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Fracture Of Femoral Neck In Adults.pptx
- 1. Fracture Of Femoral NeckIn Adults By Ihab El-Desouky (M.D.) Associate Prof. Pelvis and Reconstruction unit. Kasr Al-Ainy School of Medicine November 2018
- 2. Femoral neck fracturein Adults •Aim 1. Background 2. Anatomy 3. Epidemiology 4. Patho-anatomy + Classifications 5. Mechanism of injury 6. Clinical presentation/Radiological investigation 7. Aims of treatment 8. Management 9. Complications
- 3. Femoral neck fracturein Adults •Background: • Predominantly in the elderly, low-energy falls, with osteoporosis • In young patients (below 50 years) a high-energy mechanism, associated injuries • Intra-capsular and may compromise the tenuous blood supply to the femoral head • Basi-cervical fractures are extracapsular
- 4. Femoral neck fracturein Adults •Anatomy • The upper femoral epiphysis closes by age16-18 years. • Neck-shaft angle: 130 ±7 degrees • Femoral Anteversion: 10 ±7degrees
- 5. Femoral neck fracturein Adults •Anatomy: • Three ligaments attach : • 1. Iliofemoral: Y –ligament of Bigelow(anterior) • 2. Pubofemoral: Anterior • 3. Ischiofemoral:Posterior
- 6. Femoral neck fracturein Adults •Anatomy • Calcar Femorale Posteromedial dense plate of bone • Trabecular pattern
- 7. Femoral neck fracturein Adults • Anatomy: Blood supply 1-Capsular vessels:medial circumflex (major) +lateral cir femoral artery---- Extracapsular ring (neck base) -› Ascending cervical arteries ---- penetrate cap -› 4 groups Subsynovial intraarticular ring (head base) lateral group (lateral epiphyseal vs) Post +Sup is largest contributor to head. 2- Artery of ligamentum teres -› of Obtutaror artery 3-Medullary vessels/ endosteal supply
- 8. Femoral neck fracturein Adults •Anatomy • Greater fracture displacement = greater risk of retinacular vessel disruption • Tamponade effect of blood after # in intact capsule • Theoretical risk of AVN with increased pressure
- 9. Femoral neck fracturein Adults •Epidemiology: • 250,000 hip fractures occur in the United States each year (50% involve the femoral neck) • Elderly : (97%) • Female to male ratio:3 :1 • Patients with a femoral neck fracture are at risk for a second hip fracture and falls :by 5 -7 folds within 3 years • Young (3%)
- 10. Femoral neck fracturein Adults • Epidemiology: Bimodal distribution. • Elderly • incidence doubles each decade beyond age 50 • Earlier than intertrochanteric # • higher in females, caucasians ,smokers, lower BMI (fat), excessive caffeine & alcoholics. • Predisposing factors 1-Loss of bone strength 2-Loss of local shock absorbers (fat) 3-Reduction in protective responses (muscle weakness) 4-Increased risk of falls (alcholics,visual acuity) 5-Previous fractures: 5-7 folds • Young • high energy trauma
- 11. Femoral neck fracturein Adults • Patho-anatomy and classifications: • The hip capsule inserts into the intertrochanteric line (anteriorly) and the intertrochanteric crest (posteriorly). • Intracapsular fractures ----disruption of the capsular retinacular vessels--- blood supply to the femoral head at risk
- 12. Femoral neck fracturein Adults • Patho-anatomy and classifications: • Trauma: anterior capsule holds the femoral head fixed-----hip rotates externally+ the posterior cortex of the neck impinges on the lip of the acetabulum. • Anterior cortex fails in tension + posterior cortex is compressed --- posterior comminution—External Rotation • Distal fragment – ext rotation, Adducted and proximal migration (muscle pull)
- 13. Femoral neck fracturein Adults • Patho-anatomy and classifications: • Classifications: 1-Anatomical Location 2-Garden 3-Pauwels 4- AO/OTA 1-Anatomical Location: Sub-capital Trans-cervical Basi-cervical
- 14. Femoral neck fracturein Adults • Patho-anatomy and classifications: 2-Garden ‘s Classification (1961) Degree of displacement Relates to risk of vascular disruption Most commonly applied to geriatric/ insuffiency fractures Stage I: Stage II: incomplete fracture line complete fracture line; (valgus impacted) nondisplaced
- 15. Femoral neck fracturein Adults • Patho-anatomy and classifications: Stage III: Stage IV: complete fracture line complete fracture line; Partially displaced totally displaced (continuous) • But:Poor inter-observer reliability • Modified to: • Non-displaced: stages I &II • Displaced: stages III &IV (retinacular vs disruption)
- 16. Femoral neck fracturein Adults • Patho-anatomy and classifications: 3-Pauwels’ Classification (1935) -Fracture line angle from horizontal, three types -Relates to biomechanical stability---more vertical fracture has more shear force -More commonly applied to younger patients or higher energy fractures
- 17. Femoral neck fracturein Adults 4-AO/OTA FEMUR NECK IS 31-B • B1 nondisplaced (minimally displaced) subcapital fracture • B2 transcervical • B3 all displaced Subcapital fractures
- 18. Femoral neck fracturein Adults • Mechanism of injury • Low Energy: elderly -Direct: Falling directly onto the hip -Indirect: Twisting mechanism (tripping over a loose carpet) • High Energy: young. Motor car accident, fall from a height • Cyclical Loading :Stress fracture
- 19. Clinical presentation/Radiological investigation 1-ClinicalPresentation: History of a traumatic event (except in stress fractures) • Young patients with high-energy ---associated injuries including head. • Missed fracture can be disastrous. Clinical examination • Shortening • External rotation • Inability to SLR • Groin tenderness Femoral neck fracture in Adults
- 20. Femoral neck fracturein Adults • Radiological investigation: 1-Plain radiograph (Antero-posterior and Lateral) 2-MRI 3-CT 4-Bone Scan 1-Plain radiography: • Extent Of fracture : Complete/Incomplete • Pauwels’ angle • Break of Shenton Line • Proximal migration of the greater trochan. • Prominent lesser trochanter (ex rot) • Posterior Wall Comminution (lat. View)
- 21. Femoral neck fracturein Adults 1-Plain radiography: Views: • X-ray A/P View Pelvis •Cross-table Lateral View Of The Hip • Full femur A/P And Lateral (# femur in 5%) • Traction and internal rotation A/P view of Hip (incomplete or un-displaced #)
- 22. Femoral neck fracturein Adults 2-MRI • Occult femoral neck fracture. • elderly patient who is persistently unable to weight bear. • 100% sensitive and specific • May reduce cost by shortening time to diagnosis • Femoral head viability in FU
- 23. Femoral neck fracturein Adults 3-CT - Comminution preoperatively -Abnormalities of bone in pathological # -Check for union postoperatively 4-Bone Scan Increased uptake : 80% of cases after 24 hr ; 95% at 7 days
- 24. Femoral neck fracturein Adults 7. Aims of treatment: For elderly patients : >65 ys. • Mobilize • Weight bearing as tolerated • Minimize period of bedrest • Minimize surgical morbidity • Safest operation • Decrease chance of reoperation
- 25. Femoral neck fracturein Adults 7. Aims of treatment: For young patients : <55- 65 ys • Spare femoral HEAD • Avoid varus deformity • Improves union rate • Optimal functional outcome (offset) • Minimize vascular injury • Avoid AVN
- 26. Femoral neck fracturein Adults • Treatment Options • Non-operative • Limited role • Usually high operative risk patient • Valgus impacted fracture • Elderly need to be WB as tolerated • Mobilize early • Operative: • Reduction and fixation • Open or percutaneous • Arthroplasty • Hemi or total
- 27. Femoral neck fracturein Adults • Operative treatment: Decision Making Variables: 1-Patient Factors • Young (active) – High energy injuries • Often multi- trauma – Often High Pauwels Angle (shear) • Elderly – Lower energy injury (falls) – Comorbidities – Pre-existing hip disease
- 28. Femoral neck fracturein Adults 2-Fracture Characteristics • Displacement: (I &II) Vs (III & IV) • Stability – Pauwels’ angle – Comminution, especially posteromedial
- 29. Femoral neck fracturein Adults •Pre-operative Considerations • Traction not beneficial – No effect on fracture reduction – No difference in analgesic use – Pressure sore/ skin problems (limited Pt rolling) – Increased cost – Traction position decreases capsular volume • Capsule volume greatest in flexion/external rotation • Potential hazardous effect on blood flow by increasing intra-capsular pressure (tamponade)
- 30. Femoral neck fracturein Adults •Pre-operative Considerations: Timing of surgery in Young • Surgical Urgency
- 31. Femoral neck fracturein Adults •Pre-operative Considerations: Timing of surgery in Young -Jain et al. (2002) : fixation within 12 h Vs delayed fixation (>12 h) ----AVN 16% in the delayed group & 0% in the early group . -Barnes et al.(1976) timing of surgery did not affect the rates of nonunion and AVN within the first week post- injury -Experimental studies (Keating ;2009) ---- osteocytes viability continue up to 3 weeks post-fractures -Fixation is done on day of trauma, delayed cases up to 2 weeks --- fixation with accepted imperfect reduction
- 32. Femoral neck fracturein Adults •Pre-operative Considerations: Timing of surgery in Elderly >65ys • Surgical urgency in relatively healthy patients (decreased mortality, complications, length of stay) • Surgical delay up to 72 hours for medical stabilization warranted in unhealthy patients • 2.25 increase in MORTALITY if > 4 day delay • related to increased severity of medical problems (chest, cardiac, Renal)
- 33. Femoral neck fracturein Adults Treatment Options: Young patient • Open reduction – Improved accuracy – Decompresses capsule (capsulotomy) • May have greater risk of infection • Closed reduction – Less surgical morbidity
- 34. • Higher rateof deep infection in open reduction group • 0.5% versus 4% • No difference in AVN • 17% in both groups • No difference in nonunion • 12% in closed group versus 15% in open group (p = 0.25) MUST achieve an appropriate reduction regardless of either method Closed versus Open Reduction INJURY 2015
- 35. Closed Reduction Techniques •Leadbetter Technique • Flexion, slight adduction • Apply traction, internally rotate to 45 degrees, followed by full extension, slight abduction • Whitman technique traction to the abducted, extended, externally rotated hip followed by internal rotation.
- 36. Open Reduction: Approach •Watson-Jones • anterolateral • Between TFL and gluteus medius • Best for basicervical
- 37. • Fracture tableRadiolucent under pelvis • Use Schanz pins, weber clamps for reduction Open Reduction Technique
- 38. Femoral neck fracturein Adults Assessment of reduction: -Reduction should be judged on A/P and lateral views -Junction of the convex femoral head and neck -- ---S-shaped curve in all planes -Valgus reduction is preferable to a varus reduction (more stable less risk of fixation failure)
- 39. Femoral neck fracturein Adults • Assessment of Reduction Garden Alignment Index bony trabecular alignment. A/P view Angle between central axis of medial trabecular system in the head + medial cortex ---160°. -Lateral view the central trabecular axis is in line + femoral head at 180° Angle between 160-180° in either view good reduction
- 40. Fixation Methods • 3cannulated Screws • 4 cannulated Screws • Dynamic hip screw (with anti-rotation S) • Blade plate
- 41. Femoral neck fracturein Adults • 3 cannulated screws fixation: • 3 partially threaded screws in inverted triangle configuration (apex-distal)
- 42. Fixation Concepts • Reductionmakes it stable • Avoid ANY varus • Avoid inferior offset • Malreduction likely to fail
- 43. Fixation Concepts • Screwposition Spread • Inferior within 3 mm of cortex • Posterior within 3 mm of cortex • Need one screw resting on calcar • Threads should end at least 5mm from subchondral bone • Multiple views to check appropriate depth • Avoid posterior/superior • to avoid iatrogenic vascular damage (lat epiphyseal V.) • Should not start below level of lesser trochanter • Avoid many perforations • Avoid stress riser---subtrochanteric #
- 44. Fixation Concepts Good Bad PosteriorAnterior Lateral Epiphyseal Artery - Good spread - Hugging Calcar and posterior cortex - Posterior and inferior screws are most important - Clustered together - Nothing on calcar
- 45. Fixation Concepts • Apexdistal screws less prone to subtrochanteric fractures then apex proximal • Vertical fractures (Pauwels angle > 50) More shear forces --- prone to failure (use DHS)
- 46. Fixation Concepts • 4cannulated screws In significant comminution • Sliding hip screw • May help with comminution • Basicervical • Vertical fractures • Accessory screw for rotation • Revision if screws failed • No mechanical Advantage over screws.
- 47. Treatment Options: Geriatric Patients •Fixation • Lower surgical risk • Higher risk for reoperation • Replacement • Higher surgical risk • Fewer reoperations • Better function • Use – Stable (valgus impacted) fractures – Minimally displaced fractures • Use – Displaced fractures – Unstable fractures – Poor bone quality
- 48.
- 49.
- 50. Arthroplasty Issues: Hemiarthroplasty versusTHA • Hemi • More revisions • 6-18% • Smaller operation • Less blood loss • More stable (large head • Total Hip • Fewer revisions • 4% • Better functional outcome • More dislocations ( use Dual Mobility)
- 51. Hemiarthroplasty Issues: Unipolar vs.Bipolar Hemiarthroplasty • Unipolar • Lower cost • Simpler • Bipolar • Theoretical less wear • More modular • More expensive • Can dissociate • NO PROVEN ADVANTAGE
- 52. Arthroplasty Issues: Cement OrCementless • Cement (PMMA) • Improved mobility, function, walking aids • Most studies show no difference in morbidity / mortality • Sudden Intra-op cardiac arrest • Non-cemented (Press-fit) • Pain / Loosening higher • Intra-op or periop fracture risk higher (in men > 80 years)
- 53. Arthroplasty Issues: Surgical Approach •Posterior • 60% higher short-term mortality • Higher dislocation rate • Anterior/Anterolateral • Fewer dislocations
- 54. GERIATRIC Summary • MRIto rule out occult fracture in older patients unable to weight bear • CRPP for valgus impacted or nondisplaced fractures • Arthroplasty if displaced • Hemi in debilitated • Consider THA for active older patients and associated arthritis. • Cemented stems • Anterior and antero-laterl approach
- 55. Special Issue: Stress Fractures •Females 4–10 times more common • Amenorrhea / eating disorders (Coeliac disease common) • Hormone deficiency • Recent increase in athletic activity • Clinical Presentation • Activity / weight bearing related pain • Anterior groin pain • Limited ROM at extremes • ± Antalgic gait • Must evaluate back, knee, contralateral hip
- 56. Stress Fractures • Imaging •Plain Radiographs • Negative in up to 66% • Bone Scan • Sensitivity 93-100% • Specificity 76-95% • MRI • 100% sensitivity / specificity • Also Differentiates: synovitis, tendon/ muscle injuries, neoplasm, AVN, transient osteoporosis of hip
- 57. Stress Fractures • Classification •Compression sided • Callus / fracture at inferior aspect femoral neck • Tension sided • Callus / fracture at superior aspect femoral neck • Displaced or non
- 58. Stress Fractures: Treatment • Compressionsided • Fracture < 50% across neck • “stable” • TTT: Activity / weight bearing modification • Fracture >50% across neck • Potentially unstable with risk for displacement • TTT: fixation • Tension sided • - Nondisplaced------Unstable • TTT: fixation (Protect weight bearing till fixation ASAP) • - Displaced • TTT: fixation • Fix within 24 hours
- 59. COMPLICATIONS 1-Non-union 2-Osteonecrosis (AVN) 3-Failure offixation 4-Fracture distal for fixation (sub trochanteric) 5-Post-traumatic arthrosis. 6-Blood transfusion 7-DVT and PE 8-Mortality.
- 60. COMPLICATIONS 1-Non-union • 0-5% inNon-displaced fractures • 9-35% in Displaced fractures • Increased incidence with – Posterior comminution – Initial displacement -Imperfect reduction – Non-compressive fixation • Clinical presentation – Groin or buttock pain – Activity / weight bearing related – Symptoms : more severe / occur earlier than AVN
- 61. Non-union • Imaging • Radiographs:lucent zones • CT: lack of healing • Bone Scan: high uptake • MRI: assess femoral head viability
- 62. Non-union Treatment: • Young patients –Valgus intertrochanteric osteotomy (Pauwels) – Creates compressive forces
- 63. Non-union •Elderly patients •Arthroplasty • Resultstypically not as good as primary elective arthroplasty •Girdlestone Resection Arthroplasty • Limited indications (if infection)
- 64. Special Problems: Osteonecrosis (AVN) •Up to 10% of nondisplaced and up to 30% of displaced fractures • Increased incidence with • Inadequate Reduction • Delayed reduction ?? • Initial displacement • associated hip dislocation
- 65. Osteonecrosis (AVN) • Clinicalpresentation • Groin / buttock / proximal thigh pain • May not limit function • Onset usually later than nonunion • Imaging • Plain radiographs: segmental collapse / arthritis • Bone Scan: “cold” spots • MRI: diagnostic
- 66. Osteonecrosis (AVN) • Treatment •Elderly patients • Only 30-37% patients require reoperation • Arthroplasty • Results not as good as primary elective arthroplasty • Girdlestone Resection Arthroplasty • Limited indications Young Patients -Proximal Femoral Osteotomy If Less than 50% head collapse -Arthroplasty -Arthrodesis Significant functional limitations ** Prevention is the Key **
- 67. COMPLICATIONS • Failure ofFixation • Inadequate / unstable reduction • Poor bone quality • Poor choice of implant (Vertical #) • Treatment • Elderly: Arthroplasty • Young: -Repeat ORIF by DHS augmented by tri-calcium phosphate or bone cement -Valgus-producing osteotomy -Arthroplasty
- 68. COMPLICATIONS • Fracture Distalto Fixation (Subtrochat) – 20% if screws at or below Lesser Trochanter – Poor bone quality esp. with anterior start site – Poor angle of screw fixation – Multiple passes of drill or guide pin Treatment – Elderly & Young: – Fixation of subtrochanteric with IMN
- 69. Complications • Post-traumatic arthrosis •Joint penetration with hardware • AVN related • Blood Transfusions • THR > Hemi > ORIF • DVT / PE • Multiple prophylactic regimens exist
- 70. Complications Mortality • One-year mortality14-50% • Increased risk: • Medical comorbidities: more falls • Surgical delay > 3 days • Dementia patient
- 72.
Editor's Notes
- #6 Iliofemoral attached at intertrochanteric line Ischiofemoral attach at half of the back of neck
- #8 Called retinacula vessels at time of capsular penetration
- #17 Line between the fracture ends and line with horizontal
- #20 . GM,gluteus maximus; PI, piriformis; OI, obturator internus; GE, gemelli; QF, quadratus femoris; RF, rectus femoris; AM, adductor muscles; HS, hamstring muscles
- #21 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. BROKEN IN NECK #
- #22 Not over internal rotation
- #30 So you limit this flexion and external rotation ---lower capsular volume– increased pressure– lower Blood flow
- #32 Osteocytes viability with ability of healing
- #34 Capsulotomy Reduces intracapsular pressure from fracture hematoma Increased capsular pressure not clinically associated with AVN
- #35 2015
- #68 Use DHS in Vertical #
- #69 Remove posterior screw and pass the nail
- #72 Algorithm if elderly ptn Tilt < 20 = less comminution no = marked comminution in week bone use DHS Conservative ttt if bad general condition