceful and should not be repeated more than two or three
times.
• The Whitman technique is applying
1. Traction
2. Abduction
3. Extension
4. External rotation of the hip with subsequent internal rotation.
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14. 4. TREATMENT
THE GARDEN ALIGNMENT INDEX:
Can be used to evaluate post-reduction femoral neck angulation and alignment.
• Check trabecular alignment patterns on:
1. A/P radiograph: An angle of less than 160 degrees indicates varus, whereas an angle of
more than 180 degrees indicates excessive valgus.
2. Lateral radiographs: Angulation should be approximately 180 degrees and deviation of more
than 20 degrees indicates excessive anteversion or retroversion.
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15. 4. TREATMENT
OPERATIVE TREATMENT
Most femoral neck fractures require operative treatment. Possible exceptions include stress fractures on the
compression side of the femoral neck and femoral neck fractures in patients who are nonambulatory and
comfortable or are too infirm for operative treatment.
IMPLANT CHOICE
The choice of implant and operation is largely dependent on the patient’s physiologic age. Patients with
displaced femoral neck fractures who are older are best treated with hemiarthroplasty or total hip
arthroplasty (THA). Younger patients are treated with internal fixation. With hemiarthroplasty, controversy
exists to some degree over the use of cemented or cementless stems, as well as unipolar or bipolar
prostheses.
Data from several studies indicate that many community ambulators may be better treated with THA than
with hemiarthroplasty.
A major concern with THA for femoral neck fracture is dislocation, which has led to an increased interest
in using an anterior or anterolateral approach when THA is done for treatment of a femoral neck fracture.
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16. 5. COMPLICATIONS
1. Nonunion:
With increased age and displacement degree
2. Avascular Necrosis
With increased displacement and intracapsular hematoma
3. Prolonged Healing
By synovial fluid and angiogenic inhibiting factors
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