nof anatomy
TRANSCRIPT
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Anatomy and classification neck femur in young adult
Dr.Rajesh Kumar RajnishDept. of Orthopaedics,
UCMS & GTB hospital, Delhi
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Introduction
• Fractures of hip have been described as an orthopaedic epidemic
• Estimated global incidence-1.66 million fractures(1990).
• Expected to increase to 6.26 million fractures by 2050.
• Approx. 50% of these-intracapsular fractures.
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Hip joint
• Ball-and-socket joint composed of head of femur and acetabulum
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AnatomyProximal femur
The outline of the proximal end of the femur is characterised by almost spherical head, slightly flattened neck and two trochanters with communicating intertrochanteric ridge
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• Physeal closure age 16yrs
• Neck-shaft angle 130°-135° <Coxa vera > Coxa valga
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Anteversion (Medial femoral torsion)
• Angle subtended by femoral neck to the transcondylar axis of the knee joint.
15°- 25°
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Calcar Femorale• Dense vertical palte of bone
from Posteromedial femoral shaft under LT to GT
• Reinforcing posterinferior femoral neck
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Trabecular patterns
• Principal Compressive Group
• Principal Tensile Group • Greater Trochanteric
Group• Secondary Compressive
Group• Secondary Tensile Group• Ward's Triangle
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Blood supply
Crock described three major groups of vessels
• Extracapsular arterial ring• Ascending cervical branches of arterial
ring • Artery of ligamentum teres
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• Formed at base of femoral neck at level of capsular attachment
• Posteriorly – branch of medial circumflex femoral artery
• Anteriorly – ring is completed by branches of lateral circumflex femoral artery
• Minor contributions Superior and inferior gluteal arteries
Extracapsular ring
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Medial circumflex femoral artery
It is a branch of• profunda femoral artery • femoral artery (rarely) • Participates in formation of extracapsular ring• Major contributor in extracapsular ring
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Medial circumflex femoral artery
Gives of various branches – Medial ascending cervical arteries (inferior
retinacular, medial metaphyseal)– Posterior ascending cervical arteries– Arterial branches to superior gluteal artery– Branches to greater trochanter
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Lateral ascending cervical artery– Terminal branch– Gives off metaphyseal branches to neck &
continues as lateral epiphyseal artery, a prominent vessel, for femoral head
– Provides most of blood supply to femoral head in children 3 to 10 years of age
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Lateral circumflex femoral artery
It is a branch of• Profunda femoral artery • Femoral artery (rarely)• Participates in formation of extracapsular ring• Gives anterior ascending cervical arteries to
neck and femoral head
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Ascending cervical arteries
• Also known as retinacular arteries (Within the capsule), described initially by Weitbrecht
• Derived from extracapsular arterial ring • Enters capsule at base of neck • Subsynovial course • Supplies metaphysis and epiphysis
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• Ascend on surface of femoral neck in four groups:– Anterior– Posterior– Medial– Lateral
• Lateral group most important- largest contributor to femoral head. If damaged More chances of AVN
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Subsynovial intra-articular arterial ring
• At the articular margin of femoral head
• Formed by vessels that penetrate the head (epiphyseal arteries)
• Lateral epiphyseal vessels supplying lateral weight-bearing portion most important
• Joined by vessels from ligamentum teres.
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Artery of ligamentum teres
• Branch of Obturator artery or Medial circumflex femoral
artery• Gives blood supply to a small area of head of
the femur• Contribute little blood supply to femoral head
until age 8 and then only about 20% as an adult .
• Not sufficient to maintain blood supply of feoral head.
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Blood supply of metaphysis
• Extracapsular arterial ring • Anastomoses with intramedullary branches of
the superior nutrient artery system• Branches of the ascending cervical arteries• Subsynovial intra-articular ring (descending
metaphyseal arteries)
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Significance Blood supply of metaphysis
• Excellent vascular supply to metaphysis explains the absence of avascular changes in the femoral neck as opposed to the head.
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CLASSIFICATION
ANATOMICAL LOCATION • Subcapital• Transcervical• Basicervical (base of the neck fracture)
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Classification
Pauwels Classification
• Based on the angle of the fracture line across the femoral neck.
• Relates to biomechanical stability• Predictive of more fixation failure and
nonunion with increasing angle • More vertical fracture has more shear force
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Classification
• Pauwels – Angle describes vertical shear vector
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Garden Classification
• Based on the degree of displacement of the fracture noted on pre-reduction antero-posterior x-rays in relation to trabecular line in femoral head to those in acetabulum
• Most frequently used• Four groups
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Garden Classification
I Valgus impacted or incomplete
II Complete Non-displaced
III Complete Partial displacement
IV Complete Full displacement
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Garden Classification
• Poor interobserver and intraobserver reliability.• Outcome of undispalced and displaced
fractures are independent of grade assinged.• Modified to:– Non-displaced
• Garden I (valgus impacted)• Garden II (non-displaced)
– Displaced• Garden III and IV
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Orthopaedic Trauma Association (OTA) Classification
• Alphanumeric fracture classification• Femoral neck fractures are designated type 31B• 31 is the proximal femur group and B the
femoral neck subgroup• Its complexity limits its usefulness in routine
clinical practice• Mainly used for research purposes• Neither useful in selecting treatment option nor
in predicting outcome.
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• B1 group fracture is undisplaced to minimally displaced subcapital fracture
• B2 group includes transcervical fractures through the middle or base of the neck
• B3 group includes all displaced non-impacted subcapital fractures
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Singh Index
• Based on the pattern of proximal femoral trabecular line
• A method of estimating degree of osteoporosis• Six separate categories
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Grade VI:• All normal trabecular groups are visible• Upper end of femur seems to be completely occupied by
cancellous bone
Grade V:• Principal tensile & principal compressive trabeculae is
accentuated• Ward's triangle appears prominent
Grade IV:• Principal tensile trabeculae are markedly reduced but can still
be traced from lateral cortex to upper part of the femoral neck
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• Grade III:
• A break in the continuity of the principal tensile trabeculae opposite the greater trochanter
• this grade indicates definite osteoporosis
Grade II:• Only principal compressive trabeculae stand out
prominently
Grade I:• principal compressive trabeculae are markedly reduced
in number and are no longer prominent
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Limitations
• Little practical value.• Poor interobserver and intraobserver leves of
agreement• Does not correlate with bone density as
measured.
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Imaging and other Diagnostic Studies
Radiography •Preferred initial modality in evaluating femoral neck fractures•AP and Lateral views•Lateral view gives idea regarding dispalcement
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Limitations
• Spiral fractures are difficult to assess on a
single view.• Comminution is not easily demonstrated• Some stress fractures are simply not visible on
plain images.
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COMPUTED TOMOGRAPHY• Because of its superior resolution, cross-sectional
capabilities, and amenability to image reconstruction in the coronal and saggittal planes,
• Useful for assessing fracture comminution preoperatively and in determining the extent of union (or lack there of) postoperatively.
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MRI
• In cases of doubtful diagnosis MRI may be useful additional modality.
• Can also show soft tissue problems associated with hip pain in absence of fracture.
Limitations • Relative lack of widespread availability• Its higher costs• Exclusion of patients with cardiac pacemakers
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Nuclear Medicine
• In past technititium bone scan was used in situations when plane radiography not able to show fracture.
• Usually show positive result in fracture neck femur.
• False negative results in osteopenic bone if carried out within 48-72 hrs of injury.
• Sensitive but not specific • CT scan is more accurate