The document outlines femoral neck fractures, covering aspects such as anatomy, mechanisms of injury, classification, clinical presentation, diagnosis, treatment options, and rehabilitation strategies. It emphasizes the importance of understanding the anatomical and pathological characteristics of femoral neck fractures, particularly in elderly patients, and details both surgical and non-surgical treatment approaches. Additionally, it discusses complications and physiotherapy management for post-operative recovery.

1. FEMORAL NECK FRACTURE
by Albert Arimoro

2. Outline
 INTRODUCTION
 ANATOMY OF NECK OF FEMUR
 PATHO ANATOMY
 ETIOLOGY
 CLASSIFICATION
 MECHANISM OF INJURY
 CLINICAL PRESENTATION
 DIAGNOSIS
 MEDICAL TREATMENT
 PHYSIOTHERAPY TREATMENT
 COMPLICATIONS

3. INTRODUCTIO
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The structure of the head and neck of
femur is developed for the transmission of
body weight efficiently, with minimum bone
mass, by appropriate distribution of the bony
trabeculae in the neck. The tension
trabeculae and compression trabeculae
along with the strong calcar femorale on the
medial cortex of the neck of the femur form
an efficient system to withstand load bearing
and torsion under normal stresses of
locomotion and weight bearing.

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5. ANATOMY OF NECK OF
FEMUR
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 Neck connects head with shaft and is
about
3.7 cm long.
 It makes angle with the shaft 130+/- 7
degree ( less in female due to their
wider pelvis). It facilitate movements of
hip joint.
 It is strengthened by calcar femorale
(bony thickening along its concavity).

6.  2 borders and 2 surfaces
-upper border –concave and horizontal
meets the shaft at greater trochanter.
-lower border – straight and oblique meet
the shaft at lesser trochanter.
-anterior surface- flat .meet shaft at
intertrochanteric line . Entirely intra
capsular.
-posterior surface- convex from above
downwards and concave from side to
side.meets shaft at intertrochanteric crest.it
is crossed by horizontal groove for tendon 6
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7.  Blood sypply
Crock described the arteries of the proximal
end of the femur in three groups
(a) an extracapsular arterial ring located at
the base of the femoral neck;
(b) ascending cervical branches of the
extracapsular arterial ring on the surface
of the femoral neck (known as retinacular
arteries)
(c)the arteries of the ligamentum teres
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8. a) 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 superior and inferior gluteal
arteries also have minor contributions to
this ring
b) The ascending cervical arteries can be
divided into four groups (anterior, medial,
posterior, and lateral) based on their
relationship to the femoral neck.
lateral group provides most of the blood 8
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9. c) The artery of the ligamentum teres is a
branch of the obturator or the medial
femoral circumflex artery
only small & variable amount of
femoral head is nourished by artery
of ligamentum teres.
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10. Vascular anatomy of the femoral head and neck
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11. Anterior aspect
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12. PATHO-ANATOMY
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 Most fracture are displaced with
distal fragment – externally rotated,
adducted,
and proximally migrated.
These displacement are less marked than
in intertrochanteric fracture because the
capsule of hip joint is attached to distal
fragment and prevent extreme rotation
and displacement of distal fragment.

13.  Displacement of the lower bone
fragment caused by the pull of the
powerful muscles.
 In particular the outward rotation of
the leg so that the foot
characteristically points laterally. (GM)
gluteus maximus; (PI) piriformis; (OI)
obturator internus; (GE) gemelli; (QF)
quadratus femoris; (RF) rectus
femoris; (AM) adductor muscles; (HS)
hamstring muscles
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15. ETIOLOGY
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 Commonest site of # in elderly(7th /8th
decade).
 Post menopausal
women, osteomalacia, diabetes, stroke,
alcoholi sm, chronic debilitating disease.
 Old people– weak muscle, poor
balance – increased tendency to fall.
 Fall directly onto greater trochanter.
 Fall from height, RTA

16. CLASSIFICATION
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 -ANATOMICAL LOCATION
-subcapital
-transcervical
-basicervical (base of the neck
fracture)

17.  -PAUWEL
This is based on the angle of fracture
from the horizontal
 Type I: 30 degrees
 Type II: 50 degrees
 Type III: 70 degrees
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18. As the fracture progresses from type 1 to type 3, the obliquity
of the fracture fracture line increases, thus the shear force at the
fracture site increases
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19.  -GARDEN
This is based on the degree of valgus
displacement
 Type I: Incomplete/valgus impacted
 Type II: Complete and nondisplaced
on AP and lateral views
 Type III: Complete with partial displacement;
trabecular pattern of the femoral head does
not line up with that of the acetabulum
 Type IV: Completely displaced; trabecular
pattern of the head assumes a parallel
orientation with that of the acetabulum 19
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22.  -Orthopaedic Trauma Association
(OTA) Classification
 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
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24. MECHANISM OF INJURY
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 Low-energy trauma (most common in
older patients)
- Direct: A fall onto the greater trochanter
(valgus impaction) or forced external
rotation of the lower extremity impinges an
osteoporotic neck onto the posterior lip of
the acetabulum (resulting in posterior
comminution).
- Indirect: Muscle forces overwhelm the
strength of the femoral neck

25.  High-energy trauma- accounts for
femoral neck fractures in both younger
and older
patients, such as motor-vehicle accident
or fall from a significant height.
 Cyclical loading-stress fractures: These
are seen in athletes, military recruits, ballet
dancers; patients with osteoporosis and
osteopenia are at particular risk.
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26. CLINICAL PRESENTATIONS
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 H/O fall from height.
 nonambulatory on presentation
(EXCEPT impacted fracture patient may
still be able to walk)
 shortening and external rotation of the
lower extremity.

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28. CLINICAL EVALUATION
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 Pain is evident on range of hip
motion, with possible pain on axial
compression and tenderness to
palpation of the groin.
 Tenderness over Scarpa`s triangle
 Active SLR not possible

29. DIAGNOSIS
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Situations in which femoral neck fracture
may be missed-
 Stress fractures- elderly patient with
unexplained pain in the hip should be
considered to have stress fracture until
proven otherwise.
 Undisplaced fracture-impacted fracture
may be difficult to visualise on plain x-ray.
 Painless fracture-a bed ridden
patient may develop a silent fracture.

30.  Multiple fractures-patient with a
femoral shaft fracture may also have
a hip fracture which is easily missed
unless the pelvis is x rayed.
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31. RADIOGRAPHIC EVALUATION
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 An anteroposterior (AP) view of the
pelvis both
hip in
15
internal rotation and a cross-
table
lateral view of the involved proximal
femur are indicated
 Technetium bone scan or preferably
magnetic resonance imaging may be of
clinical utility in delineating nondisplaced
or occult fractures that are not apparent
on plain radiographs.

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33. The Importance of a True AP Hip
Position
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34. Shenton's
Line
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 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. If there is any
sharp angulation of Shenton's line the
patient could have a neck of femur
fracture. An abnormal Shenton's line
can be the most obvious indicator of a
patient's fractured neck of femur
demonstrated on an AP pelvis /hip
image.

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36. TREATMENT
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Goals of treatment are
 to minimize patient discomfort,
 restore hip function,
 allow rapid mobilization by obtaining
early anatomic reduction and stable
internal fixation or prosthetic
replacement.

37.  In children-
close reduction and Hip spica.
If not reduced then ORIF with Moore`s pins.
 Adults
impacted or garden type 1 & 2
Non-operative Treatment- bed rest for
elderly person whose medical condition
carries an excessively high risk of mortality
from anesthesia and surgery
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38. Operative Treatment- include the
following
- Internal fixation with multiple
cancellous lag screws.(preffered
treatment)
- Sliding hip screw –
advantages-
1)biomechanical strength
greater than multiple cancellous
screws.
2)minimization of risk of
subsequent subtrochanteric fracture
secondary to a stress riser effect. 38
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39. Disadvantage
s-
1)stabilization include a larger
surgical exposure
2)potential to create rotational
malalignment of the femoral head at the
time of screw insertion.
Fracture of the femoral neck
stabilized with three well-
placed, 6.5-mm, short
threaded cancellous lag
screws.
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40.  age more than 60 years
normal hip- Hemiarthroplasty with Austin-
Moore prosthesis.
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41.  Indications for hemiarthroplasty
 Comminuted, displaced
femoral neck fracture in the
elderly
 Pathologic fracture
 Poor medical condition
 Poorer ambulatory status before
fracture
 Neurologic condition (dementia,
ataxia, hemiplegia, parkinsonism)
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42. Advantages of Hemiarthroplasty over
open reduction and internal fixation :
1) It may allow faster full weight
bearing
2) It eliminates nonunion, osteonecrosis,
failure of fixation risks .
Disadvantages:
1) It is a more extensive procedure with
greater blood loss
2) A risk of acetabular erosion exists in
active individuals
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44. preexisting degenerative condition -
total hip replacement
Indications
 osteoarthritis,
 rheumatoid arthritis,
 severe osteoporosis
 pathologic conditions with acetabular
involvement such as Paget's disease
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46. PHYSIOTHERAPY MANAGEMENT
Rehabilitation begins promptly.
Two to three days postoperative
•Instruct patient in deep breathing and
cough. Goal: Prevent postoperative
pneumonia and atelectasis.
•Initiate isometrics and ankle pumps with
involved extremity. Goal: Prepare patient for
active exercise program.
•Initiate bedside sitting once physician has
cleared patient for this activity. Goal: Prepare
patient to begin transfer and progressive gait
training processes.

47. Three to five days postoperative
• Gait train patient, observing weight-bearing precautions. Progress to walker
or crutches. Goal: Establish independent gait with assistive device, using
proper gait pattern on all surfaces and stairs.
• Initiate training in activities of daily living, including bed mobility and
transfers to and from bed and toilet. Goal: Achieve independence with all
transfers.
• Initiate active range of motion/strengthening program. Individualize exercise
programs according to each patient's needs, but generally include the
following.
• Goals: Increase strength of involved extremity; increase independence with
exercise program.
• Supine: hip abduction and adduction, gluteal sets, quadriceps sets,
straight leg raise, hip and knee flexion, short arc quadriceps, internal and
external rotation.
• Sitting: Long arc quadriceps, hip flexion, ankle pumps[16]
.
• When internal fixation is performed, partial weight-bearing is recommended
for a period of 8–10 weeks (according to the radiological evaluation of

48. COMPLICATIONS
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 General-
1. Deep vein
thrombosis
2. Pulmonary
embolism
3. Pmeumonia
4. Bed sores
 Osteoarthritis
 Avascular necrosis

49. cause of AVN and non-
union
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 Tearing the capsular vessels the
injury deprives the head its main
blood supply
 Intra articular bonehas only flimsy
periosteum and no contact with soft
tissue which could promote callus
formation
 Synovial fluid prevents clotting
of the fracture hematoma