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- 1. Orthopedic case BY THANA MEKSONG PRIYAPATMANITYAGUL TANKHUN CHITTASENEE MEDICAL CADET OF PHRAMONGKUTKLAO COLLEGE OF MEDICINE DEPARTMENT OF ORTHOPEDIC MAHARAT NAKHON RATCHASIMA HOSPITAL
- 2. Case • A 81year-old Thai female patient • No known underlying disease • Chief complaint : ปวดสะโพกซ้าย 3 วันPTA PhramongkutklaoCollegeofMedicine
- 3. A : Canspeak, can flex and extend C- spine, C-spine not tender B : trachea in midline, RR 20/min, no subcutaneous emphysema, lungs clear, equal breath sound both lungs, CCT negative C : BP 125/68 mmHg, PR 72 bpm, tender and mild swelling at left hip on skin traction left leg, no external wound, no deformities, no ecchymosis, dorsalis pedis artery 2+ both legs Primary Survey in MNRH PhramongkutklaoCollegeofMedicine
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- 5. D : E4V5M6,pupil 3 mm react to light both eyes E : BT 36.5oC, tender and mild swelling at left hip on skin traction left leg, no deformities, limit ROM left hip, dorsalis pedis artery 2+ both legs, sensory intact Primary Survey in MNRH PhramongkutklaoCollegeofMedicine
- 6. SpO2 98% RA DTX98 mg% CXR AP supine : Not seen rib fracture, not seen pneumohemothorax, no pneumopericardium, CT ratio 0.5, not seen subcutaneous emphysema Film pelvis AP : Fracture left neck of femur Garden type3 Film left femur AP,lat : Fracture left neck Adjunct to primary survey PhramongkutklaoCollegeofMedicine
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- 10. A : Nofood or drug allergy M : No underlying disease P : No previous surgery L : Last meal at 8 A.M. E : 3 days prior to MNRH ขณะที่ผู้ป่ วยก้าว ขึ้นบนเตียงใต้ถุนบ้าน ผู้ป่ วยสะดุดล้ม ก้น กระแทกพื้น ปวดสะโพกซ้าย ลุกเดินไม่ได้ ขยับแล้วมีอาการปวด ไม่มีศีรษะกระแทก ไม่ สลบ วันนี้อาการปวดไม่ดีขึ้น ไปรพช. filmพบ Secondary survey in MNRH PhramongkutklaoCollegeofMedicine
- 11. Vital signs :BT 36.5oC, PR 72 bpm, RR 20/min, BP 125/68 mmHg General appearance : An elderly Thai woman, good consciousness Head and Maxillofacial : No wound, no deformity Cervical spine and Neck : No wound, no tenderness along the midline Respiratory system : Equal breath sound both lungs, no tracheal shift, CCT negative, Physical examination PhramongkutklaoCollegeofMedicine
- 12. Cardiovascular system :distal pulse intact, normal S1S2, no murmur Abdomen : No external wound, soft not tender, no guarding, no rebound tenderness Extremities : tender and mild swelling at left hip on skin traction left leg, limit ROM left hip, no external wound, no ecchymosis, no deformities, dorsalis pedis artery 2+ both legs Physical examination PhramongkutklaoCollegeofMedicine
- 13. Film pelvis AP: Fracture left neck of femur Garden type3 Film left femur AP,lat : Fracture left neck of femur Garden type3 Film left knee AP : not seen fracture Investigation PhramongkutklaoCollegeofMedicine
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- 17. Closed fracture leftneck of femur Garden type3 Diagnosis PhramongkutklaoCollegeofMedicine
- 18. Pain control Skin traction2 kg left leg Set OR for Lt. bipolar hemiarthroplasty Management PhramongkutklaoCollegeofMedicine
- 19. General Knowledge • Neckof femur fractures are typically caused either by: • Low energy injuries – such as a fall in frail older patient • High energy injuries – such as a road traffic collision, affecting the ipsilateral side. PhramongkutklaoCollegeofMedicine
- 20. BASIC ANATOMYPhramongkutklaoCollegeofMedicine 1. Reticularvessels main blood supply. Originates from an extra-capsular arterial ring, supplied by medial and lateral circumflex vessels (profunda femoris A.). Reinforced by the superior and inferior gluteal arteries (internal iliac A.) 2. Foveal artery 3. Metaphyseal vessels
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- 26. • Intracapsular –either subcapital (through the junction of the head and neck) or basocervical fracture (through the base of femoral neck) • Extracapsular – either intertrochanteric (between the two trochanters) or subtrochanteric (<5cm distal to the lesser trochanter) classification PhramongkutklaoCollegeofMedicine
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- 28. PhramongkutklaoCollegeofMedicine •Subcapital: femoral head/neckjunction •Transcervical: mid portion of femoral neck •Basocervical: base of femoral neck
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- 31. Simplified garden classification •Nondisplaced : Included garden type I, II • Displaced : Included garden type III,IV
- 32. Pauwels Classification Based onvertical orientation of fracture line • Type 1: < 30 deg from horizontal • Type 2:30 to 50 deg from horizontal • Type 3:> 50 deg from horizontal (most unstable with highest risk of nonunion and AVN)
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- 35. Mechanism of injury PhramongkutklaoCollegeofMedicine •Fallsin the elderly •Significant trauma (e.g. motor vehicle collisions) in younger patients
- 36. • History ofa recent fall or trauma • Significant pain (in the groin, over the hip, in the thigh, or the knee) • Inability to weight bear. • History of chronic metabolic problems such as osteoporosis or renal failure Clinical feature PhramongkutklaoCollegeofMedicine
- 37. • shortened legand externally rotated • pain on pin-rolling the leg and axial loading • Unable to straight leg raise. • Distal neurovascular deficits are rare in isolated neck of femur fractures Clinical feature PhramongkutklaoCollegeofMedicine
- 39. • Plain radiographof hip ( AP with maximal internal rotation, lateral ) • Normal trabecular pattern, defect in cortex, shortening or angulation of femoral neck • Normal angle between femoral neck and shaft is 45 degrees • Normal angle between medial femoral shaft and trabecular lines running through the shaft to femoral head is 160-170 degrees Investigation PhramongkutklaoCollegeofMedicine
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- 42. PhramongkutklaoCollegeofMedicine • Line betweenanatomical long axis and femoral shift
- 43. Plain radiograph PhramongkutklaoCollegeofMedicine •Shenton’s linedisruption: loss of contour between normally continuous line from medial edge of femoral neck and inferior edge of the superior pubic ramus •Lesser trochanter is more prominent due to external rotation of femur •Femur often positioned in flexion and external rotation (due to unopposed iliopsoas)
- 44. Plain radiograph PhramongkutklaoCollegeofMedicine •Asymmetry oflateral femoral neck/head •Sclerosis in fracture plane •Smudgy sclerosis from impaction •Bone trabeculae angulated •Non-displaced fractures may be subtle on x-ray
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- 46. PhramongkutklaoCollegeofMedicine Left Subcapitalfemoral neck fracture
- 47. Left basicervical femoralfracturePhramongkutklaoCollegeofMedicine
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- 49. ManagementPhramongkutklaoCollegeofMedicine Fracture TypeSurgical Option Summary Subcapital* Hip hemiarthroplasty Replacement of the femoral head and neck via a femoral component fixed in the proximal femur Intertrochanteric and Basocervical* Dynamic hip screw Consists of a lag screw into the neck, a sideplate, and cortical screws. The lag screw is able to slide through the sideplate, allowing for compression and primary healing of the bone. Non-displaced intra-capsular Cannulated hip screws Three non-parallel screws in an inverted triangle formation. Are also used in valgus-impacted fractures Subtrochanteric Intramedullary Femoral Nail The metal rod is placed through the medullary cavity of the femur for stabilization
- 50. • Perform earlysurgery within 24 hours in patient with medically stable • As soon as possible in patient with active comorbid medical illness • Avoid delaying surgery beyond 72 hours • Thrombo-prophylaxis should be performed in patients awaiting surgery Timing of operative management PhramongkutklaoCollegeofMedicine
- 51. Reserved for debilitatedpatients Stable, impacted patient Patients over 70 years old with poor health Non-operative management PhramongkutklaoCollegeofMedicine
- 52. Infection Thromboembolism Chronic pain Osteonecrosis (Avascular necrosis ) Nonunion Complications PhramongkutklaoCollegeofMedicine
- 53. Pre & Post-operation PhramongkutklaoCollegeofMedicine •Analgesia • Thromboembolism prophylaxis • Infection prophylaxis • Postoperative delirium • Osteoporosis • Prevent constipation • Nutrition • Prevention of pressure ulcer • Bladder catheterization • Blood transfusion • Rehabilitation
- 54. Key Points PhramongkutklaoCollegeofMedicine • Neckof femur fractures are associated with a high one year mortality • They will present as an acutely painful hip that is shortened and externally rotated. • Treatment of neck of femur fracture is primarily surgical. The specific procedure required will depend on the classification of the fracture. • Ensure early assessment by ortho-geriatricians alongside physiotherapists and occupational therapists.
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Editor's Notes
- #21 The femoral head’s blood supply is primarily uni-directional, most arriving from the medial femoral circumflex artery* (arising from the deep femoral artery). The medial femoral circumflex artery lies directly on the femoral neck and is thus vulnerable to damage in a fracture. The blood supply to the proximal end of the femur is divided into 3 major groups. The first is the extracapsular arterial ring located at the base of the femoral neck. The second is the ascending cervical branches of the arterial ring on the surface of the femoral neck. The third is the arteries of the ligamentum teres. A large branch of the medial femoral circumflex artery forms the extracapsular arterial ring posteriorly and anteriorly by a branch from the lateral femoral circumflex artery (see images shown below). The ascending cervical branches 1ascend on the surface on the femoral neck anteriorly along the intertrochanteric line. Posteriorly, the cervical branches run under the synovial reflection toward the rim of the articular cartilage, which demarcates the femoral neck from its head. The lateral vessels are the most vulnerable to injury in femoral neck fractures. A second ring of vessels is formed as the ascending cervical vessels approach the articular margin of the femoral head. From this second ring of vessels, the epiphyseal arteries are formed. The lateral epiphyseal arterial group supplies the lateral weight-bearing portion of the femoral head. The epiphyseal vessels are joined by the inferior metaphyseal vessels and vessels from the ligamentum teres. Femoral neck fractures frequently disrupt the blood supply to the femoral head (see images below). The superior reticular and lateral epiphyseal vessels are the most important sources of this blood supply. Widely displaced intracapsular hip fractures tear the synovium and the surrounding vessels. The progressive disruption of the blood supply can lead to serious clinical conditions and complications, including osteonecrosis and nonunion.