Basic presentation on neck of femur fracture

1. FRACTURE NECK
OF FEMUR
D R . M . P R A V E E N
A S S I S TA N T P R O F E S S O R , D E P T O F O R T H O P A E D I C S , S M C H

2. INTRODUCTION - ANATOMY

4. INTRODUCTION -ANATOMY
• Normal Neck-shaft angle =130±7degrees
• Femoral anteversion

5. INTRODUCTION - ANATOMY

6. INTRODUCTION BLOOD SUPPLY

7. INTRODUCTION
BLOOD SUPPLY OF NECK OF FEMUR
(1)An extracapsular arterial ring located at the base of femoral neck
(2)Ascending cervical branches of the extracapsular arterial ring of
the surface of the femoral neck known as retinacular arteries)
(3)The arteries of the ligamentum teres

8. INTRODUCTION
BLOOD SUPPLY OF NECK OF FEMUR
• 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 ascending cervical arteries can be divided into four groups (Anterior,
Medial, Posterior, and lateral) based on their relationship with femoral neck.
Lateral group provides most of the blood supply to the femoral head and neck
• The artery of ligamentum teres is a branch of the Obturator or the Medial
femoral circumflex artery ( Only a small amount of femoral head is nourished
by this)

9. INTRODUCTION
FRACTURE NECK OF FEMUR
• Commonly seen in elderly women – low energy falls
• Very low incidence in younger patients – high energy trauma
• Mechanism of injury:
– Low energy trauma – Direct or Indirect
– High energy trauma – MVA or fall from heights
– Cyclical loading-stress fractures
– Insufficiency fractures – osteoporosis or osteopenia

10. FRACTURE NECK OF FEMUR IS AN UNSOLVED FRACTURE, WHY??
• Elongated position of femoral neck in joint capsule
• Absence of cambium layer of periosteum, periosteum is replaced by retinaculum, which is a reflected
part of capsule
• Fracture heals without external callus, almost heals entirely from intramedullary endosteal callus
• Peculiar blood supply of the head of femur
• Intracapsular callus formed will get washed by synovial fluid.
• Intracapsular hemorrhage following fracture neck of femur causes tamponade effect and obliterate
retinacular vessels and further decrease blood supply to head

11. REVASCULARIZATION OF THE HEAD
OCCURS FROM;
• The areas of the femoral head that remains viable
• Vascular ingrowth from the distal fragment
• Capillary ingrowth from distal fragment( It’s a slow process and occurs when
the fixation is rigid and stable)

12. CLASSIFICATION
• Anatomical location
SUBCAPITAL BASICERVICAL
TRANSCERVICAL

13. CLASSIFICATION – PAUWEL’S
• Angle subtended by the fracture to the horizontal
• More the angle, more the shearing forces, more the instability

14. CLASSIFICATION – GARDEN’S

15. CLINICAL FEATURES
• H/o trauma – High or low energy
• Non ambulatory (except in impacted and stress fractures)
• Pain over the groin
• Deformities – external rotation of the limb with shortening
• Tenderness – on hip ROM, axial compression and over the groin, Scarpa’s
triangle
• In low energy fracture – h/o LOC, syncopal attacks, chest pain, prior hip pain
(pathological #)
• Preinjury ambulatory status – determinant of treatment

16. CLINICAL FEATURES

17. RADIOLOGICAL EVALUATION
• Plain radiograph of pelvis with both hip joint – AP view, with 15 deg
of internal rotation of the limb
• Cross table lateral view of proximal femur of fracture side
• CT scan – undisplaced femoral neck fractures
• MRI – imaging of choice in delineating non-displaced or occult
fractures
– Bone scans and CT scan is reserved for those who have contraindications
for MRI

18. AP VIEW VARIATIONS

19. LATERAL VIEW FROG LATERAL

20. RADIOLOGICAL EVALUATION
SHENTON’S LINE IN AN X-RAY

21. RADIOLOGICAL EVALUATION

22. TREATMENT
• Goals of the treatment are:
– Minimize patient discomfort
– Restoration of hip function
– Early stable fixation of fracture or prosthetic replacement
– Allow rapid mobilization
• Early bed to chair mobilization - to avoid risks and complications
of prolonged recumbence (Venous stasis, DVT, Pulmonary
Embolism, poor pulmonary toilet, atelectasis, pressure sores)

23. TREATMENT
• Preoperative skin traction – below knee traction
– Immobilization of limb gives pain relief
– Reduce the risk of further soft tissue injury
– Helps to maintain reduction
– Easier intraoperative fracture reduction
• Use is contraversial

24. TREATMENT
• Non-operative treatment – can be employed in undisplaced
fractures; in patients with severe medical comorbidities
– Good results have been reported from some studies
– Advantage: surgery can be avoided
– Disadvantage: Greater risk of fracture displacement
– Hence there is no role of non-operative in treatment of fracture neck of
femur

25. TREATMENT - SURGICAL

26. TREATMENT - SURGICAL

27. TREATMENT - SURGICAL
• Displaced fractures
• In young patients: urgent reduction and internal fixation and
capsulotomy
– Multiple screw fixation – 3 cannulated cancellous screws in inverted
triangular configuration
– Sliding hip screw or dynamic hip screw
– Angled blade plates

28. TREATMENT - SURGICAL

29. TREATMENT - SURGICAL
• Displaced fractures
• In elderly patients:
– High functional demand and good bone quality:Total hip replacement
– Low functional demand and poor bone quality: Hemiarthroplasty
– Severely ill, demented, bedridden patients: non-operative

30. TREATMENT - SURGICAL

31. COMPLICATIONS
• Non-union: if the fracture has not united by 3months
– 5% in undisplaced and 25% in displaced fracture
– In elderly: arthroplasty
– In young patients: proximal femoral osteotomy
• Osteonecrosis: avascular necrosis of femoral head
– 10% in undisplaced and 30% in displaced fractures
– Early without x-ray changes: core decompression
– Late with x-ray changes: arthroplasty in elderly;
osteotomy/arthrodesis/arthroplasty in younger patients

32. COMPLICATIONS
• Fixation failure: poor reduction/fixation; osteoporotic bone
• Prosthetic dislocation and prosthetic loosening
• Prominent hardware: due to fracture collapse and screw backout
• Others: complications of prolonged recumbence, infection

33. THANK YOU