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SLIDE CASE REPORT NECK FEMUR FRACTURE
- 1. Neck Femur Fracture Resident : Dr. Putu Acarya Nugraha Dr. Ardian Mario Dr. Timothy Alexander Dr. Zulkifli Supervisor : Dr. Fadlyansah Farid, MARS, Sp.OT
- 2. Name : Mrs. H Age : 63 years old Registration : 0001959 Identity
- 3. Chief Complain : Pain at right groin Suffered since 1 month ago before being admitted to Wahidin Sudirohusodo General Hospital. The patient fell while walking on a slippery floor with the right hip hitting the floor first. The pain is felt continuously and worsens when the leg is moved and relieved with rest. After the accident, the patient was unable to stand and walk. Before the incident, the patient can walk normally without assistance. The patient then taken to Hasanudin University Hospital 1 week after the accident. A radiological examination was carried out, and analgesic was given. The surgery was planned but the patient and family refused. The patient then come to Wahidin Sudirohusodo General Hospital for further treatment and agree to do the surgery History Taking
- 4. There was no history of loss of consciousness There was no history of going to bone setter There was no history of diabetes mellitus and hypertension History Taking
- 6. Clinical Findings Look : Deformity (+), Swelling (-), Hematoma (-), Wound (-) Feel : Tenderness (+) Move : Active and passive movement of hip joint can not be evaluated due to pain NVD : Sensory is good Pulsation of dorsalis pedis and posterior tibialis arteries are palpable. Capillary refill time < 2 seconds.
- 7. Leg Length Discrepancy Right Left ALL 86 88 TLL 76 78 LLD 2 cm
- 10. Laboratory Finding PEMERIKSAAN HASIL NILAI RUJUKAN SATUAN WBC 6.3 4,00 – 10,0 10^3 / ul RBC 4.83 3,80 – 5,20 10^6 / ul HGB 12.1 12,0 – 16,0 Gr/dl HCT 38 37,0 – 48,0 % PLT 266 150 - 400 10^3 / ul PT 9,9 10-14 menit APTT 27.8 22-30 menit
- 11. Diagnosis Closed Facture Right Neck Femur Garden Type 3
- 12. Management • IVFD Crystalloid • Analgetic • Apply Skin Traction with load of 3kg • Refer to Orthopedic Consultant
- 13. CREDITS: This presentation template was created by Slidesgo, including icons by Flaticon and infographics & images by Freepik DISCUSSION
- 14. Introduction Stress fractures of the femoral neck are uncommon injuries. In general, these injuries occur in 2 distinct populations: • (1) young, active individuals with unaccustomed strenuous activity or changes in activity, such as runners or endurance athletes, and • (2) elderly individuals with osteoporosis. Elderly individuals may also sustain femoral neck stress fractures
- 15. Epidemiology Ref:1. Coon MS, Best BJ. Distal Femur Fractures. [Updated 2022 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan. 250.000 hip fractures 50% involve the femoral neck 80% in women (esp. age>30y) Young patients : very low (high-energy trauma) Elderly (72 years) : majority (low-energy falls)
- 16. Risk Factors Ref:1. Coon MS, Best BJ. Distal Femur Fractures. [Updated 2022 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan. female sex white race increasing age poor health tobacco alcohol use fall history low estrogen level previous fracture
- 17. Anatomy Egol KA, Koval KJ, Zuckerman JD. Handbook of fractures. Sixth edition. Philadelphia: Wolters Kluwer; 2020. 1 p Thompson JC, Netter FH. Netter’s concise orthopaedic anatomy. 2nd ed. Philadelphia, PA: Saunders Elsevier; 2010. 404 p.
- 18. Anatomy Egol KA, Koval KJ, Zuckerman JD. Handbook of fractures. Sixth edition. Philadelphia: Wolters Kluwer; 2020. 1 p Thompson JC, Netter FH. Netter’s concise orthopaedic anatomy. 2nd ed. Philadelphia, PA: Saunders Elsevier; 2010. 404 p.
- 19. MECHANISM OF INJURY/BIOMECHANICS Egol KA, Koval KJ, Zuckerman JD. Handbook of fractures. Sixth edition. Philadelphia: Wolters Kluwer; 2020. 1 p • Most common in older patients. • Direct : A fall onto the greater trochanter or forced external rotation of the lower extremity. • Indirect : Muscle forces overwhelm the strength of the femoral neck. Low-energy trauma • Accounts for femoral neck fractures in both younger and older patients, such as motor vehicle accident or fall from a significant height. High-energy trauma • These are seen in athletes, military recruits, and ballet dancers. Cyclical loading-stress fractures • Patients with osteoporosis and osteopenia are at particular risk. Insufficiency fractures
- 20. CLASSIFICATION Garden Fracture Classification • Garden grade I : incomplete femoral neck fracture, with valgus impaction • Garden grade II : complete but non-displaced fracture • Garden grade III : complete and partially displaced fracture with alignment of the femoral neck relative to the neck in varus deformity • Garden grade IV : complete fracture with complete displacement.
- 21. CLASSIFICATION Pauwel Classification This is based on the angle of fracture from the horizontal • Type I:<30 degrees • Type II: 31 to 70 degrees • Type III: >70 degrees Increasing shear forces with increasing angle leads to more fracture instability.
- 22. DIAGNOSIS HISTORY SYMPTOMS Egol, K dkk. Femoral Neck Fractures; Handbook of Fractures, 5th Ed. Lippincott Williams & Wilkins, 2015. Hal: 349. Solomon, L dkk. Fractures of the Femoral Neck; Apley’s System of Orthopaedic and Fractures, 9th Ed. Arnold, 2010. Hal: 847. acute onset of hip pain inability to ambulate Mechanism of injury • low-energy • higher-energy Antecedent hip pain • presence of OA or pathological fracture
- 23. Physical Examination DIAGNOSIS • LOOK : deformities, swelling, hematoma, shortening, wound • FEEL: Pressure sores, examination of the skin and overlying soft tissues, neurovascular distal • MOVE: may find it difficult to move and a fracture should be suspected it here is pain that creates limitations. Measurement Leg Length Discrepancy - True leg length - Apparent leg length Rex, C. Examination of Patient withBone and Joint Injuries; Clinical Assessment and Examination in Orthopedics, 2nd Ed. Jaypee Brothers Medical, 2012. Hal: 17-21.
- 24. DIAGNOSIS X-RAY: Anteroposterior (AP) pelvic x-ray and proximal femoral x-ray in AP and lateral. CT scan Magnetic resonance imaging (MRI) Egol, K dkk. Femoral Neck Fractures; Handbook of Fractures, 5th Ed. Lippincott Williams & Wilkins, 2015. Hal: 349. Solomon, L dkk. Fractures of the Femoral Neck; Apley’s System of Orthopaedic and Fractures, 9th Ed. Arnold, 2010. Hal: 847. IMAGING
- 25. TREATMENT Fracture management 01 Recognition Know and asses the fracture 02 03 04 Rehabilitation Aims to restore functional activities as much as possible Retention Immobilize the Fracture Reduction Closed reduction & Open reduction Rasjad, C. 2015. "Pengantar Ilmu Bedah Orthopedi ed.4 ". PT. Yarsif Watampone, Jakarta. Pp: 340-349
- 26. TREATMENT NON - OPERATIVE Indication : • extreme medical risk for surgery • demented non-ambulators who have minimal hip pain. Early bed to chair mobilization is essential to avoid increased risks and complications of prolonged recumbency, including : • poor pulmonary toilet, • atelectasis, • venous stasis, and • pressure ulceration Egol KA, Koval KJ, Zuckerman JD. Handbook of fractures. Sixth edition. Philadelphia: Wolters Kluwer; 2020. 1 p Ref:1. Coon MS, Best BJ. Distal Femur Fractures. [Updated 2022 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan.
- 27. TREATMENT OPERATIVE Young patients : emergent open reduction internal fixation. Non-displaced fractures : percutaneous cannulated screws or a sliding hip screw. Ref:1. Coon MS, Best BJ. Distal Femur Fractures. [Updated 2022 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan. Displaced fractures in elderly patients : • Less active individuals may receive a hemiarthroplasty. • More active individuals are treated with total hip arthroplasty.
- 28. COMPLICATION • Avascular Necrosis • Non-Union 1."Femoral Neck Fractures: A Review of Current Management" by Robert V. O'Toole, MD, and Michael J. Archdeacon, MD, JBJS Reviews, 2015. 2."Hip Fractures in Adults" by Jeffrey N. Katz, MD, and Jonathan D. Adachi, MD, New England Journal of Medicine, 2021.
- 29. PROGNOSIS • The prognosis of a femoral neck fracture depends on several factors, • In general, femoral neck fractures have a high risk of complications such as • non-union • avascular necrosis • and hip arthritis. • Studies have shown that the overall success rate of femoral neck fracture surgery is approximately 80-90%. • However, some patients may experience complications or require additional surgeries or interventions. 1."Femoral Neck Fractures: Epidemiology, Classification, Management, and Outcomes" by Robert V. O'Toole, MD, and Michael J. Archdeacon, MD, Journal of Orthopaedic Trauma, 2014. 2."Hip Fractures in Older Adults: A Clinical Review" by Sarah D. Berry, MD, MPH, and Douglas P. Kiel, MD, MPH, JAMA, 2019. 3.Karim L, Heard S, Maynard M, Rossiter N. The effectiveness of a multidisciplinary hip fracture care model in reducing the incidence of second hip fractures in the elderly.
- 30. CREDITS: This presentation template was created by Slidesgo, including icons by Flaticon and infographics & images by Freepik Thank You
Editor's Notes
- ■ More than 250,000 hip fractures occur globally each year, 50% involve the femoral neck ■ Eighty percent occur in women, especially age >30 years. The incidence in younger patients is very low and is associated mainly with high-energy trauma. The majority occur in the elderly (average age of 72 years) as a result of low-energy falls. ■ Risk factors include female sex, white race, increasing age, poor health, tobacco and alcohol use, previous fracture, fall history, and low estrogen level.
- ■ More than 250,000 hip fractures occur globally each year, 50% involve the femoral neck ■ Eighty percent occur in women, especially age >30 years. The incidence in younger patients is very low and is associated mainly with high-energy trauma. The majority occur in the elderly (average age of 72 years) as a result of low-energy falls. ■ Risk factors include female sex, white race, increasing age, poor health, tobacco and alcohol use, previous fracture, fall history, and low estrogen level.
- Ref:Thompson, Jon C. Netter's Concise Atlas of Orthopaedic Anatomy. Teterboro, NJ :Icon Learning Systems, 2002. APA. Thompson, Jon C. (2002)
- Ref:Thompson, Jon C. Netter's Concise Atlas of Orthopaedic Anatomy. Teterboro, NJ :Icon Learning Systems, 2002. APA. Thompson, Jon C. (2002)
- Non-operative treatment for traumatic fractures is indicated only for patients who are at extreme medical risk for surgery; it may also be considered for demented non-ambulators who have minimal hip pain. Early bed to chair mobilization is essential to avoid increased risks and complications of prolonged recumbency, including poor pulmonary toilet, atelectasis, venous stasis, and pressure ulceration
- Young patients with femoral neck fractures will require treatment with emergent open reduction internal fixation. Non-displaced fractures are treated typically with percutaneous cannulated screws or a sliding hip screw. With displaced fractures of the femoral neck in elderly patients, the treatment depends on the patient's baseline activity level and age. Less active individuals may receive a hemiarthroplasty. More active individuals are treated with total hip arthroplasty. Total hip arthroplasty is a more resilient procedure, but it also carries an increased risk of dislocation when compared to a hemiarthroplasty.
- The prognosis of a femoral neck fracture depends on several factors, including the age and overall health of the patient, the severity of the fracture, and the type of treatment received. In general, femoral neck fractures have a high risk of complications such as non-union (failure of the bone to heal), avascular necrosis (death of bone tissue due to a lack of blood supply), and hip arthritis. These complications can lead to long-term disability and reduced quality of life. However, with timely and appropriate treatment, such as surgery to repair the fracture or replace the hip joint, the prognosis can be improved. Physical therapy and rehabilitation are also important for restoring mobility and function after a femoral neck fracture. Studies have shown that the overall success rate of femoral neck fracture surgery is approximately 80-90%, with the majority of patients experiencing significant improvement in pain, mobility, and quality of life. However, some patients may experience complications or require additional surgeries or interventions. The prognosis after femoral neck fracture surgery can vary depending on several factors, including the patient's age and overall health, the severity and type of the fracture, the type of surgery performed, and the postoperative rehabilitation program. Generally, surgery for femoral neck fractures aims to realign and stabilize the broken bones to promote healing and restore normal function. However, there is a risk of complications such as infection, blood clots, and implant failure. Studies have shown that the overall success rate of femoral neck fracture surgery is approximately 80-90%, with the majority of patients experiencing significant improvement in pain, mobility, and quality of life. However, some patients may experience complications or require additional surgeries or interventions. The long-term prognosis after femoral neck fracture surgery can also be influenced by factors such as the development of osteoarthritis or avascular necrosis of the femoral head, which can lead to chronic pain and disability. Rehabilitation after surgery is crucial for optimizing outcomes and preventing complications. Physical therapy and exercise programs can help patients regain strength, flexibility, and mobility, and reduce the risk of falls and future fractures