fracture neck femur
DESCRIPTION
Intra capsular fracture of femur neckTRANSCRIPT
13/5/2013
INTRACAPSULAR FRACTURE
NECK OF FEMUR
BHAGEERATH REDDY PR NO 11
04/12/2023 2
• Anatomy of Hip Joint• Fracture femur neck Aetiology Mechanism of Injury Classification Clinical features Investigations Treatment
04/12/2023 3
HIP JOINT
• Articular Capsule• Iliofemoral ligament• Pubofemoral ligament• Ischiofemoral ligamnet
Ligaments :
04/12/2023 4
Trabecular pattern of proximal hip
Principal compressive group
Ward’s triangle
04/12/2023 5
Blood supply:
Femoral artery Profunda femoris artery
Lateral circumflex arteryMedial circumflex artery
EXTRACAPSULAR ARTERIAL RINGEXTRA CAPSULAR ARTERIAL RING
Retinacular arteries
SUBSYNOVIALINTRACAPSULAR ARTERIAL RING
Epiphyseal branchesMetaphyseal branches
Artery of ligament teres
04/12/2023 6
04/12/2023 7
04/12/2023 8
• Older patients – Osteoporosis or Osteomalacia
• Elderly women • Major trauma in young adults like RTA,fall etc.
FRACTURE NECK OF FEMURAETIOLOAETIOLOGY
04/12/2023 9
• Trivial fall – direct blow over the greater trochanter
• Lateral rotation of the extremity posterior communition of the neck.
• Cyclical loading due to muscle force and torsion
Mechanism of injury
04/12/2023 10
CLASSIFICATION
Broad classification:Fracture neck of femur
INTRACAPSULAR EXTRACAPSULAR
04/12/2023 11
Structural classificationIMPACTEDUNDISPLACED
DISPLACED
04/12/2023 12
causatively
STRESS FRACTURES
TRAUMATIC FRACTURES
PATHOLOGICAL FRACTURES
POSTIRRADIATION FRACTURES
04/12/2023 13
04/12/2023 14
Based On Fracture Character
Anatomical location
04/12/2023 15
Fracture angle:
PAUWEL’S CLASSIFICATIONPrerequisites : Traction Internal rotation
04/12/2023 16
GARDEN’S CLASSIFICATION
04/12/2023 17
DELBET’S CLASSIFICATION
Transepiphyseal fracture
Inter trochanteric fracture
Sub trochanteric fracture
Transcervical fracture
04/12/2023 18
CLINICAL FEATURES
PainRestriction of movements
Minimal shorteningExternal rotation deformity
h/o fall
Tenderness over ant.hip jt lineO/E
04/12/2023 19
Active straight leg rising is difficult
Groin painAntalgic gait
04/12/2023 20
Investigations
Radiography
1.EXTENT OF FRACTURE COMPLETE
INCOMPLETE2.FRACTURE ANGLE3.BREAK IN SHENTON’S LINE4.POSTERIOR WALL COMMUNITION5.PROMINENT LESSER TROCHANTER6.DEGREE OF OSTEOPOROSIS
04/12/2023 21
04/12/2023 22
Shenton’s line
It is the line drawn from the superior margin of the obturator foramen to the margin of neck.
04/12/2023 23
Singh’s indexDegree of osteoporosis
04/12/2023 24
Other investigations• Oxygen tension measurement• Venography• Intraosseous pressure recording
• Isotope scanning• Bone scan with Tc-99m, sulphur colloid, etc.
04/12/2023 25
TreatmentTREATMENT
Aims of treatment
• Early anatomical reduction – prevents further vascular damage.
• Impaction of fracture fragments• Rigid internal fixation: enables the vascularization from the surrounding soft tissues and uninjured bones – early callus formation.
04/12/2023 26
Fracture neck of femur
Undisplaced Displaced
Physiologically <60 years Physiologically >60 years
Closed reduction under x-ray control Prosthetic replacement
Reduction possible Reduction not possible Normal hip Hip with pre existing arthritis
Multiple screw fixation
Open reduction screw fixation
hemiarthroplasty THR
ConservativeMultiple screws
04/12/2023 27
Garden I: Conservative Hip Spica for -old fracture. -unfit for surgery. surgical multiple pins by Moore,Knowles cannulated screws.Garden II: fracture fixed with DHS, multiple cannulated AO screws.Gardens III/IV: conservative treatment rarely indicated. SURGERY – anatomical reduction impaction stable internal fixation
Treatment plans as per Garden’s Classification
04/12/2023 28
Reduction techniques
Closed reduction with hip in extension• Whitman’s method
• Massie• Mc Elevenny• Deyerle
Closed reduction with hip in flexion
• Lead better method
• Smith Peterson• Flynn
04/12/2023 29
INTERNAL FIXATION for fracture neck of femurChoices of implants for internal fixation:Multiple pins (Knowles,Moore): - - impacted fractures - medically unfit persons - fractures in children.ASNIS: - provide improved pullout and bending and torque strengths.*Fixed angle nailSliding or Telescopic nails (Dynamic Hip Screws): nail offers collapsibility continuous impaction at the fracture site lessen the chances of nail penetration.
04/12/2023 30
DHSMS
04/12/2023 31
Blade plate fixation:
04/12/2023 32
Complications of Internal Fixation
InfectionNonunionAvascular necrosisLoose fixation
04/12/2023 33
Meyer’s Muscle Pedicle Graft:
04/12/2023 34
COMPLICATIONS OF FEMORAL NECK FRACTURE
Thromboembolism
Non union:1/3 cases heal with OR+IFRate – 85-95% *Causes:• Inaccurate reduction• Poor Internal Fixation• Lack of Cambium layer in periosteum.• Avascularity of femoral head• Posterior wall communition
Incidece; 40%
04/12/2023 35
Clinical features:• Unable to bear weight on affected side• Trendelenberg test +ve• Telescopic test +ve• Wasting of muscles• Minimal shortening of affected limb.
04/12/2023 36
Treatment
Head is viable
Head is not viable
Osteotomy Acetabular cartilage viable
Acetabular cartilage not viable
THRHemireplacement arthroplastyBipolar arthroplasty
04/12/2023 37
AVASCULAR NECROSIS
Due to actual AVN: 2˚ to ischemiaLate segmental collapse: due to collapse of subchondral and articular cartilage.
INCIDENCE: Aseptic necrosis: 66-84%Late segmental collapse: 7-27%Survival of head depends upon:• Uninjured vascular supply• Revascularization
04/12/2023 38
04/12/2023 39
Investigations: RadiographyBonescan
Treatment: • Symptomatic treatement: bed rest, NSAIDS.• Displacement or Angulation Osteotomy in early stages.
• Hemireplacement arthroplasty• THR.
04/12/2023 40
Osteotomy
04/12/2023 41
Hemiarthroplasty
04/12/2023 42
04/12/2023 43
04/12/2023 44
04/12/2023 45
• An unsolved problem• Fracture in elderly• Majority due to trivial fall.• Garden’s classificatio is widely accepted.
• It is an Orthopaedic Emergency.• Speed is the watchword in management.
• Early anatomical reduction,impaction and rigid internal fixation are the aim of treatment.
• DHS and Multiple cannulated cancellous screws is the currently accepted method of fixation.
• Nonunion ad AVN are very common.
Fracture neck of femur at a glance
04/12/2023 46