it comprises of the anatomy, epidemiology, mechanism of injury and management options. there is also the fracture classifications management was grouped into operative and conservative there is also a section for children.

1. MANAGEMENT OF
NECK OF FEMUR
FRACTURE
DR P. MENSAH
1

2. SCOPE OF WORK
• Introduction
• Epidemiology
• Surgical Anatomy
• Classification
• Mechanism Of Injury
• Clinical Presentation
• Investigations
• Management Options
• Complication
• Neck Of Femur Fracture In Children
• Conclusion
• References
2

3. Introduction
• The femur being the longest bone in the human body has different
parts among which are the head, neck, greater and lesser
trochanters, shaft and the distal condyles, and therefore fracture can
occur in any of these areas.
• Its also the strongest and largest bone in the human body.
• It therefore requires high-energy trauma for it to fracture unless there
is an ongoing pathology that weakens the bone
3

4. Introduction
• Neck of femur fracture is the most common fracture requiring surgical
treatment.
• It is a typical fragility fracture in the elderly, as a consequence of
osteoporosis, advancing age or chronic disease.
• The fracture is often indicative of a generalized decline in health,
including cognitive ability, balance, muscle power and eyesight.
4

5. Introduction
• In addition, an acute inter-current illness, such as urinary tract
infection, is often the precipitant of the fall that breaks the neck of
femur.
• These patients are often medically and socially vulnerable and have a
high level of perioperative and postoperative mortality and
dependency.
• Prompt and effective surgical and medical care has a substantial
effect on improving this prognosis.
• The associated annual healthcare costs in the UK amount to £2 billion
and €2–4 billion in Germany
5

6. Epidemiology
• In 2000, there were an estimated 424,000 neck of femur fractures worldwide in
men and 1,098,000 in women.
• Based on changing demographics and the increase in life expectancy, by 2025
neck of femur fractures in men are expected to rise by 89%, resulting in 800,000
neck of femur fractures per year in men, while the number of neck of femur
fractures in women will rise by 69% and reach 1.8 million.
AO PRINCIPLES OF FRACTURE MANAGEMENT
6

7. Epidemiology
• In addition, 5% of patients with neck of femur fracture have a
simultaneous fragility fracture (most commonly at the wrist or
proximal humerus)
• There is also an 8% chance of sustaining a fracture of the contralateral
neck of femur in the next 8 years.
• Up to 50% of women are expected to suffer a neck of femur fracture
in their lifetime.
7

8. Epidemiology
• Around 30% will die within a year of their fall and 25% of the
remainder will never return to independent living.
• There is a significant risk of mortality and morbidity post injury;
according to the National Hip Fracture Database England, Wales and
Northern Ireland in 2015, 7.5% of patients will die within 1 month of
hip fracture rising to 24% within 12 months.
8

9. Epidemiology
• Hip fracture rates are highest in Northern and Central Europe, moderate in North
America, Japan and Oceania and at the lowest in south Asia and Africa.
• For each decade after 50 the risk of hip fracture doubles.
• Numbers of annual hip fracture cases treated are:
- UK=100,000
- Germany=135,000
- Netherlands 18,500
• More than 50% of femoral neck fractures are intracapsular and up to 80% are
displaced
9

10. Epidemiology
• In 2014, Ejimofor et al, published an article on “The Pattern of
femoral fracture and associated injuries in a Nigerian tertiary trauma
centre.
• It was a 10 year (1994 to 2004) retrospective study.
• Their results 562 femoral fractures were seen over the period with
63.7% males and 36.3% females
• MOI= RTA – 62.8%, Minor falls/trips – 18%, fall from height – 11.2%
• AREA OF FRACTURE= Neck – 16%, mid-shaft – 26.5%, Head – 0.9%,
Pertrochanteric – 9.8%, Subtrochanteric – 12.5%
10

11. Epidemiology - In CCTH – from Jan 2018 – Oct 2021
• 46 cases in total – Neck of femur Fracture
• 19 males and 27 females
• 0 -19 = 4
• 20-39 = 2
• 40-59 = 9
• 60-79 = 11
• > 80 = 20
11

12. Surgical Anatomy
12

13. Surgical Anatomy
13

14. 14

15. Surgical anatomy
15

16. Types of Neck Of femur Fracture
• Based on capsule – its important because of blood supply
• Intracapsular
• Extracapsular
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17. Types of Intracapsular
17

18. Classification of Intracapsular
• Garden Classification
• Pauwels Classification
18

19. 19

20. Garden Classification
20

21. 21

22. Types of Extracapsular
• Fractures involving the trochanters
are extracapsular and occur in
metaphyseal bone with a good
blood supply and do not threaten
the vascularity of the femoral
head.
• The aim of treatment is immediate
full weight bearing and early
rehabilitation, thus the treatment
is operative
22

23. Classification of Extracapsular Fracture
23

24. Mechanism of Injury
• Low Energy falls in Elderly
 Falling directly onto the hip
Twisting Mechanism
Sudden completion of an impartial fracture
Pathological fracture
• High Energy in the Young
Motor Vehicle Accident
Pedestrian Vehicle Accident
Fall from height
24

25. 25

26. Clinical Presentation
• Pain in the affected hip
• There will be tenderness over the groin
• There will be pain on attempted passive
rotation of the limb.
• The patient will be unable to perform a straight-
leg raise.
• The lower limb will be shortened and externally
rotated if the fracture is displaced.
• Bruising only appears later.
26

27. Investigation
• Xray – is the preferred initial modality:
- Universally available
- Ease of Acquisition
- Easy to read
• Recommended Views
- Obtain A-P View pelvis - This is required to allow full assessment of the hip and
pelvic ring.
- Cross-table lateral - assess for any displacement of the head, which should
normally be aligned centrally on the neck
- full length femur of ipsilateral side - to use as template
- Garden Classification is based on AP pelvis
27

28. 28

29. 29

30. • CT- Scan is required in the evaluation of complex hip injury, such as a native
hip dislocation or femoral head fracture. It can also be used in the
assessment of occult hip fracture.
• MRI is also a suitable modality
for the assessment of occult hip
fracture, and it will also demonstrate
other soft tissue causes of hip pain,
such as a psoas abscess.
30

31. Management Options
• Initial Management
 Save life before limb
- Young
- Old
Once the safety of the patient has been established, attention is directed to the fracture
A treatment algorithm should address
• The age
• The level of activity
• Bone density
• Additional diseases (comorbidities)
• Estimated life expectancy
• The compliance of the patient
31

32. Management Options
• Conservative (Non-operative)
• Operative
32

33. Conservative (Non-operative)
• Not advised – fractures at this level have poor capacity for union due to the
following:
1. Interference with blood supply to proximal fragment
2. Difficulty in controlling the small proximal fragment
3. The lack of organization of the fracture haematoma due to the presence
of the synovial fluid
• Also it is:
Cumbersome for the patient
Labour intensive for Nurses
Bad outcomes for Clinicians 33

34. Conservative (Non-operative)
• Only considered in situations where there is no facility or skill for operative
management.
• Also for patient who have a lot of co-morbidities and is unfit for surgery
• 5 – 8% of elderly patients would not be fit for surgery because of terminal
illness
• Traction is the non-operative management – for at least 6 – 8 weeks but
often 10 – 12 weeks
Skin Traction
Skeletal traction
34

35. 35

36. Disadvantages of prolonged skin traction
• Loosening
• Constriction
• Friction with skin irritation
• Allergy
36

37. Operative
37

38. Operative
• Two essential principles to be followed in the operative management
of this fracture
a) Perfect anatomical reduction
b) Rigid internal fixation
• The type of surgery done is dependent on
Characteristics of fracture
Age of Patient
38

39. Methods of Internal fixation
• Cannulated screws
• Dynamic Hip Screw
• Proximal Femoral Nailing
• Arthroplasty
39

40. Cannulated screws
• Indications
- Nondisplaced transcervical fracture
- Garden I and II fracture patterns in the elderly
• Can be done percutaneously
40

41. Traction table
41

42. 42

43. Dynamic Hip Screws
• The dynamic (or sliding) hip screw (DHS) is a remarkably successful
device comprising a lag screw in the femoral head and neck, which
articulates with the barrel of a side plate that is secured to the
femoral shaft.
• The screw has flat sides that correspond to the internal shape of the
barrel, allowing longitudinal sliding but preventing postoperative
rotation.
• This construct allows maintenance of fixed neck-shaft angle, and
linear controlled collapse and compression of the fracture, as the lag
screw slides into the barrel of the plate during postoperative
mobilization.
43

44. 44

45. 45

46. 46

47. DHS : Tip – Apex Ratio
47

48. Proximal femoral Nailing
• Its an intramedullary fixation device used for Extracapsular fracture.
• The shaft of the nail prevents lateral displacement of the fragments
(or the corollary— medialization of the femoral shaft).
• Fixation may be associated with shorter operation time, less blood
loss, and earlier weight bearing
48

49. 49

50. 50

51. 51

52. 52

53. DHS VS PFN
53

54. DHS VS PFN
Like the DHS, The PFN has:
• Lag screw that is placed centrally adjacent to the apex of the head
• A fixed angle between the femoral neck and shaft to allow controlled linear collapse
In contrast to the DHS, it has the advantages that it:
• Has a relatively short lever arm between the device and the fracture, making it more suited to
comminuted fractures or those involving the subtrochanteric region
• Has a reduced sliding distance of the lag screw which minimizes the distance by which the
femoral neck shortens in comminuted intertrochanteric fractures, (in theory) improving
subsequent function by maintaining hip offset
• Can be implanted percutaneously.
54

55. DHS VS PFN
However, it has some disadvantages compared with the DHS, in that:
• There is a higher rate of implant-related fracture, principally at the distal tip of
the nail, and particularly with short nails
• It is considerably more expensive
• It is a technically more difficult operation
• Despite its theoretical advantages, it has not been shown conclusively that any
intertrochanteric fractures (i.e. excluding reverse oblique and subtrochanteric
patterns) have a better clinical outcome with a nail than with a DHS.
55

56. Arthroplasty
56

57. Arthroplasty – replacement of the hip
• Patients older than 80 years, or patients with accompanied ipsilateral
arthrosis, rheumatoid arthritis, or a fracture in pathological bone
should be treated with replacement arthroplasty, either
hemiarthroplasty or total hip replacement.
• Patients of any age with severe chronic illness or a limited life
expectancy should also be managed with a prosthesis
• Surgeons must be aware that some women develop osteoporosis at
an earlier age.
57

58. • Its either hemi-arthroplasty or total hip replacement
• The head of the hemiarthroplasty may be a single block (unipolar) or
may have an independent articulation between a small head and a
larger outer shell (bipolar).
• The latter theoretically reduces acetabular wear but this advantage
has yet to be proven conclusively.
58

59. Set up and procedure for Arthroplasty
59

60. Hemiarthroplasty
60

61. 61

62. Total hip replacement
62

63. 63

64. 64

65. 65

66. Femoral Neck Fractures in children
• Hip fractures rarely occur in children but, when they do, they are
potentially very serious.
• There is a high risk of complications, such as osteonecrosis,
premature physeal closure and coxa vara.
• The fracture is usually due to high-energy trauma (e.g. falling from a
height or an RTA)
• Pathological fractures sometimes occur through a bone cyst or benign
tumour.
• Also look for evidence of possible child abuse
66

67. • Growth centers of the proximal femoral epiphysis
- Accounts for 13 – 15% of leg length
- 30% of length of femur
- Proximal femoral physis grows 3mm/yr
- Entire lower limb grows 23mm/yr
67

68. Delbet’s Classification
• This is based on the location of the fracture.
• Type I – a fracture-separation of the epiphysis. The epiphyseal
fragment may also be dislocated from the acetabulum.
• Type II – a transcervical fracture of the femoral neck. This is the
commonest variety, accounting for almost 50% of paediatric hip
fractures.
• Type III – a basal (cervicotrochanteric) fracture. This is the second
most common injury.
• Type IV – an intertrochanteric fracture.
68

69. Classification
69

70. Treatment
• Non-operative
- Indication – type I, II, III, UNDISPLACED TYPE IV, < 4years
- Hip Spica cast in abduction
- Weekly radiographs for 3 weeks
• Operative
- Closed reduction and internal fixation – if can be reduced closed
- Open reduction and internal fixation
70

71. 71

72. Operative Management – Cannulated Screws
72

73. Case Study – 9 year Old female
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74. 74

75. 75

76. 76

77. Conclusion
• The ABC’s of primary care for the injured always takes precedence
over the fracture treatment.
• Because of the Nature of the blood supply, Neck of Femur fractures
are to be reduced and kept reduced as soon as possible.
77

78. References
• Keith Moore – Clinical Oriented Anatomy 7th Edition
• AO principles of fracture Management
• Apley Solomons system of orthopaedics and trauma
• McRae's Orthopaedic Trauma and emergency fracture management
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79. 79

80. Thank You
80