Fracture neck of femur


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Fracture neck of femur

  1. 1. Fracture neck of Femur: Diagnosis and Treatment Presented By S.Renuga Devi BME,Final year 31510121035 1 10/16/2013
  2. 2. 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. 2 10/16/2013
  3. 3. 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. 3 10/16/2013
  4. 4. 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). 4 10/16/2013
  5. 5.  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 is crossed by horizontal groove for tendon of obturator externus. 5 10/16/2013
  6. 6. Blood supply 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 6 10/16/2013
  7. 7. 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. 7 10/16/2013
  8. 8. c) 8 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. 10/16/2013
  9. 9. PATHO-ANATOMY  Most fracture are displaced with distal fragment – externally rotated, adducted, and proximall migrated. These displacement are less marked than in intertrochanteric fracture because the capsule of hip joint is attached to distal fragment and prevent extreme rotation and displacement of distal fragment. 9 10/16/2013
  10. 10. CLASSIFICATION  ANATOMICAL LOCATION  Subcapital  Transcervical  Basicervical (base of the neck fracture) 10 10/16/2013
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  12. 12. PAUWEL This is based on the angle of fracture from the horizontal  Type I: 30 degrees  Type II: 50 degrees  Type III: 70 degrees 12 10/16/2013
  13. 13.  As the fracture progresses from type 1 to type 3, the obliquity of the fracture line increases, thus the shear force at the fracture site increases. 13 10/16/2013
  14. 14. GARDEN     14 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 10/16/2013
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  17. 17. Orthopaedic Trauma 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 17 10/16/2013
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  19. 19. 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 19 10/16/2013
  20. 20.  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. 20 10/16/2013
  21. 21. 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. 21 10/16/2013
  22. 22.  Multiple fractures-patient with a femoral shaft fracture may also have a hip fracture which is easily missed unless the pelvis is x- rayed. 22 10/16/2013
  23. 23. Radiography Radiography is the preferred initial imaging modality in evaluating femoral neck fractures because of its near universal availability, ease of acquisition, and documented correlation with surgical results over many years of use. 23 10/16/2013
  24. 24. limitations:  Spiral fractures are difficult to assess on a single view.  Comminution is also not as easily demonstrated as it is with CT.  Some stress fractures are simply not visible on plain images at all.  However, radiography will likely remain the mainstay in the evaluation of these injuries in the near future, and cross-sectional imaging will play an increasing but supplementary role. 24 10/16/2013
  25. 25. COMPUTED TOMOGRAPHY  CT plays an increasingly important role in evaluating the hip after a fracture.  CT is exquisite useful for imaging abnormalities of the bone itself.  Because of its superior resolution, cross-sectional capabilities, and amenability to image reconstruction in the coronal and sagittal planes, CT is useful for assessing fracture comminution preoperatively and in determining the extent of union (or lack thereof) postoperatively. 25 10/16/2013
  26. 26. Degree of Confidence:  CT is the most useful test for evaluating bony injury. However, axial fractures in the plane of the images can on occasion be missed with CT.  This potential is decreased with the use of images reconstructed in orthogonal planes and newer multidetector CT scanners 26 10/16/2013
  27. 27. MRI  MRI is both sensitive and specific in the detection of femoral neck fractures, because it can show both the actual fracture line and the resulting bone marrow edema.  The superior contrast of MRI when appropriate pulse sequences are used, the intrinsic spatial resolution, and the ability to image in multiple planes (coronal, axial, and less commonly, sagittal) makes MRI the premiere imaging modality, especially in the setting of stress fractures, which can appear normal on initial plain images.  The fracture line can be visualized as linear low-signalintensity areas surrounded by bone marrow edema, which is hypointense relative to normal marrow on T1-weighted images or hyperintense on T2-weighted images. 27 10/16/2013
  28. 28. Drawbacks  Drawbacks of MRI include its longer imaging time, its relative lack of widespread availability,  Its higher costs, and the exclusion of patients with cardiac pacemakers and certain metal hardware in their body. . 28 10/16/2013
  29. 29. Nuclear Medicine  Approximately 80% of fractures can be visualized 24 hours after trauma, as seen by diffusely increased tracer uptake. By 3 days after trauma, 95% of fractures are visualized, and maximal fracture sensitivity is found at 7 days; this knowledge may be helpful in equivocal cases.  Nuclear medicine studies with technetium-99m methylene diphosphonate (99mTc-MDP) have also been found to be effective in predicting healing complications related to femoral neck fractures. 29 10/16/2013
  30. 30. TREATMENTS  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. 30 10/16/2013
  31. 31. Surgical Treatment : Two essential principles to be followed in the surgical management of this fracture are (a) perfect anatomical reduction. (b) rigid internal fixation. The earlier method of stabilising the fracture was by internal fixation with Smith Petersen Trifin nail.  The fracture is reduced by manipulation with the patient in a special orthopaedic table. The fracture is internally fixed with an S.P. Nail under radiological control. The more recent method of internal fixation of the fracture is the use of multiple compression screws. 31 10/16/2013
  32. 32. Fracture neck of femur in older patients In older patients above 60 years, such fractures are treated by removing the head of the femur and replacing it by metal prosthesis like Austin Moore's prosthesis. This enables the patient to be ambulant and start early weight bearing. Fracture neck of femur in Children The fracture is reduced by manipulation and the leg immobilised in full plaster spica in abduction for 8-10 weeks. When indicated internal fixation could be done with multiple thin Austin Moore's Pins. 32 10/16/2013
  33. 33. Dynamic Hip Screw: •Most commonly used device for both stable and unstable fracture patterns. •Plate angle is variable 130 to 150 degrees. •Has to be positioned centrally in the femoral head. •Use of radiological views to know the exact position. 33 10/16/2013
  34. 34.  Austin Moore's prosthesis 34 Total hip joint Replacement 10/16/2013
  35. 35. Broad treatment guidelines Age group undisplaced • More than 70 years DHS • Young adults DHS • Children HIP spica Multiple Moore`s pinning 35 • DHS = dynamic hip screws • THR = total hip replacement Displaced • • • • Prosthesis THR DHS Osteotomy or prosthesis • Multiple Moore`s pinning • Osteotomy • arthrodesis 10/16/2013
  36. 36. Complications  Thromboembolism : - leading cause of death within first 7 days ( 40 % )  Nonunion  Avascular necrosis 36 10/16/2013
  37. 37. Nonunion  Failure of union of this fracture still occurs due to improper reduction of imperfect internal fixation.  Nonunion rate 85 – 95 %  If there is no evidence of radiological healing taking place between 6 and 12 months at treatment on a radiograph , it is declared as nonunion. 37 10/16/2013
  38. 38. Causes :  Inaccurate reduction  Poor internal fixation  Avascularity of femoral head Clinical features :  Unable to bear the weight on the affected side  Wasting of the muscles  Minimal shortening of the affected lower limb 38 10/16/2013
  39. 39. Avascular Necrosis  Avascular necrosis of the head of the femur is an     39 unpredictable complication met with after any type of internal fixation. The patient presents with pain in the hip and limping. There is limitation of all movements of the hip with muscle spasm. Radiography shows patchy areas of increased density in the head of the femur. Treatment in the early stages is by rest, traction and weight relieving caliper. When indicated, osteotomy or replacement arthroplasty is done. 10/16/2013
  40. 40. 40 10/16/201 THANK YOU