3. z
ANATOMY OF NECK OF FEMUR
3
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. 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.
4
5. Blood sypply
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
5
6. 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.
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7. z
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.
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10. z
PATHO-ANATOMY
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Most fracture are displaced with
distal fragment – externally rotated, adducted,
and proximally 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.
11. Displacement of the lower bone fragment
caused by the pull of the powerful muscles.
In particular the outward rotation of the leg
so that the foot characteristically points
laterally. (GM) gluteus maximus; (PI)
piriformis; (OI) obturator internus; (GE)
gemelli; (QF) quadratus femoris; (RF) rectus
femoris; (AM) adductor muscles; (HS)
hamstring muscles
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13. z
ETIOLOGY
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Commonest site of # in elderly(7th /8th decade).
Post menopausal
women, osteomalacia, diabetes, stroke, alcoholi
sm, chronic debilitating disease.
Old people– weak muscle, poor balance –
increased tendency to fall.
Fall directly onto greater trochanter.
Fall from height, RTA
15. -PAUWEL
This is based on the angle of fracture from the
horizontal
Type I: 30 degrees
Type II: 50 degrees
Type III: 70 degrees
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16. 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
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17. -GARDEN
This is based on the degree of valgus displacement
Type I: Incomplete/valgus impacted
Type II:Complete and nondisplaced onAP 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
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20. -OrthopaedicTraumaAssociation (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
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22. z
MECHANISM OF INJURY
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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
23. 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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24. z
CLINICAL PRESENTATIONS
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H/O fall from height.
nonambulatory on presentation (EXCEPT
impacted fracture patient may still be able to
walk)
shortening and external rotation of the lower
extremity.
26. z
CLINICAL EVALUATION
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Pain is evident on range of hip motion, with
possible pain on axial compression and
tenderness to palpation of the groin.
Tenderness overScarpa`s triangle
ActiveSLR not possible
27. z
DIAGNOSIS
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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.
28. 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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29. z
RADIOGRAPHIC EVALUATION
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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.
34. The patient is
positioned as shown
above with a slightly
raised knee (15-20
degrees) and a
smaller cephalic
tube angle (15-20
degrees).
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35. z
Shenton'sLine
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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.
37. z
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.
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38. In children-
close reduction and Hip spica.
If not reduced thenORIF with Moore`s pins.
Adults
impacted or garden type 1 & 2
Non-operativeTreatment- bed rest for elderly
person whose medical condition carries an
excessively high risk of mortality from anesthesia
and surgery
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39. OperativeTreatment- include the following
- Internal fixation with multiple cancellous lag
screws.(preffered treatment)
- Sliding hip screw –
advantages-
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
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40. z
Disadvantages-
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1) stabilization include a larger surgical
exposure
2) potential to create rotational malalignment of
the femoral head at the time of screw insertion.
Fracture of the femoral neck
stabilized with three well-
placed, 6.5-mm, short
threaded cancellous lag
screws.
42. displaced or garden type 3& 4
age less than 60 years-
internal fixation by
1)Multiple cancellous screw-most commonly used.
2)Dynamic hip screw (DHS)
3)smith peterson nail (S.P. nail)
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43. age more than 60 years
normal hip- Hemiarthroplasty withAustin-Moore
prosthesis.
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44. 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)
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45. 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
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50. z
cause of AVN and non-union
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Tearing the capsular vessels the injury
deprives the head its main blood supply
Intra articular bone has only flimsy
periosteum and no contact with soft tissue
which could promote callus formation
Synovial fluid prevents clotting of the
fracture hematoma
51. z
refrences
10/16/2012 51
• Essential orthopaedics – J. Maheshwari
• Handbook of Fractures- Kenneth J. Koval
M.D
• & Joseph D.
Zuckerman M.D
• Rockwood & Green's Fractures inAdults-
• Robert W.
Bucholz
MD,
James D.
Heckman
MD,
• Charles M. Court-
Brown MD.
• Apleys System of orthopaedics and fractures
• David
Warwick
MD.
