By Dr. Shatrughna Ram, F.R.C.S., M.Ch. (Ortho), F.I.C.S. Advanced Orthopaedic Centre, Patna 800016, INDIA www.drshatrughnaram.com

1. Fracture neck of femur
Dr. Shatrughna Ram
F.R.C.S., M.Ch. (Ortho), F.I.C.S.
Advanced Orthopaedic Centre
Patna 800016, INDIA
www.drshatrughnaram.com

2. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Introduction
• Relatively common fracture
• Increasing incidence due to
• High speed of travel
• Ageing population and osteoporsis
• High Morbidity and mortality
• 10% Hospital mortality in elderly
• 30% of the elderly die within one year of operation
• After one year resume their normal mortality rate
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3. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Introduction Contd...
• 10% surgical non-union, 20% avascular necrosis in fresh
displaced fracture fixation
• Much higher in old displaced fractures
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4. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
History
• Lagenbeck (1850)
• First internal fixation
• Whitman (1904)
• Closed reduction and hip spica
• Smith - Peterson (1931)
• SP Nail fixation
• Richard’s Hip screw (DHS)
• Physical pressure causes bone absorption
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5. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
History Contd…
• Asnis and other cannulated screws
• Osteogenic potency remains poor
• Fibular graft alone or with 1Asnis screw (1998)
• needs cumbersome of Hip Spica or flaper and prolonged bed rest
• Ram & Roshan (2006)
• Fibular graft with 2 Asnis screw
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6. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Type of Fracture of Neck of Femur
• Sub capital
• Trans cervical
• Basal
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7. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Basal Fracture Neck of Femur
• Vascularity
• plenty
• Non-union
• not a problem
• Treat like I.T. fracture
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8. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Displaced Sub-capital & Transcervical
Fracture (Gardens III & IV)
• Great challenges to Orthopaedic surgeons
• Prosthetic replacement
• For the elderly
• McMurray’s or abduction osteotomy
• For the younger
• Fibular graft alone
• Cumbersome of hip spica or flaper and prolonged bed rest
• Fibular graft with 2 cannulated screws
• Early return to function
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9. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Discussion
• Great challenges to Orthopaedic surgeons
• Unsolved fracture – treatment and results
• Results depend upon
• Extent of injury – displacement and comminution
• Adequacy of the reduction and fixation
• Time interval between injury and fixation: < 1day, < 3 days , < 1week, > 1 week
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10. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Garden’s classification
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11. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Results of Early Treatment
Garden’s
classification
Non-surgical Surgical (ORIF)
Non-union Non-union AVN
Grade I 10% 0% 0%
Grade II 50% 5% 10%
Grade III
100% 10% 20%Grade IV
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12. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Causes of Non-union
• Poor circulation
• Synovial fluid bathing the fracture
• Absence of Periosteum
• all healing is endosteal
• Temponad
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13. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Blood Circulation
 Extra capsular arterial ring
 Ascending cervical branches
 Arteries of the Ligamentum teres
 The poor blood supply further deteriorates with trauma and temponad
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14. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Blood Circulation Contd…

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15. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Treatment for Fresh Fracture Neck of
Femur
Garden’s type 1 & 2
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16. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Treatment for Fresh Fracture Neck of
Femur Contd…
Garden’s type 3 & 4
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17. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Encouraged with better results of late
treatment in neglected femoral neck
fracture in young adults
• Baksi
• ORIF + muscle pedicli graft - 100% union
• Nagi et al
• ORIF + Fibular graft - 100% union
• Ram et al
• ORIF + 2 Cannulated Screws & Fibular Graft - 91% union
• Clinical orthopedics 2006, No. 447
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18. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
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19. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Treatment for Fresh Fracture Neck of
Femur Contd…
• Strut free fibular graft with 2 cannulated screws
Garden’s type 3 & 4
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20. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Method
• Fracture reduced accurately on a traction table – closed or open
• 3 guide wires placed and reamed
• Whole fibular graft fixed in the centre
• 2 Asnis screws: 1 above and 1 below
• Radiological control: Image intensifier
• No plaster
• Walking in 3-5 days with crutches
• Partial weight to full weight bearing in 8 -20 wk
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21. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Advantages of Free Fibular Graft
• Easy to take and apply
• Practically no morbidity at donor site
• No cumbersome of hip spica or flaper
• Early mobilization
• Better fracture union rate (? 95%)
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22. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Treatment for Old Fracture Neck of Femur
Contd...
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23. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Treatment for Old Fracture Neck of Femur
Contd...
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24. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Treatment for Old Fracture Neck of Femur
Contd...
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25. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Treatment for Old Fracture Neck of Femur
Contd...
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26. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Treatment for Old Fracture Neck of Femur
Contd...
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27. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Treatment for Old Fracture Neck of Femur
Contd...
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28. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Treatment for Old Fracture Neck of Femur
Contd...
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29. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Treatment for Old Fracture Neck of Femur
Contd...
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30. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Treatment for Old Fracture Neck of Femur
Contd...
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31. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Treatment for Old Fracture Neck of Femur
Contd...
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32. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Treatment for Old Fracture Neck of Femur
Contd...
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33. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Conclusion
• Adequate reduction and fixation of displaced femoral neck
fracture with free fibular graft and 2 cannulated screws gives a
high union rate ( ? 95%).
• It eliminates the burden of hip spica, flaper or bed rest and
prolonged physiotherapy.
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34. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Thank you!