Fracture Neck of the femur with a case presentation and theory background reference: Apley's System of Orthopaedics and Fractures Oxford Handbook of Orthopaedics and Trauma

1. FRACTURE NECK OF FEMUR
H.S Dr. Kaung Min Thant
H.S Dr. Khin Moe Pyae Thu
H.S Dr. Su Myat Naing
H.S Dr. Saint Phyu Sin Moe
H.S Dr. Soe Myat Thwe
Supervisor – SAS Dr. Aung Khaing Soe
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2. CONTENT
1. Literature Review
• Epidemiology
• Classification
• Blood supply of Proximal Femur
• Clinical features  History , Phsycial Examination
• Investigation
• Treatment
• Complication
2. Particular Case of Fracture Neck of Femur
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3. LITERATURE REVIEW
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4. EPIDEMIOLOGY
INCIDENCE
• Age – elderly (more than 6th decades)
• Sex – Female >Male
RISK FACTORS
• In elderly - secondary to osteoporosis, weak muscle, poor balance causing
increased tendency to fall
• Others - bone weakening disorders, risk of fall such as stroke, alcoholism
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5. MECHANISM OF INJURY
• The fracture results from simple fall with less force in osteoporotic people
(Pathological fracture)
• In younger people, high-energy mechanism such as fall from height and road
accidents  other associated injuries must be screened.
• There is also stress fractures occurred in runners and military personnel.
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6. CLASSIFICATION
Anatomical Classification
• Intracapsular Fractures- from the subcapital region of femoral head to basicervical
region of femoral neck, immediately proximal to trochanters
• Extracapsular Fractures- outside the capsule divided into
–inter-trochanteric and sub-trochanteric
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7. Garden’s Classification
• Stage I- incomplete impacted fracture
• Stage II - complete but undisplaced
fracture
• Stage III- complete fracture with moderate
displacement
• Stage IV - severely displaced fracture
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8. BLOOD SUPPLY
Three main arteries that supply the femoral
head.
1. Lateral epiphyseal branch of the medial
femoral circumflex
2. Ascending branch of the lateral femoral
circumflex both ascend from the deep
femoral artery
3. Ligamentum teres artery which descends
from the posterior branch of the obturator
artery and attaches at the fovea
• Healing of femoral neck fractures is
bedeviled by bone ischemia and tardy union
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10. CLINICAL FEATURES
History Taking
• Elderly - history of trauma, often low-energy
• Young adults - history of trauma, often high-energy
• After slip and fall, patient cannot stand up by himself, cannot walk,
• Pain is felt predominantly in the groin and thigh, and referred to knee
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11. On examination
Look- affected limb is shortened, abducted, externally rotated
minimal swelling may present or not, bruises & abrasions may be present
Feel - maximal tenderness over the front of hip
Move - no active movement and passive movement(limited by pain)
Measure - apparent length, real length, true length – may shorten on the affected side
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12. Special Tests
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13. INVESTIGATION
FOR DIAGNOSIS,
• Plain X-ray
• AP (hip in internal rotation)
• Frog - leg lateral (hip external rotation and abducted)
• acute - groin lateral
• Both hip X-ray
• CT (best for soft tissue injury, bony fragment in complex anatomical structure, Volume
rendered CT)
• MRI (if not seen on Standard radiograph, for occult fracture within 24 hour range)
• Bone scan (for stress fracture, insufficiency fracture)
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NORMAL HIP – GROIN LATERAL

14. FOR UNDERLYING CAUSE
• Pathological fracture  old age  other metastasis site 
CT head , CT chest , CT abdomen
• Female  suggest mammogram
• Send biopsy after surgery
• Osteoporosis  DEXA scan (Bone density scan)
• Trauma
GENERAL INVESTIGATION – CP(A), U&E, CRP
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15. Normal Hip X-ray (both)
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17. Garden Types
a. I  Valgus impacted b. II  complete non-displaced c. III  complete partial displaced
d. IV  complete full displaced07/07/2020 17

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Subcapital #NOF - Rt Transcervical #NOF - Rt

19. TREATMENT
I. Non – operative Treatment
Indication
• Severe comorbid disease (+)
• Medically Unfit for surgery
II. Operative Treatment
General Treatment- analgesics, sedatives, antibiotics if fracture is open.
Medical evaluation & pre-op preparation
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20. Indications for specific surgical techniques
SURGICAL TECHNIQUES INDICATIONS
1. Hemiarthroplasty and THA • Low demand, elderly patients
• If prior evidence of hip pain and/or radiographic
evidence of degenerative arthritis, a THA is
recommended
2. Cannulated screw(2 screw, 3 screws, 4
screws)
• Non-displaced ,intracapsular #NOF ,elderly
• Displaced fractures in younger patients with ideal
bone quality
3. Sliding Hip screw (SHS) • Stable, intertrochanteric hip fractures
• Basicervical fracture patterns
• Vertical #NOF patterns
4. Intramedullary Nail(IMN) • Comminuted IT or subtrochanteric fracture
patterns
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22. 07/07/2020 22
Multiple Hip Screw
Hemiarthroplasty
1. Thompson’s(cemented)

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Hemiarthroplasty
2.Austin-Moore( non-cemented)
Hemiarthroplasty
3. Bipolar

24. Total Hip Arthroplasty
Indication
• Delayed treatment
• Acetabular damage is suspected
• Patient with metastatic disease
• Better hip function & quality of life

25. • Rehabilitation, Early mobilization in patients who received hemiarthroplasty or
total hip replacement
• Supportive treatments ( Calcium tablets, Vit D supplements,…)
• Awareness & prevention & treatment of COMPLICATIONS
 General - bedsores, hypostatic pneumonia, DVT, pulmonary embolism
 Specific - AVN of femoral head, non-union, infection, osteoarthritis,
malfunction
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26. PARTICULAR CASE OF FRACTURE NECK OF FEMUR
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27. History
• A 54 year old female who resided at Taung Po Hla township, Oatkan Town was
admitted to Yangon Orthopedic Hospital, Unit 2 at 10:30a.m. on June 12th 2020.
• Her chief complaint was left leg injury due to fall
• Patient said she fell from stairs about three feet height.
 Pain over left hip(+)
 loss of function – she couldn’t walk after the incidence
 deformity (+)
 swelling (-)
 Apart from that, she had no external injuries.
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28. Physical Examination
On her arrival,
• Her general conditions were fair.
• No abnormality detected on chest and abdominal examination.
On Local examination,
• Hip is externally rotated, abducted, shortened.
• Local bone tenderness (+)
• Restriction of movement (+)
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29. Investigation -X-ray was taken on June 12th.
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Plain X-ray of both hip (AP view) showing left sided Fracture neck of femur – Garden Type IV

30. Treatment
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• p.o Norgetex 1 tab b.d
• p.o Omez 1 tab b.d
• Traction is applied

31. OPERATION REPORT
• Date – 24.6.2020
• Operation – 10:30 a.m. to 11:30 a.m.
• Name of Operation performed – Bipolar hemiarthroplasty
• Tissue removed – Femoral head
• Position – Right lateral decubitus
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32. Under aseptic condition and spinal anesthesia,
• Approach – Posterior
• Incision – From skin to capsule layer by layer
• Findings – Left sided #NOF
• Procedure – Remove the head and neck of
femur
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33. • Bipolar (size – 39 IRENE)
was chosen.
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34. • Drainage tube was inserted.
Incision was closed back layer by
layer.
Post operative treatment
• Monitor vital signs
• Keep abduction and extension of hip
• Continue IV antibiotics.
• Recheck X-ray both hips (AP view , lateral view)
• IM Diclo 1 stat and prn
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35. PATIENT POST OP X-RAY REPORT ON JUNE 25TH
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36. THANK YOU !!
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