Brief description,classification with treatment modalities & algorithyms in details

1. DR.KUNAL MONDAL,
PGT,
IPGMER & SSKMH

2.  A fracture through the intra articular part of the
femoral neck
 Another term is intra-capsular proximal femoral
fracture.
 Hip fractures comprise 20% of the operative
workload of an orthopedic trauma unit.
 Intra-capsular femoral neck fractures account for 50%
of all hip fractures
 The lifetime risk Women 40% to 50% ,Men 13% to
22%
 Age-occur most frequently in elderly female patients
 They are uncommon in patients younger than 60
years
 Only 15% of these fractures are undisplaced.

4.  The upper femoral epiphysis closes by age16
years.
 Neck-shaft angle: 130 ±7 degrees
 Femoral Anteversion: 10 ±7degrees
 Three ligaments attach in this region:
1. Iliofemoral :Y –ligament of Bigelow
(anterior)
2. Pubofemoral : Anterior
3. Ischiofemoral :Posterior

7.  major contributor is medial femoral
circumflex Artery
 some contribution to anterior and inferior
head from lateral femoral circumflex
 some contribution from inferior gluteal artery
small and insignificant supply from artery of
ligamentum teres

8. • AT BIRTH
BOTH MED. & LAT. CIRCUMFLEX FEMORAL ARTERIES SUPPLY THE
HEAD
THE FOVEAL ARTERY SUPPLIES ONLY SMALL AREA OF MEDIAL
HEAD
•BY 15-18 MONTHS
BLOOD VESSELS WHICH CROSS PHYSIS AT BIRTH DISSAPEAR BY AGE OF
3 YR
CONTRIBUTION OF LAT. CIRCUMFLEX FOMORAL ARTERY
DIMINISHES AND ENTIRE BLOOD SUPPLY COMES FROM MED.
CIRCUMFLEX ARTERY. THIS ARRANGEMENT PERSISTS IN ADULTS
• BY 8 YR
• THE FOVEAL ARTERY PROVIDES 20% OF BLOOD TO FEMUR HEAD
AND MAINTAINS IT INTO ADULTHOOD

10.  Most fracture are displaced with distal
fragment
 Externally rotated,
 Adducted, and
 Proximal migrated.
 Displacement are less marked than inter-
trochanteric fracture because the capsule of
hip joint is attached to distal fragment

11. NOF FRACTURE
 Classified by location of fracture line
 Garden classification
 Pauwels classification
 AO classification

12.  Subcapital
 Transcervical
 Basicervical

13.  Based on the degree of displacement ,which is judged on the
AP radiograph by determining the relationship of the
trabecular lines in the femoral head to those in the
acetabulum.
Stage I-incomplete fracture line (valgus
impacted)
Stage II-complete fracture line; non-
displaced
Stage III-complete fracture line
partially displaced
Stage IV-complete fracture line;
completely displaced

14.  Based on the angle of fracture from the horizontal
 Classifcation was proposed to be predictive of
fixation failure or nonunion with an increasing
angle of fracture.

16.  Low-energy trauma (most common in older
patients)
 Direct-
 • A fall onto the greater trochanter (valgus impaction)
forced external rotation of the lower extremity
 Indirect-
 • Muscle forces overwhelm the strength of the
femoral neck
 High-energy trauma-
 • motor-vehicle accident or fall from a significant
height.
 Cyclical loading-stress fractures-Seen in
athletes, military recruits, ballet dancers

17.  Examination-
1. The affected leg is typically shortened and
externally rotated.
2. All motions of the hip are painful.
3. SLRT negetive on affected side

18.  Plain radiographs will identify the fracture in
the majority of cases

19. In 2% of cases, the fracture may be difficult
or impossible to visualize on plain
radiographs
 • Technetium bone scan
 • CT scan
 • Magnetic resonance imaging (MRI)

20. Treatment depends on-
 • Age of the patient
 • Duration of fracture
 • Geometrical pattern of the fracture

21. Undisplaced Femoral Neck Fractures
 • Nonoperative Treatment –limited use
 • Operative Treatment-
1. Cannulated screw system
2. sliding hip screw device with a short plate
3. Arthroplasty
Displaced Femoral Neck Fractures
 • Reduction with Ancillary Techniques & fixation
 • Hemiarthroplasty-Unipolar /Bipolar
Hemiarthroplasty
 • Total Hip Replacement

22.  Open
 Close-Whitman technique in hip extension.
 (applying traction to the abducted,extended ,
externally rotated hip with subsequent
internal rotation)

23.  On the AP image,
 The angle between the medial shaft and the central
axis of the medial compressive trabeculae should
measure between 160 and 180 degrees.
 <160 degrees indicates varus
 >180 degrees indicates valgus
 On the lateral image
 Angulation should be approximately 180 degrees
and deviation of more than 20 degrees indicates
excessive anteversion or retroversion.

25.  Cancellous screw-
 • The screws must be parallel
 • Guide wires may be inserted freehand under x-ray control to
ensure they are parallel, or an aiming device may be used if available
 • Screw should be 7.0 mm or 7.3 mm
 • A washer may be used to avoid penetration of the screw head
through the thin cortex.

26.  Indications
 Basicervical fracture(consider placement of additional
cannulated screw above sliding hip screw to prevent rotation)
 Ipsilateral to femoral shaft fracture,fixed with compression
hip Screw and derotational screw

27.  HEMIARTHROPLASTY-Involves replacing the
femoral head with a prosthesis, while
retaining the natural acetabulum
(endoprosthesis)
 • TYPES
 • STEM PROSTHESIS (not in use)
 • MEDULLARY PROSTHESIS
 Unipolar
o AUSTIN MOORE
o THOMPSONS
 Bipolar

28. AUSTIN
MOORE
PROSTHESIS
THOMPSON
PROSTHESIS
BIPOLAR
PROSTHESIS

29.  INDICATION
 Older active patients
 Arthroplasty for Garden III and IV in patient> 85 years.
THA Hemiarthroplasty

30. FRESH # ( 1-21 DAYS)
 • AGE 1-16YRS :PHYSIS OPEN AND IMPLANT SHOULD
CAUSE MINIMUM DAMAGE
 • UNDISPLACED : INTERNAL FIXATION WITH 2-2.5mm K-
WIRE or MOORE’S PINS
 • DISPLACED : CLOSED REDUCTION AND INTERNAL
FIXATION K-WIRES/MOORE’S PINS (FOR BASAL #
CANNULATED SCREWS 4mm CAN ALSO BE USED)

31.  • IF CLOSED REDUCTION FAILS THEN OPEN
REDUCTION AND INTERNAL FIXATION
SHOULD BE DONE
 • ALTERNATIVELY –
1. Mc-MURRAYS OSTEOTOMY WITH HIP SPICA
2. ABDUCTION OSTEOTOMY WIYH
INTERNALFIXATION WITH PAEDIATRIC DHS /
135°PAEDIATRIC BLADE PLATE

32.  AGE 16-50YRS
1. SUBCAPITAL #
 • UNDISPLACED : INT. FIXATION WITH 2-3
CANNULATED SCREWS
 • DISPLACED : CLOSED REDUCTION AND INT. FIXATION
WITH CANNULATED SCREWS
 OTHER OPTIONS:
1. ABDUCTION OSTEOTOMY WITH 135° BLADE PLATE/
DOUBLE ANGLE BLADE PLATE /MODIFIED DHS
2. CLOSED REDUCTION AND INT. FIXATION WITH 2 CCS
AND ONE FREE FIBULAR GRAFT

33. 2. TRANSCERVICAL #
 • UNDISPLACED # : INT. FIXATION WITH CCS
 • DISPLACED # : CLOSED REDUCTION AND INT.FIXATION WITH
CCS
 IF CR FAILS THEN :
• ORIF WITH CCS
 • ORIF WITH CCS AND FREE FIBULAR GRAFT /MUSCLE PEDICLE
GRAFT
3. BASAL #
 • UNDISPLACED : INT. FIXATION WITH DHS
 • DISPLACED : CRIF WITH CCS / DHS,IF CR FAILS THEN ORIF
WITH/ / DHS

34.  AGE : 50-60YRS
1. SUBCAPITAL #
 • UNDISPLACED : INT. FIXATION WITH CCS
 • DISPLACED :
 CRIF WITH CCS
 CRIF WITH CCS AND FREE FIBULAR GRAFT
 ABDUCTION OSTEOTOMYREPLACEMENT ARTHROPLASTY :
BIPOLAR / THR
 IF CR FAILS THEN ORIF WITH CCS AND FREE
FIBULAR GRAFT/REPLACEMENT ARTHROPLASTY

35. 2. TRANSCERVICAL FRACTURE
 • UNDISPLACED : INT. FIXATION WITH CCS
 • DISPLACED : CRIF WITH CCS +/- FIBULAR GRAFT.IF
CR FAILS THEN ORIF WITH CCS AND FREE FIBULAR
GRAFT / BONE MUSCLE PEDICLE GRAFT, REPLACEMENT
ARTHROPLASTY
3. BASAL FRACTURE
 • UNDISPLACED : INT. FIXATION WITH CCS OR DHS
 • DISPLACED : CRIF WITH CCS / DHS / 135º BLADE PLATE
 IF CLOSED REDUCTION FAILS-ORIF WITH CCS / DHS /
135º BLADE PLATE/REPLACEMENT ARTHROPLASTY

36.  AGE ABOVE 60YRS
 1. SUB CAPITAL #
• UNDISPLACED :INT. FIXATION WITH CCS/REPLACEMENT ARTHROPLASTY
• DISPLACED :REPLACEMENT ARTHROPLASTY IS THE CHOICE/CRIF WITH CCS AND FREE FIBULAR
GRAFT CAN BE TRIED
IF CR FAILS THEN REPLACEMENT ARTHROPLASTY
 2. TRANSCERVICAL#
• UNDISPLACED :INT. FIXATION WITH CCS/REPLACEMENT ARTHROPLASTY
• DISPLACED-REPLACEMENT ARTHROPLASTY IS CHOICE
• CRIF WITH CCS CAN BE TRIED IF CR FAILS THEN REPLACEMENT ARTHROPLASTY
 3. BASAL #
• UNDISPLACED: INT. FIXATION WITH CCS OR DHS
• DISPLACED #-CRIF WITH CCS OR DHS
IF CR FAILS THEN REPLACEMENT ARTHROPLASTY IS THE CHOICE

37.  Sandhu described a classification system for
NU/neglected femoral neck fracture
incorporating changes at various stages.
 Based on changes, he classified the neglected
femoral neck fracture into 3 types (described
as 3 stages)

38.  The radiological findings are:
Stage I
 a. Fracture surfaces are still irregular
(irregular or jagged)
 b. The size of the proximal fragment is 2.5
cm or more
 c. Gap between the fragments is 1 cm or less
 d. Head of the femur is viable with no sign of
AVN on X-ray or MRI.

39.  Stage II
 a. Fracture surfaces are smooth and sclerosed
 b. The size of the proximal fragment is 2.5
cm or more
 c. The gap between the fragments is more
than 1 cm but <2.5 cm
 d. The head of the femur is viable.

40.  Stage III
 a. Fracture surfaces are smoothened out
 b. The size of the proximal fragment is <2.5
cm
 c. The gap between the fragments is more
than 2.5 cm
 d. The head of the femur shows signs of AVN.

41.  Decision making
 Late presenters
 Irrespective of vascularity of head, good
reduction achieved and neck-shaft angle
maintained &
 If presented within 3 wks – Fix it
 If presented 3wks- 3months- fixation+
BG,MPBG
 If presented after 3months with shortening and
varus of the head- Osteotomy +/- BG
 If there is segmental collapse-Replacement
arthroplasty Arthrodesis

42. Closed reduction & internal fixation
 Closed reduction & internal fixation with
one screw and double fibular graft or two
screws and one fibular graft
 CR or OR and bone muscle pedicle graft
based on quadratus femoris or sartorius or
tensor fascia
 Abuction osteotomy and osteosynthesis
with DHS or 135degree anle blade plate or
120 degree double angle plate

43.  Open reduction, freshening of fracture
surfaces and Internal fixation two screws and
one free fibular graft
 ORIF with multiple screws and muscle
pedicle bone graft
 Valgus osteotomy

44.  Total hip arthroplasty
 Hemiarthroplasty
 Excision Arthroplasty

46.  A type of fracture to femur where fracture
line run between two trochanters
 IMPORTANT-
 Since they occur in cancellous bone with abundant blood
supply – no problems of nonunion and osteonecrosis
 Deforming muscle forces will usually produce shortening,
external rotation and varus position at the fracture

47.  BOYD AND GRIFFIN CLASSIFICATION
 Type 1-Stable (Two part)
 Type 2-Unstable with posteromedial communition
 Type 3-Subtrochanteric extension into lateral shaft,
extension of the fracture distally at or just below the lesser
trochanter (the term Reverse Obliquity was coined by Wright)
 Type 4-Subtrochanteric with intertrochanteric extension
with the fracture lying in atleast two planes

50.  Group 1 fractures (31A1) – Pertrochanteric simple (two-part)
fractures, with the typical oblique fracture line extending from the
greater trochanter to the medial cortex; the lateral cortex of the greater
trochanter remains intact.
 A1.1 – Along intertrochanteric line
 A 1.2 – Through greater trochanter
 A 1.3 – Below lesser trochanter
 Group 2 fractures (31A2) – Pertrochanteric multifragmentary -
comminuted with a posteromedial fragment; the lateral cortex of the
greater trochanter however, remains intact. Fractures in this group are
generally unstable, depending on the size of the medial fragment.
 A2.1 – With one intermediate fragment
 A2.2 – With several intermediate fragments
 A2.3 – Extending more than 1cm below lesser trochanter.

51.  Group 3 fractures (31A3) – TRUE INTERTROCHANTERIC -
are those in which the fracture line extends across both the medial
and lateral cortices; this group also includes the reverse obliquity
pattern.
 A3.1 – Simple oblique
 A3.2 – Simple transverse
 A3.3 - Multifragmentary

52.  Posteromedial large separate fragmentation
 Basicervical patterns
 Reverse obliquity patterns
 Displaced greater trochanteric (lateral wall
fractures)
 Failure to reduce the fracture before internal
fixation

53.  NON-OPERATIVE-Can be done for:
 1.An elderly person whose medical condition
carries an excessively high risk of mortality from
anaesthesia and surgery.
 2.Nonambulatory patient who has minimal
discomfort following fracture
 METHODS-
Russell skeletal traction
Balanced traction in Thomas splint
Plaster spica immobilization
Derotation boot

54.  Plate Constructs
 Cephalomedullary nailing
 Condylo-cephalic nailing
 External Fixation
 Arthroplasty

55.  The 135◦ plate is most commonly utilized; this
angle is easier to insert in the desired central
position of the femoral head and neck than
higher angle devices and creates less of a stress
riser in the subtrochanteric region.
 The most important technical aspects of screw
insertion are:
1. Placement within 1cm of subchondral bone to provide
secure fixation
 2. Central position in the femoral head (Tipapex
distance- should be <25mm to minimize the risk of lag
screw cutout)

57.  These devices offer maximal stability with
initial compression and fixed angle stability
from locking screws

58.  The intramedullary fixation device
incorporates a sliding hip screw, the
advantage of controlled fracture impaction is
maintained
 Shorter operative time and less soft-tissue
dissection than a sliding hip screw.
 Due to its position close to the weight-
bearing axis the stress generated on the
intramedullary implants is negligible.

60.  Loss of fixation and implant failure
 Nonunion
 Malrotation deformity
 Osteonecrosis
 Medical, psychosocial, thromboembolic
 Infection

61. THANK YOU