re-written by: daniel habashi femoral neck fractures

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  • Slide 1
  • Re-written by: Daniel Habashi Femoral neck fractures
  • Slide 2
  • Anatomy Physeal closure at the age of 16 Neck-shaft angle 130 +/- 7 . Anteversion 10 degr +/- 7 degr Calcar femorale Posteromedial Dense plate of bone
  • Slide 3
  • Blood Supply Greater fracture displacement = greater risk of vascular disruption to femoral head Revascularization of the head Intact vessels Vascular ingrowths across the fracture site
  • Slide 4
  • Epidemiology 250 thousand hip fractures annually
  • Slide 5
  • Classification Pauwels Angle describes vertical shear vector Type 1 = 30 Type 2 = 50 Type 3 = 70
  • Slide 6
  • Classification Garden (1961) I Valgus impacted or incomplete II Complete non displaced III Complete partial displacement IV complete full displacement ** portends risk of AVN and nonunion
  • Slide 7
  • Classification Functional classification Stable Impacted Garden I Non-displaced Garden II Unstable Displaced Garden III and IV
  • Slide 8
  • Treatment Non-Operative Very limited role Activity modification Skeletal traction Operative ORIF Hemiarthroplasty Total hip replacement
  • Slide 9
  • Decision making variables Patient characteristics Young (under 65) High energy injuries Often multi-trauma High Pauwels angle (vertical shear pattern) Elderly Lower energy injury Comorbidities Pre-existing hip disease Fracture characteristics Stable Unstable
  • Slide 10
  • Young patients Non-displaced fractures At risk for secondary displacement Urgent ORIF recommended OPEN REDUCTION INTERNAL FIXATION Displaced fractures Patients native femoral head best AVN related to duration and degree of displacement Irreversible cell death after 6-12 hours Emergent ORIF recommended
  • Slide 11
  • Pre-operative considerations Regional vs general anesthesia Mortality / long term outcome No difference
  • Slide 12
  • Pre-operative considerations Surgical timing Surgical delay for medical clearance in relatively healthy patients probably not warranted Increased mortality, complications, length of stay Surgical delay up to 72 hours for medical stabilization warranted in unhealthy patients
  • Slide 13
  • Non-displaced fractures ORIF standard of care Predictable healing Nonunion under 5% Minimal complications AVN under 8% Infection under 5% Relatively quick procedure Minimal blood loss Early mobilization Unrestricted weight bearing with assistive device PRN
  • Slide 14
  • Approach for open reduction SMITH-PETERSON Anterior approach Best for transcervical
  • Slide 15
  • Sliding compression screw fixation Compression hip screws Sacrifices large amount of bone May injure blood supply Biomechanically superior in cadavers Anti-rotation screw often needed Increased cost and operative time No clinical advantage over parallel screws May have role in high energy / vertical shear fractures
  • Slide 16
  • Hemiarthroplasty Unipolar vs. Bipolar Bipolar theoretical advantages Lower dislocation rate Less acetabular wear / protrusio Less pain More motion
  • Slide 17
  • Hemiarthroplasty cemented vs. non- cemented Cement (PMMA) Improved mobility, function, walking aids Most studies show no difference in morbidity / mortality Sudden intra-op cardiac death risk slightly increased:
  • Slide 18
  • Cemented vs. non-cemented Conclusion Cement gives better results Function Mobility Implant stability Pain Cost-effective Low risk of sudden cardiac death Use cement with caution
  • Slide 19
  • Pre-operative considerations Surgical approach Posterior approach to hip 60% higher short-term mortality vs. anterior Dislocation rate No significant difference
  • Slide 20
  • ORIF or Replacement Prospective, randomized study ORIF vs. cemented bipolar hemi vs. THA Ambulatory patients > 60 years of age
  • Slide 21
  • Stress Fractures Patient population Females 4-10 times more likely
  • Slide 22
  • Stress fractures Clinical presentation Activity weight bearing related Anterior groin pain Limited ROM at extremes +/- antalgic gait Must evaluate back, knee, contralateral hip
  • Slide 23
  • Stress fractures Imaging Plain radiographs are negative in up to 66% Bone scan Sensitivity 93-100% Specificity 76-95% MRI 100% sensitive / specific Also differentiates synovitis, etc
  • Slide 24
  • Stress fractures - complications Tension sided and compression sided fxs over 50% treated non-operatively Varus malunion
  • Slide 25
  • Femoral neck nonunion Definition: not healed by one year 0-5%
  • Slide 26
  • And then he just finished it and thats it.