Orthopedic Presentation

NECK OF FEMUR FRACTURES/HIP FRACTURE

PRESENTER : ABDUL MUSHIB IBRAHIM

UPSM

DEFINITION

• Fracture that occurs in the proximal end of the femur.

ANATOMY OF FEMUR

• FUNCTION: for transmission of Body Weight.

• BLOOD SUPPLY Femoral Artery Profunda Femoris

Medical Circumflex Femoral Artery Lateral Epiphyseal, Superior metaphyseal & Inferior Metaphyseal Arteties.

FEMORAL NECK FRACTURES

Aetiology

• Metabolic bone diseases such as: Osteoporosis Paget's disease Osteomalacia Osteogenesis imperfecta• Benign or malignant primary bone tumours(R)• Infection (R)

FEMORAL NECK FRACTURE

• 2 broad groups of fractures are recognized in the neck of femur.

1.Intracapsular Fractures2.Extracapsular Fractures

1-Intracapsular Fractures

• Divided according to the level of fracture line in the neck as follows:

1- Subcapital.2-Transcervical3-Basal

2-Extracapsular Fractures

• Are all grouped as trochanteric fractures of various types.

Intracapsular Discussion

• Also called High Fracture Neck of Femur.• The Proximal fragment losses part of its blood

supply hence union of this fracture is difficult.

Intracapsular fractures are a headache becoz:

• Blood vessels are damaged thus no blood supply.• Intramedullary vessels are nearly alwasys torn.• Ligamentum teres-supply minimal blood which is

usually insignificant.• There is no contact with soft tissue thus response

to injury & callus formation is weak.• Blood remains inside the joint capsule, increasing

intracapsular presure & futher damaging the femoral head.

• Synovial fluid hinders clotting.

CLASSIFICATION (1961)

• Relies upon the appearance of the Hip on AP X-ray view.

• Used to determine appropriate Rx.

GARDENS CLASSIFICATION• 4 Classes

GRADE I

• Incomplete Fracture of the Neck

GRADE II

• Complete without displacement.

GRADE III

• Complete with partial displacement.

GRADE IV

• Complete Fracture with Full Displacement.

Sub Capital Fractures

• 1-PAUWEL’S• TYPE I-Obliquity 0-30˚• TYPE II-Obliquity 30-50˚• TYPE III-Obliquity > 70˚

* The > obliquity, the ↑ Chance of delayed of Non –Union.

CLINICAL FEATURES• HISTORY Elderly, with History of Fall. Unable to Walk.

• PHYSICAL EXAMINATION On Inspection: Injured leg lies in a position of

external rotation & there is shortening of leg.

CLINICAL FEATURES

• On Palpation: Tenderness over anterior & lateral aspects of the Hip joint.

-Greater Trochanter is elevated on the affected side.

-All Movements are painful except in RARE case of IMPACTED type fracture.

Diagnosing

• X-Ray AP and lateral views .• CT Scan situations where a hip fracture is suspected

but is not obvious on x-ray.• Pre-operative general investigation: blood tests, ECG and chest x-ray

MANAGEMENT

• NON OPERATIVE CONSERVATIVE

• OPERATIVE SURGICAL

• MANAGEMENT IN CHILDREN

Non Operative-Conservative

• Conservative treatment have poor capacity for union due to the following factors:

A.Interference with Blood supply to the proximal fragment.

B.Difficulty in controlling the small proximal fragment.

C.Lack of organization of the fracture hematoma due to the presence of the synovial fluid.

Operative Treatment

• 2 Principles followed:1.Anatomical Reduction2.Internal Fixation

-Compression Screws-In older PX-replacing the head of femur by

metal prothesis.

Operative

MANAGEMENT IN CHILDREN

• Fracture is reduced by manipulation.• Leg is immobolised in full plaster in abduction

position for 8-10 weeks.• When internal Fixation indicated then Austin

Moore’s Pins are used.

COMPLICATION

• Avascular Necrosis

2-EXTRACAPSULAR FRACTURE

• Also called Low Fracture of Neck of Femur.• Blood Supply to proximal fragment is not

interfered with.• There is greater area of contact between the 2

fragments thus fractures unite easily.• Mal-united fracture presents with Coxa Vera

Deformity.

CLINICAL FEATURES

• HISTORY• INSPECTION: Injured leg lies externally

rotated.• The Degree of rotation is more then in the

intracapsular frature.• Marked local swelling & echymoses over the

trochanteric area.• All movements of the hip is painful & limited.

Diagnosing

• X-Ray AP and lateral views .• CT Scan situations where a hip fracture is suspected

but is not obvious on x-ray.• Pre-operative general investigation: blood tests, ECG and chest x-ray

MANAGEMENT

• Principle is1.Reduction of fracture2.Maintaince of fragment in good position.

• CONSEVATIVE TREATMENT- Application of continous skeletal traction.

OPERATIVE TREATMENT- Manipulative reduction & internal fixation.

COMPLICATION

• Malunion with coxa vera.

Thank You

• Referance:1- Orthopedic Book. Vol 12-http://www.e-radiography.net/radpath/f/

femur%20fracture/neck_of_femur.htm