Fracture neck of Femur is a fracture of necessity and this PPT is an extract molded into a presentation straight from ROCKWOOD

1. Fracture neck of Femur
Diagnosis and Treatment
Chairperson: Prof & HOD Dr Kiran Kalaiah
Moderator: Dr HD Veeranna
Speaker: Dr Markandaiya Acharya
SRI SIDDHARTHA MEDICAL COLLEGE,
TUMKUR

2. Introduction
• A fracture through the intra articular part of the femoral neck
• Another term is intracapsular proximal femoral fracture.
• Hip fractures comprise 20% of the operative workload of an
orthopedic trauma unit.
• Intracapsular femoral neck fractures account for 50% of all hip
fractures
• The lifetime risk
• women 40% to 50%
• men 13% to 22%
• Age
• occur most frequently in elderly female patients
• They are uncommon in patients younger than 60 years
• only 15% of these fractures are undisplaced.

3. Risk Factors for Hip Fractures

4. MECHANISM OF INJURY
• Low-energy trauma (most common in older patients)
• Direct:
• A fall onto the greater trochanter (valgus impaction)
• forced external rotation of the lower extremity
• Indirect:
• Muscle forces overwhelm the strength of the femoral neck
• High-energy trauma-
• motor-vehicle accident or fall from a significant height.
• Cyclical loading-stress fractures:
• Seen in athletes, military recruits, ballet dancers

5. Surgical Anatomy: Skeletal
Anatomy

8. Anatomy : Ligaments

9. Anatomy : Blood Supply

10. Femoral
artery
Profunda
femoris artery
Medial circumflex
femoral artery
Lateral circumflex
femoral artery
Retinacular
vessels
Extar capsular
arterial anastomosis
Artery of
ligamentum
teres
Epiphyseal
brunch
Metaphyseal
brunch
Subsynovial Intra
capsular arterial
anastomosis

11. BLOOD SUPPLY BEFORE
MATURITY
• AT BIRTH
• BOTH MED. & LAT. CIRCUMFLEX FEMORAL ARTERIES SUPPLY THE
HEAD
• THE FOVEAL ARTERY SUPPLIES ONLY SMALL AREA OF MEDIAL
HEAD
• BY 15-18 MONTHS
• BLOOD VESSELS WHICH CROSS PHYSIS AT BIRTH DISSAPEAR
• BY AGE OF 3 YR
• CONTRIBUTION OF LAT.CIRCUMFLEX FOMORAL ARTERY
DIMINISHES AND ENTIRE BLOOD SUPPLY COMES FROM MED.
CIRCUMFLEX ARTERY. THIS ARRANGEMENT PERSISTS IN ADULTS
• BY 8 YR
• THE FOVEAL ARTERY PROVIDES 20% OF BLOOD TO FEMUR HEAD
AND MAINTAINS IT INTO ADULTHOOD

12. PATHO-ANATOMY
• Most fracture are displaced with distal fragment
• Externally rotated,
• Adducted, and
• Proximall migrated.
• Displacement are less marked than intertrochanteric fracture
because the capsule of hip joint is attached to distal fragment

13. Diagnosis : History
• Most patients will have a history of a simple, low-energy fall
• 2% to 3% of cases, there is no history of trauma
• 25% to 30% of older patients there is cognitive impairment
and there may be an unreliable history
• An acute medical event or deterioration of a preexisting
condition may have contributed to the fall causing the hip
fracture, and this possibility should always be considered

14. CLASSIFICATION
• ANATOMICAL LOCATION
• Subcapital
• Transcervical
• Basicervical (base of the neck fracture)

15. PAUWEL classification
Based on the angle of fracture from the horizontal
• Classifcation was proposed to be predictive of fixation failure
or nonunion with an increasing angle of fracture.
• Has not been shown to be reliable in predicting the outcome

16. GARDEN classification
• based on the degree of displacement,
which is judged on the AP radiograph
by determining the relationship of the
trabecular lines in the femoral head to
those in the acetabulum.
• Types I and II -undisplaced
Types III and IV -displaced

17. Garden’s Complete/incomplete Displaced/undispl
aced
Aligned/ migrated
I Incomplete Undisplaced Aligned
II Complete Undisplaced Aligned
III Complete Displaced Oblique
IV Complete Displaced Proximally
Migrated

18. Types I Types II
Types III Types IV

19. OrthopaedicTraumaAssociation
(OTA)/AOClassification
• 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

21. Diagnosis : Examination
• Undisplaced fracture
• limited Findings.
• painful range of motion of the hip
• Displaced femoral neck fractures
• the affected leg is typically shortened and externally rotated.
• All motions of the hip are painful

22. Diagnosis : missed fracture
• Stress fractures
• Undisplaced fracture
• Painless fracture
• Multiple fractures

23. Imaging : X Ray
• Plain radiographs will identify the fracture in the majority of
cases
• Pitfalls
• degree of displacement can be difficult to discern in some
patients
• lateral radiograph may be difficult to acquire due to pain
• there may be doubt about the diagnosis

25. Imaging : Other diagnostic study
• In 2% of cases, the fracture may be diffcult or impossible to
visualize on plain radiographs
• Technetium bone scan
• Magnetic resonance imaging (MRI)
• CT scan

27. TREATMENT
• Treatment depends on,
• Age of the patient
• Duration of fracture
• Geometrical pattern of the fracture

28. Treatment : Aims
• Early Anatomical reduction :
• Prevent further vascular damage
• Rigid internal fixation
• Enables vascularization from surrounding soft tissue and callous
formation

29. Treatment : Options
• Undisplaced Femoral Neck Fractures
• Nonoperative Treatment –limited use
• Operative Treatment
• Cannulated screw system
• sliding hip screw device with a short plate
• Arthroplasty
• Displaced Femoral Neck Fractures
• Reduction and fixation - less popular
• Reduction with Ancillary Techniques
• Hemiarthroplasty
• Unipolar Hemiarthroplasty
• Bipolar Hemiarthroplasty
• Total Hip Replacement

31. UndisplacedFractures:Nonoperative
Treatment
• Patients can be mobilized touch weight-bearing with crutches,
and the fracture can be expected to heal in 4 to 6 weeks
• Advantage - avoids surgery
• The risk of displacement varies from 19% to 46%

32. Undisplaced Fractures : Fixation

33. UndisplacedFractures: Arthroplasty
• Patient operated with a bipolar hemiarthroplasty
• Had less pain,
• Were more satisfied with the result of the operation,
• Had a better quality of life 4 months postoperatively

34. Displacedfracture: Fixation withAncillary
Techniques
• Treatment of the hemarthrosis
• Studies have failed to show evidence that aspiration or capsulotomy
to drain the hemarthrosis is actually of any beneft.
• Open reduction and compression of femoral neck fractures
• No benefit was conferred by compression of the fracture
• risk of nonunion was significantly greater with compression
• Timing of reduction and fixation after injury
• cellular changes in the femoral head are seen by 6 hours after
fracture, but osteocyte cell death occurs quite slowly and may not be
complete until 2 to 3 weeks after the fracture occur
• Barnes et al found that the timing of surgery had no influence on the
rates of AVN and nonunion in patients treated with reduction and
fxation up to 7 days after injury

35. Displaced Fractures : Fixation

36. Displaced fracture : THR
• THR Versus Hemiarthroplasty
• Baker et al(2001)
• THA patients could walk significantly further and had better
outcome
• The requirement for revision was higher in the hemiarthroplasty
group
• Blomfeldt et al(2006)
• Duration of surgery was longer in the THA group
• blood loss was significantly higher,
• hip function was significantly better in the THA group.
• Health-related quality of life was better in the THA group also,

37. Displaced fracture: hemiarthroplasty

38. METHODSOFREDUCTIONOFFRACTUR
• OPEN
• CLOSED
• IN HIP FLEXION
• LEAD BETTER
• SMITH PETERSON
• FLYNN
• IN HIP EXTENSION
• WHITMAN
• Mc EVELENNY
• DEYERLE
• Massie

39. LEADBETTER’S METHOD
TRACTION
HIP FLEXION 90 DEGREES
45 DEGREE INTERNAL ROTATION
FULL FLEXION + ADDUCTION
ABDUCTION+EXTERNAL ROTATION
• MOST SUCCESSFUL
• REDUCTION TESTED BY HEEL
PALM TEST

40. FLYNN METHOD
• MOST ATRAUMATIC.
• BASED ON SPIRAL CONFIGURATION OF CAPSULE FIBRES.
HIP FLEXION AND SLIGHT ABDUCTION
LATERAL TRACTION OF NECK
INTERNAL ROTATION
EXTENSION

41. If the hip is flexed and
slightly abducted, the
spiral of the capsular
fibres is unwound producing
the “loosepacked” condition
of the hip joint

42. In the “loose-packed” state, manual
traction along line of the femoral
neck disimpacts the fracture
fragments.
The traction produces an hour-glass
shape to the capsule, which realigns
the disimpacted fracture fragments.

43. The most comfortable set-up is for
the assistant to support the heel of
the injured leg, whilst the surgeon’s
ipsilateral hand pulls along the line of
the femoral neck, the other
hand controlling the knee.

44. Whilst manual traction is maintained
along line of the femoral neck, the leg is
first internally rotated, to correct any
retroversion, and is then brought down
to the extended position. This produces
a “tight-packed” hip and impacts the
realigned fracture fragments.
The injured leg is then placed on
moderate traction in the position of
reduction, on a fracture table.
The uninjured leg and ipsilateral
arm are raised and supported

45. Open reduction
• If closed reduction fails, an open
reduction must be carried out. The
reduction of the neck fracture is
carried out under direct vision.
• Once the capsule is opened up while
applying traction the head is
manipulated with hooks or K-wires,
inserted to act as joy sticks until an
anatomical reduction is achieved.

46. Garden alignment index
• angle between the medial shaft
and the central axis of the
medial compressive trabeculae
should measure between 160
and 180 degrees.
• <160 degrees indicates varus
• >180 degrees indicates valgus

48. Fixation : Positioning
• Positioning of the patient
• The patient is positioned
supine on the fracture table.
• The ipsilateral arm is elevated in
a sling and
• the contralateral uninjured leg is
placed on a leg holder.
• C-arm image intensifier control
during surgery is a must

49. Fixation : cancellous screw

50. cancellous screw : key points
• The screws must be parallel
• Guide wires may be inserted freehand under x-ray control to
ensure they are parallel, or an aiming device may be used if
available
• It may be best to start by placing a wire in the center of the
neck and head.
• Drill over the wires with a 3.6 mm cannulated drill bit
• Screw should be 7.0 mm or 7.3 mm
• A washer may be used to avoid penetration of the screw
head through the thin cortex

52. Fixation : sliding hip screw

56. sliding hip screw : Key points
• C-arm should be used in the AP to make sure that the wire
subtends the CCD (collum-center-diaphysis) angle of the neck
• guide wire should be positioned along the axis of the neck and
through the middle of the head, and advanced to within 5 mm
of the subchondral bone.
• screw should not be pushed forcefully or it may distract the
fracture.
• In young patients with hard bone it is best to use the tap to
precut the thread for the screw. Otherwise the screw may not
advance , It may actually displace the fracture by twisting the
proximal fragment
• Antirotation screw must be parallel to the DHS in both the AP
nd lateral planes.

57. Hemiarthroplasty
• involves replacing the femoral head with a prosthesis, while
retaining the natural acetabulum (endoprosthesis)
• TYPES
• STEM PROSTHESIS (not in use)
• MEDULLARY PROSTHESIS
• Unipolar
• AUSTIN MOORE
• THOMPSONS
• Bipolar

58. Figure : STEM PROSTHESIS

59. MEDULLARY PROSTHESIS
• It has a head and a stem
• Anchored in medullary canal
• It is either fixed by press fit (inference fit) or by bone cement

60. PARTS OF PROSTHESIS
• HEAD:
• 37mm to 59mm
• NECK
• COLLAR
• STEM:
• triangular in shape thin and becomes
easy for insertion but chances of
breakage of the tip

61. AUSTIN MOORE PROSTHESIS
• Moores prosthesis is fenestrated .
• Bone grows through the
fenestrations & Anchor the
prosthesis inside the shaft
• It can only be used in presence of
neck with Calcar femorale

62. THOMPSONS PROSTHESIS
• Designed for non union of fracture
neck of femur when there is no
neck available
• Designed to rest on the
intertrochanteric line

63. BIPOLAR PROSTHESIS
• Erosion and protrusion of acetabulum
would be less because motion is
present between metal head
& polyethylene socket (inner bearing).
• Because of compound bearing surface,
bipolar designs provide greater overall
range of motion than either unipolar
designs or conventional THR.

64. MODULAR PROSTHESIS
• Implant of choice for displaced femoral
neck of femur fractures
• In most cases, inserted as a cemented
femoral stem with neck length, offset,
and acetabular adjustment
• This theoretically decreases the stress
on the acetabular cartilage
• Provides a relatively easy conversion to a
THA, if required in future

65. Hemiarthroplasty Issues:
Unipolar vs. Bipolar

66. Cement Vs Press fit

67. Approaches
• POSTERIOR APPROACHES
• Gibsons approach(postero lateral approach)
• Southern or Mores approach
• LATERAL APPROACHES
• Anterolateral approach (Watson Jones approach)
• Harris lateral approach
• McFarland & Osborne lateral approach

68. Gibsons approach(postero lateral
approach)
Positioning
lateral decubitus position
supports to prevent rotation away from
true lateral, and appropriate padding to
limit focal pressure
Skin incision
Start incision posterior to the lateral side of the
greater trochanter 6 cm along the femoral axis.
Proximally, the incision runs slightly curved
towards the PSIS to a point approximately 6 cm
proximal to the greater trochanter

69. • Dissection of fascia lata
In line with the skin incision.
• Protection of sciatic nerve
Retraction of the gluteal muscle flap
posteriorly shows short external
rotators inserting on femur (at least
partially obscured by fat). The sciatic
nerve can be palpated posteriorly in
the depths of the wound..

70. • Exposure of short rotator tendons
Before dividing the tendons, place
heavy, nonabsorbable stay sutures
for retraction and subsequent
repair.
• capsulotomy
joint should be opened with a
broad-based, 3-sided capsulotomy
as shown.

71. • Closure
Done layer by layer
• After posterior capsulotomy, the
hip is dislocated with internal
rotation.

72. Direct lateral approach
• Skin incision
• longitudinal incision through skin and
subcutaneous tissue, with its proximal
end directed slightly posteriorly.
• fascia lata is devided over the greater
trochanter
• gluteus maximus is split proximally to
reveal the underlying gluteus medius.
• anterior gluteus medius is incised from
the greater trochanter preserving a
substantial portion of gluteus medius
insertion posteriorly

73. Superficial surgical dissection
• Gluteus medius and minimus is retracted to
show the hip capsule superiorly and adjacent
supraacetabular ilium.
• capsule is released anteroinferiorly and
anterosuperiorly to expose the femoral head
and neck and permit free external rotation of
the femur.
• A “T”– shaped capsulotomy is done to
expose the joint,
Deep dissection
Exposure of the proximal femur is gained by
gentle external rotation of the leg.
The lower leg is placed into a pocket made from
sterile drapes.

74. Wound closure
• Heavy sutures, typically placed
through holes in the bone, are used to
reattach the anterior flap to the
intertrochanteric region.
• Close also the gluteus medius tendon
and fascia proximally, and the vastus
lateralis fascia distally.
• Close the fascia lata, subcutaneous
tissue and skin as desired.

75. Anterolateralapproach (Watson-
Jones)

77. Iliofemoral approachto the hip
joint(Iliofemoral or Smith-Peterson)

78. Procedure : Hemiarthroplasty
• Through selected approach hip joint is exposed.
• Head is removed by using cork screw by incising the
ligamentum teres
• The neck is osteotomised approximately 1cm proximal to the
lesser trochanter.
• Femoral head size should be measured by using caliper or
template
• Soft tissues from the posterior and lateral aspect of femoral
neck to the lesser trochanter is excised
• Box osteotome is used to open the femoral canal.
• Sequential reaming done with rasp (reamer) until the
appropriate size (2size smaller to the template) in appropriate
anteversion.

79. • Trial femoral component neck and head is placed.
• Reduce the hip Hip stability is assessed through range of
motion.
• Trial implant replaced with appropriate prosthesis
• If cementing , the bone plug is inserted and vaccum is
created by suction.
• Prosthesis is inserted using manual force and light taps with
mallet until the fully seated to the level of calcar cut .
• Excess cement is removed.
• Head is reduced.
• Stability is reasessed.

80. Key points of prosthesis
FEMORAL HEAD
• select the size of femoral head which is removed
• If correct size not available, 1 size smaller size is preferred to
bigger size
• large head equatorial contact  tight joint with a
decreased motion and pain
• Small head  polar contact occurs with increased stress over
reduced areaerosion, prosthetic migration & pain

81. FEMORAL NECK LENGTH
• Long neck reduction may be difficult and pressure on
acetabular cartilage is increased.
• Prostheses should be inserted so that the distance between
the greater trochanter and center of the femoral head is
restored.

82. POSITION
• Fixed in neutral or slightvalgus,
• Avoid varus, anteversion or retroversion.
• Excessive retroversion external
rotational deformity and increased risk of
dislocation with internal rotation.
• Excessive anteversion can in-toeing
• 10 degree of anteversion is ideal to prevent
dislocations

83. COMPLICATIONS: Hemiarthroplasty
• Erosion of acetabulum
• Fracture of stem of prosthesis
• Dislocation of Prosthesis
• Fracture of femur
• Retroversion and anteversion of prosthesis
• Varus angulation
• Neck length variation
• Possibility of the sciatic nerve injury

84. ComplicatIonsIn Femoral
neck Fractures
• Mortality
• Deep Venous Thrombosis and Pulmonary Embolism
• Fixation Failure
• Nonunion
• Avascular Necrosis
• Prosthesis Dislocation
• Prosthetic Loosening and Revision

85. Take home massage
• Proximal femoral insufficiancy fracture will continue to form a
considerable component of the orthopedic trauma workload
for the foreseeable future
• Fixation is the treatment of choice for undisplaced fracture or
younger patients with displaced fractures
• The optimum arthroplasty choice remains a source of debate.
• The bipolar hemiarthroplasty is most commonly used and
popular choice, but there is no evidence that it is superior to a
unipolar implant
• More data are needed to determine whether wider use
of THA is justifed

86. Thank you…