CASE REPORT

FEMORAL NECK FRACTURE / FRACTURE OF COLLUM FEMUR

Disusun untuk memenuhi sebagian tugas kepaniteraan klinik bagian

Ilmu Bedah RSUD Kendal

Disusun oleh :
Abdul Roni
01.211.6305

Pembimbing :
dr. Wisnu Murti, Sp.OT.

FAKULTAS KEDOKTERAN
UNIVERSITAS ISLAM SULTAN AGUNG
SEMARANG
 2015HALAMAN PENGESAHAN

Nama : Abdul Roni

NIM : 012116305
Fakultas : Kedokteran
Universitas : Universitas Islam Sultan Agung ( UNISSULA )
Tingkat : Program Pendidikan Profesi Dokter
Bagian : Ilmu Bedah
Judul : Femoral Neck Fracture / Fracture of Collum Femur

Semarang, November 2015

Mengetahui dan Menyetujui
Pembimbing Kepaniteraan Klinik
Bagian Ilmu Bedah RSUD Kendal

Pembimbing,

dr. Wisnu Murti, Sp.OT.

 CHAPTER I

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; however, hip fractures are much more common and are often devastating injuries.
Elderly osteoporotic women are at greatest risk.1

Stress fractures of the femoral neck are uncommon, but they may have serious
consequences. Koval and Zuckerman noted the age-adjusted incidence of femoral neck
fractures in the United States is 63.3 cases per 100,000 person-years for women and 27.7
cases per 100,000 person-years for men. Femoral neck fractures in elderly patients occur most
commonly after minor falls or twisting injuries, and they are more common in women.2

These fractures are often associated with multiple injuries and high rates of avascular
necrosis and nonunion. Results of this injury depend on (1) the extent of injury (ie, amount of
displacement, amount of comminution, whether circulation has been disturbed), (2) the
adequacy of the reduction, and (3) the adequacy of fixation. Recognition of the disabling
complications of femoral neck fractures requires meticulous attention to detail in their
management.1

Femoral neck fractures are a subset of proximal femoral fractures. The femoral neck is
the weakest part of the femur. Since disruption of blood supply to the femoral head is
dependant on the type of fracture and causes significant morbidity, diagnosis and
classification of these fractures is important.3
 CHAPTER II

PATIENTS STATUS

I. IDENTITY
a. Name : Mrs. Ruci
b. Age : 70 years old
c. Sex : Female
d. Religion : Islam
e. Job : Housewife
f. Address : Cepiring, Kendal
g. Room : Flamboyan
h. Register number : 484544
i. Date of in patient : November1, 2015

II. ANAMNESA
Autoanamnesa and alloanamnesa with the patient and the patients family held on
November 3, 2015 in flamboyn room and also supported by medical records.

Primary Survey :
A (Airway) : Airway and cervical spine stabilisation (Cleared)
B (Breathing) : Adequate breathing (respiration rate : 24x/minutes)
nothing abnormality
Circulation (C) : Adequate circulation
Disability (D) : E4V5M6 , pupil refleks +/+ isokor
Exposure (E) : Abnormality on lower right extremity

Main complaints : Vomiting blood

OtherComplaints : Defecating blood, Pain in right hip joint and can not walk

Present status :
Patient come to emergency roomaccompanied by her family because of
vomiting blood. The symptomps are felt since more about six hours ago. Patient
vomiting blood had twice and the color are fresh red. At previous, patient drink
some drug to lessen her pain. Patient felt pain because of fall in the bathroom since
more about one month. Patient falls with the upper right thight hit the floor.Patient
complaining a pain on his right hip joint, swollen and hard to move it. Beside that,
patient also feel pain of his right waist. After that patient didnt immediately taken
to hospital, but until now patient often consume some drug to lessen her pain.

Medical condition history:

- History of asthma and allergies : denied
 - History of heart disease : denied
- History of hypertension : denied
- History of diabetes : denied

Family history:
- History of asthma and allergies : denied
- History of heart disease : denied
- History of hypertension : denied
- History of diabetes : denied

Socioeconomic status:
Patients did not work. The cost of treatment using SKTM.
Impression: not enough in socioeconomic.

III. Physical Examination

Held on November 3, 2015 at 14:00 pm in Flamboyan room of Kendal Hospital

General Condition : Looks weak

Awareness: Composmentis, GCS 15
Vital Signs
1. Blood pressure : 110/80 mmHg
2. Heart rate : 80 x / minute, regular
3. Temperature : 36,2 oC
4. Breathing : 24 x / minute

Physical Assessment
General Appearance : clean in appearance, well groomed, and cooperative
Skin : brown, skin turgor normal
Head : mesocephal form, injuries (-)
Eyes : isokor pupil (d : 3mm/3mm), light reflex (+/+), palpebral conjungtival
pallor (+/+), sclera jaundice (-/-)
Ears : Discharge (-/-)
Nose : septal deviation (-), discharge (-/-),
Mouth : Normal, cyanosis (-)
Neck : symmetrical, deviation of the trachea (-), enlarged lymph nodes clear (-), an
enlarged thyroid gland (-)
Chest : normochest, symmetrical
Abdomen : lesion (-), tenderness (+) in the upper and right abdomen
Extremities : Right leg (hip joint) : no edema or lesions but pain and weak
Motor
5 5
2 5
Sensorik
N N
N N
Localized Status oflower extremities in right hip joint region:
Look :
o Skin color : normal
o Edema : (-)
o Pale and wrinkled : (-)
o Vulnus : (-)
o Deformity : (+) eksorotasi, fleksi
Feel :
o skin temperature : normal
o Tenderness : (+)
o Krepitation : (-)
o Dorsalis pedis artery pulsation: (+)
o True leg length right / left : 78 cm / 80 cm
o Apparent leg length right / left : 82 cm / 84 cm
o Anatomical leg length right / left : 37 cm/ 37 cm

Move of femoral dextra :

Aktif :
o Flexion : (-)
o Endorotation : (-)
o Exorotation : (-)
Pasif :
o Flexion : (-)
o Endorotation : (-)
o Exorotation : (-)

IV. Laboratory Results

1. Blood laboratory

Examines Results Normal Results

Hb 7,7 gr% 11,5 16,5 gr%
Leucosite 14.900 cell/mm3 4.000 10.000 cell/mm3
Trombosite 309.000 cell/mm3 150.000 500.000 cell/mm3
Ht 26,5 % 35 49 %

2. EKG
 OMI Anteroseptal
3. Radiology : X- Ray Pelvic

Interpretation : Fr. Collum Femur Dextra

V. DIAGNOSE
Hematamesis
Hematoxezia
Dispepsia ec Gastropathy NSAIDs
Fr. Collum Femur Dextra

VI. PLANNING THERAPY

 Medical
Soft Diit 1700 kkal
IVFD Fatrolit 20 drops per minute
Omeprazole 1 amp per 12 hours IV
Sucralfat 40 mg
PRC transfusion 2 kolf
Non-Medical :
Conservative :
NVD evaluation
Vital Sign evaluation
Operative :
Consul to orthopedic
Can be planned hemiarthroplasty

CHAPTER III

CONTENTS REVIEW

A. Functional Anatomy
The femoral aspect of the hip is made up of the femoral head with its articular
cartilage and the femoral neck, which connects the head to the shaft in the region of the
lesser and greater trochanters. The synovial membrane incorporates the entire femoral
head and the anterior neck, but only the proximal half of the posterior neck. The shape
and size of the femoral neck vary widely.
Crock standardized the nomenclature of the vessels around the base of the femoral
neck. The blood supply to the proximal end of the femur is divided into 3 major groups.
The first is the extracapsular arterial ring located at the base of the femoral neck. The
second is the ascending cervical branches of the arterial ring on the surface of the femoral
neck. The third is the arteries of the ligamentum teres.
A large branch of the medial femoral circumflex artery forms the extracapsular
arterial ring posteriorly and anteriorly by a branch from the lateral femoral circumflex
artery. The ascending cervical branches ascend on the surface on the femoral neck
anteriorly along the intertrochanteric line. Posteriorly, the cervical branches run under the
synovial reflection toward the rim of the articular cartilage, which demarcates the femoral
neck from its head. The lateral vessels are the most vulnerable to injury in femoral neck
fractures.
 A second ring of vessels is formed as the ascending cervical vessels approach the
articular margin of the femoral head. From this second ring of vessels, the epiphyseal
arteries are formed. The lateral epiphyseal arterial group supplies the lateral weight-
bearing portion of the femoral head. The epiphyseal vessels are joined by the inferior
metaphyseal vessels and vessels from the ligamentum teres.
Femoral neck fractures frequently disrupt the blood supply to the femoral head (see
images below). The superior retinacular and lateral epiphyseal vessels are the most
important sources of this blood supply. Widely displaced intracapsular hip fractures tear
the synovium and the surrounding vessels. The progressive disruption of the blood supply
can lead to serious clinical conditions and complications, including osteonecrosis and
nonunion.
Femoral neck fractures are usually intracapsular. The femoral neck has essentially
no periosteal layer; hence, all healing is endosteal in origin. The synovial fluid bathing
the fracture may interfere with the healing process. Angiogenic-inhibiting factors in
synovial fluid can inhibit fracture repair. These factors, along with the precarious blood
supply to the femoral head, make healing unpredictable and nonunions fairly frequent.

B. Bone Physiology
Bone is a dynamic tissue, which continually reacts to stressful events. According to
data from Maitra and Johnson, stress fractures result from an imbalance between bone
resorption and bone deposition during the host bone response to repeated stressful
events.4 Most cortical stress involves tension or torsion; however, bone is weaker in
tension and tends to fail by fracturing along a cement line.
Maitra and Johnson went on to report that tension forces promote osteoclastic
resorption, whereas compressive forces promote an osteoblastic response.4 With repeated
 stress, new bone formation cannot keep pace with bone resorption. This inability to keep
up results in thinning and weakening of cortical bone, with propagation of cracks through
cement lines, and, eventually, the development of microfractures. Without proper rest to
correct this imbalance, these microfractures can progress to clinical fractures, the sine qua
non of overuse.
A stress fracture is the result of a dynamic process over time, unlike an acute
fracture, which is usually the result of a single supraphysiologic event. Markey reported
that stress fractures can be described as a normal host response to abnormal stress, and
this is different from insufficiency fractures, which are an abnormal host response to
normal stresses.5

C. Mechanism
Most commonly6 :
falls in the elderly
significant trauma (e.g. motor vehicle collisions) in younger patients

In elderly patients, the mechanism of injury various from falls directly on to the hip
to a twisting mechanism in which the patients foot is planted and the body rotates. There
is generally deficient elastic resistance in the fractured bone.7
The mechanism in young patients is predominantly axial loading during high force
trauma, with an abducted hip during injury causing a neck of femur fracture and an
adducted hip causing a hip fracture-dislocation.6

D. Causes
Training errors are the most common risk factors for femoral neck fractures,
including a sudden increase in the quantity or intensity of training and the introduction of
a new activity. Other factors include low bone density, abnormal body composition,
dietary deficiencies, biomechanical abnormalities, and menstrual irregularities.
Predisposing factors, such as anatomic variations, relative osteopenia, poor physical
conditioning, systemic medical conditions that demineralize bone, or temporary
inactivity, can make bone more susceptible to stress fractures. As reported by
Monteleone, studies have indicated that women have an increased incidence of stress
fractures, which may be the result of anatomic variations.8 Women tend to direct axial
force during weight bearing along different axes of long bones compared with men.
Women also have 25% less muscle mass per body weight than men. This may
concentrate, rather than dissipate, the stabilizing forces through the bony anatomy.
Markey reported that Hersman et al documented women have a higher incidence of
stress fractures.5 This higher incidence is partly a result of mechanical differences and
 anatomic variations between men and women. Differences in women include various
stride lengths, number of strides per distance, a wider pelvis, coxa vara, and genu
valgum.
Exercise-induced endocrine abnormalities are well known to result in amenorrhea or
nutritional deficiencies, which can lead to bone demineralization and can place these
patients at risk for various overuse injuries. Stress fractures, especially in trabecular
bone, have shown a decrease in bone mineral content. This decrease can be
reproduced by a decrease in circulating estrogen, which is observed in amenorrheic
female athletes. Lack of protective estrogen leads to a decrease in bone mass. The
female athlete triad of amenorrhea, osteoporosis, and disordered eating affects many
active women. Irreversible bone loss places the patient at a higher risk for fractures.
Most people are not competitive athletes and may not be at a level of optimum
fitness. Individuals often force themselves to participate at a level for which they are
not physically fit. Flexibility, muscle strength, and neuromuscular coordination
contribute to injuries when individuals are not properly trained.

E. Classification
In 1961, Garden described the classification of femoral neck fractures. In this
classification, femoral neck fractures are divided into the following 4 grades based on the
degree of displacement of the fracture fragment:
Grade I is an incomplete or valgus impacted fracture.
Grade II is a complete fracture without bone displacement.
Grade III is a complete fracture with partial displacement of the fracture fragments.
Grade IV is a complete fracture with total displacement of the fracture fragments.

Frandersen et al concluded that clinically differentiating the 4 grades of fractures is

difficult. Multiple observers were able to completely agree on the Garden classification in
 only 22% of the cases. Hence, classifying femoral neck fractures as nondisplaced
(Garden grades I or II) or displaced (Garden grades III or IV) is more accurate.
Devas, in 1965, classified stress fractures into 2 types that differ radiologically and
have different clinical outcomes.9 The first is the tension stress fracture, which results in a
transverse fracture directed perpendicular to the line of force transmitted in the femoral
neck and originates at the superior surface of the femoral neck. This fracture pattern is at
increased risk for displacement. These fractures carry a risk for further advancement of
the fracture line superiorly and eventual displacement, leading to nonunion and avascular
necrosis. Hence, early diagnosis and treatment are essential.
The second type is a compression type of femoral neck stress fracture, which has
evidence of internal callus formation on radiographic images. The fracture is usually
located at the inferior margin of the femoral neck without cortical discontinuity. This
fracture pattern is thought to be mechanically stable. The compression fracture occurs
mostly in younger patients, and continued stress does not usually cause displacement.
The earliest radiographic evidence of a compression stress fracture is usually a haze of
internal callus in the inferior cortex of the femoral neck. Eventually, a small fracture line
appears in this area, and it gradually scleroses.
Fullerton and Snowdy described a femoral neck stress fracture classification with
the following 3 categories10 : (1) tension, (2) compression, and (3) displaced, as depicted
below. Tension fractures occur on the superolateral aspect of femoral neck and are at high
risk for displacement. Compression fractures are similar to those described by Devas,
which occur on the inferomedial aspect of the femoral neck and have a low risk for
displacement.

F. Clinical Presentatition
1. History
Establishing a diagnosis in an athlete experiencing groin or hip pain with
ambulation begins with a detailed history and physical examination. The basic
history should include a temporal account of the patient's symptoms and a complete
description of complaints. The clinician should ask the patient whether the symptoms
are associated with participation in a specific sport or activity. A comprehensive
training history should be obtained, and recent changes in activity level, equipment,
intensity levels, and technique should be noted.
A careful menstrual history should be obtained from all female patients.
Amenorrhea is often associated with decreased serum estrogen levels. Lack of
protective estrogen leads to decreases in bone mass. The female athlete triad of
amenorrhea, osteoporosis, and disordered eating affects many active women. Signs
and symptoms of the female triad include the following:
Fatigue
Anemia
Depression
Cold intolerance
Lanugo
Eroded tooth enamel
Use of laxatives
Poor eating habits can lead to disturbances of the endocrine, cardiovascular,
and gastrointestinal systems and to irreversible bone loss. The clinician should be
alert to stress fractures and understand the possible signs of the female athlete triad,
particularly noting unusual fractures that occur from minimal trauma.Most athletes
describe an insidious onset of pain over 2-3 weeks, which corresponds with a recent
change in training or equipment. Typically, runners have recently increased their
mileage or intensity, changed their terrain, or switched running shoes. The physician
should inquire about the individual's training log and mileage.
Features common to all stress fractures include the following:
Participation in repetitive cyclic activity
Insidious onset of pain
Recent change in activity or equipment
Atraumatic history
Pain with weight bearing
Relief of pain with rest
Menstrual irregularities
Predisposing osteopenia
Patients usually report a history of gradual- or acute-onset anterior hip, groin,
or knee pain that worsens with exercise. A typical feature of a stress fracture is a
history of exercise-related localized pain that increases with activity and either abates
with rest or persists with less forceful activity. Pain progressively worsens with
 continued training. The pain is reproducible with repeated activity, and it is relieved
with rest.
The examiner should inquire whether these symptoms have occurred in the
past, and, if so, whether the patient tried using ice or heat or any medications (eg,
acetaminophen, aspirin, nonsteroidal anti-inflammatory drugs [NSAIDs]). Questions
should be asked about previous participation in a physical therapy program, and the
physician should attempt to understand the treatment plan used.

2. Physical
A comprehensive physical examination of the athlete with groin or hip pain
should include an in-depth evaluation of the neurologic and musculoskeletal systems.
Combining the findings from the history and physical examination should increase
the overall predictive value of the evaluation process. The degree and type of fracture
usually dictate the severity of clinical deformity.
Inspection: The examination begins with observation of the patient during the
history portion of the evaluation. Note any grimacing or abnormal gait patterns.
Patients with displaced femoral neck fractures are usually unable to stand or
ambulate. Observe the iliac crest for any difference in height, which may
indicate a functional leg-length discrepancy. Alignment and length of the
extremity is usually normal; however, the classic presentation of patients with
displaced fractures is a shortened and externally rotated extremity. Assessing for
any muscle atrophy or asymmetry is also important.

Palpation: Determine any tender points in the anterior groin and hip regions.
The most common physical feature of stress fractures in general is local bony
tenderness; however, the neck of the femur is relatively deep and bony pain or
tenderness may be absent. Palpate the trochanter for any tenderness that might
indicate trochanteric bursitis.

Range of motion: Determine the range of motion for hip flexion, extension,
abduction, adduction, and internal and external rotation and for knee flexion and
extension. Findings include pain and restriction at the end of passive range of
motion at the hip. Perform a passive straight-leg raise, Thomas, and rectus
femoris stretch test. Examine the iliotibial band by performing the Ober test.

In addition to range of motion of the hip, assess the spine and other lower
extremity joints, because pain referral patterns may be confusing. Examine the
 low back both actively and passively, looking at forward flexion, side bending,
and extension. Perform a straight-leg raise test and tests for the Lasegue and
Bragard signs. A patient with anterior thigh and knee pain may actually have
pathology at the hip joint. Reproduction of the patient's pain with hip internal
rotation, external rotation, or other provocative maneuvers may further
distinguish hip pathology from spine involvement.

Muscle strength: Manual muscle testing is important to determine whether

weakness is present and whether the distribution of weakness corresponds to any
nerve injuries. Additionally, evaluate the dynamic stabilizers of the pelvis,
including hip flexors, extensors, and abductors. A Trendelenburg gait pattern is
indicative of hip abduction weakness. Test hip flexion (L2, L3), extension (L5,
S1, S2), abduction (L4, L5, S1), and adduction (L3, L4).

Sensory examination: Upon sensory examination, a dermatomal decrease or

loss of sensation can indicate or exclude any specific nerve damage. Muscle
stretch reflexes are helpful in the evaluation of patients presenting with hip pain.
Abnormal reflexes can indicate nerve root abnormality. The asymmetry of
reflexes is most significant; therefore, a patient's reflexes must be compared with
the contralateral side.
Hop test: Approximately 70% of patients with stress fractures of the femur
demonstrate a positive hop test result. The hop test involves the patient hopping
on the affected leg to reproduce symptoms. Other maneuvers that can place a
stress on the femur also may reproduce pain.

3. Supporting Examination
Plain radiographs
Plain radiographs have traditionally been ordered as the initial step in the
workup of hip fractures. The main purpose of x-ray films is to rule out any
obvious fractures and to determine the site and extent of the fracture. Plain
radiographs have poor sensitivity. The presence of periosteal bone formation,
sclerosis, callus, or a fracture line may indicate a stress fracture; however, a plain
radiograph may appear normal in a patient with a femoral neck stress fracture,
and radiographic changes may never appear.
Radiographs may show a fracture line on the superior aspect of the
femoral neck, which is the location for tension fractures. Tension fractures must
be distinguished from compression fractures, which, according to Devas9 and
 Fullerton and Snowdy10, are usually located on the inferior aspect of the femoral
neck.
The standard radiographic examination of the hip includes an
anteroposterior view of the hip and pelvis and a cross-table lateral view. The
frog-leg lateral view is poorly tolerated and may result in fracture displacement.
If a femoral neck fracture is suggested, an internal rotation view of the hip may
be helpful to identify nondisplaced or impacted fractures. If a hip fracture is
suggested but not seen on standard x-ray films, a bone scan or magnetic
resonance imaging (MRI) study should be performed.

Bone scanning
Bone scans can be helpful when a stress fracture, tumor, or infection is
suggested. Bone scans are the most sensitive indicator of bone stress, but they
have poor specificity. Shin et al reported that bone scans have a 68% positive
predictive value.11 Bone scans are limited by relatively poor spatial resolution of
the pertinent anatomy of the hip.
In the past, a bone scan was thought to be unreliable before 48-72 hours
after a fracture; however, a study by Holder et al found a sensitivity of 93%,
regardless of the time from injury.12

MRI
MRI has been shown to be accurate in the assessment of occult fractures
and can be reliably performed within 24 hours of the injury; however, these
studies are expensive.
With MRI, a stress fracture typically appears as a fracture line at the
cortex surrounded by an intense zone of edema in the medullary cavity.
In a study by Quinn and McCarthy, T1-weighted MRI findings were
found to be 100% sensitive in patients with equivocal radiographic findings. 13
Shin et al showed that MRI findings are 100% sensitive, specific, and accurate in
identifying a femoral neck fracture.11

4. Differential Diagnose
Slipped Capital Femoral Epiphysis (SCFE)
Slipped capital femoral epiphysis (SCFE) is one of the most important
pediatric and adolescent hip disorders encountered in medical practice. Although
SCFE is a rare condition, an accurate diagnosis combined with immediate treatment
is critical. Despite the fact that the underlying defect may be multifactorial (eg,
 mechanical and constitutional factors), SCFE represents a unique type of instability
of the proximal femoral growth plate. Clinically, the patient may report hip pain,
medial thigh pain, and/or knee pain; an acute or insidious onset of a limp; and
decreased range of motion of the hip.
On plain radiographs, the femoral head is seen displaced, posteriorly and
inferiorly in relation to the femoral neck and within the confines of the acetabulum.
[8] Treatment is primarily operative internal fixation. The goal is to prevent
complications such as avascular necrosis (AVN).

A Klein line is a line drawn along the superior border of the femoral neck that
would normally pass through a portion of the femoral head. If
not, slipped capital femoral epiphysis is diagnosed.

X-ray of a hip following operative

percutaneous fixation of a
slipped capital femoral epiphysis.

G. Treatment
Acute Phase
1. Physical Therapy
The goals of treatment in patients with femoral neck fractures are to promote
healing, to prevent complications, and to return function. The primary goal of fracture
management is to return the patient to his or her premorbid level of function. This is
completed with either surgical or nonsurgical management. Several factors must be
considered before a treatment plan is recommended.
With uncomplicated fractures of the femoral neck, treatment for the athlete
should focus on rest and reversing any training errors. Modifying one's risk factors is
also important at this point to prevent progression of the fracture.
A physical therapist may be useful for reinforcing the physician's instructions
for rest and helping the patient modify his or her training program to allow healing.
 The athlete can maintain physical fitness and mobility by exercising the remaining
extremities and performing nonweight-bearing strengthening activities that do not
cause strain on the affected hip joint. The physical therapist can evaluate the patient
for any gait or anatomic abnormalities that may have predisposed the patient to
development of the fracture. Some patients may need orthotics to prevent excessive
pronation, which causes increased stress on the femoral neck. The physical therapist
completes patient education throughout the rehabilitation process, whether surgical or
nonsurgical treatment is rendered.

2. Medical Issues/Complications
A patient's medical condition must be considered when considering surgical
repairs of femoral neck fractures. If the nonoperative approach is taken, the patient
should be mobilized as soon as possible to avoid the complications of prolonged
immobilization.
Most complications are associated with fracture displacement or a delay in
diagnosis. Complications include delayed union, nonunion, refracture, osteonecrosis,
and avascular necrosis. Early fixation failure (within 3 mo of surgery) occurs in 12-
24% of displaced femoral neck fractures treated by internal fixation.
In a long-term study that followed elderly patients treated with internal
fixation, Blomfeldt et al reported a hip complication rate of 42% and a reoperation
rate of 47% at 48 months.14 Stappaerts found that the most important factors
associated with loss of fixation were advanced age and inaccurate reduction.15
Scheck emphasized the importance of posterior comminution of the femoral
neck as a cause of fixation failure and nonunion.16 Additionally, Heetveld et al
reported that no difference was noted between osteopenic and osteoporotic patients
treated with internal fixation when considering revision to arthroplasty.17

3. Surgical Intervention
The decision for operative or nonoperative treatment of femoral neck
fractures and the decision regarding the type of surgical intervention are based on
many factors.18 This article does not address all these issues. Consultation with an
orthopedist is necessary. Tension fractures are potentially unstable and may require
operative stabilization. Nondisplaced femoral neck fractures may need to be
stabilized with multiple parallel lag screws or pins.
The treatment of a displaced fracture is based on the person's age and activity
level. In the elderly population, premorbid cognitive function, walking ability, and
 independence in activities of daily living should be considered when determining the
optimal method of surgical repair.
Compression fractures are more stable than tension-type fractures, and they
can be treated nonoperatively. Treatment for nondisplaced fractures is bed rest and/or
the use of crutches until passive hip movement is pain free and x-ray films show
evidence of callus formation. Patients should be monitored closely with serial x-ray
films, because the risk of displacement of the fracture is high. Immediate open
reduction and internal fixation is indicated if the fracture widens.
A displaced fracture in a young patient is an orthopedic emergency, and early
open reduction and internal fixation is necessary. The prognosis for returning to a
high level of sport participation is poor in this situation. In elderly patients, treatment
options include open reduction and internal fixation or prosthetic replacement.
The decision between these options should be made on an individual basis. A
series of studies by Blomfeldt et al demonstrated that total hip replacement in elderly
patients with higher cognitive function and a more independent lifestyle was
associated with a significantly lower complication and reoperation rate. 14
Additionally, health-related quality of life was superior at 2 years and equal at 4 years
when compared with patients treated with internal fixation. Conversely, neither total
hip replacement nor internal fixation was found to be advantageous in patients with
severe cognitive impairment. Both prosthetic replacement and internal fixation were
associated with a high rate of mortality and decreased functioning in activities of
daily living.
In patients with an overt fracture line and no displacement on x-ray films, the
initial treatment is complete nonweight-bearing ambulation with crutches. The
clinician should obtain an x-ray film every 2-3 days the first week to detect any
extension or widening of the fracture line. If pain does not resolve or if evidence of
fracture line expansion is noted, internal fixation is indicated. In patients with a
positive bone scan result and no visible fracture line on the x-ray film, the initial
treatment is proportional to the severity of the symptoms. Treatment begins with non
weight-bearing or partial weight-bearing (based on symptoms) activities with
crutches until symptoms resolve.

4. Consultations
For high-risk fractures that require surgical intervention, consultation with an
orthopedic surgeon is necessary.

Recovery Phase
1. Physical Therapy
Once the painful symptoms of a stable femoral neck fracture are controlled
during the acute phase of treatment, strengthening exercises for the hip stabilizers and
associated muscles can be initiated. The main objectives are to improve and restore
range of motion of the hip.
Once the patient is pain free, weight bearing can be progressed. When patients
are able to tolerate partial weight-bearing ambulation, general conditioning workouts,
including swimming and cycling, are permitted. Serial x-ray films are obtained at
weekly intervals until the patient can ambulate with full weight bearing and no pain.
Running is gradually reintroduced, and progression of distance is slow. If pain
occurs, a couple of days of rest are recommended, mileage is reduced, and then
mileage is progressed again depending on the individual's symptoms.
Surgery is indicated for patients with overt fractures or displacement on the
tension side. Usually, fixation with a plate and screws is used. Postoperatively, the
patient rests until pain resolves and then progresses to full activity as healing occurs.
Once the plate is removed, further rehabilitation is needed. Removal of the plate
depends on the age and activity level of the patient. Some patients prefer weight
bearing with crutches. Patients are usually allowed to return to running; however,
contact sports are limited.
Strengthening of the gluteus medius, a hip abductor, is important for
postoperative stability. Other important muscles include the iliopsoas; gluteus
maximus; adductor magnus, longus, and brevis; quadriceps; and hamstrings.
Functional goals include normalizing the patient's gait pattern. Activities are then
progressed to sport-specific training and strengthening.
Maintaining aerobic conditioning throughout the rehabilitation process is
important. If protected or nonweight-bearing ambulation is necessary, then upper
body exercise, such as an upper body ergometer, can be used. Once partial weight-
bearing ambulation is allowed, aquatic training may be used, such as swimming or
deep-water running.
2. Surgical Intervention
Patients with overt fractures or displacement on the tension side require
surgical intervention for proper healing. Generally, internal fixation is required with
the use of a plate and screws.

Maintenance Phase
1. Physical Therapy
The maintenance phase represents the final phase of the rehabilitation process
in patients with femoral neck fractures. Eccentric muscle-strengthening exercises,
 including more dynamic conditioning exercises (eg, with a large gym ball), are added
to the patient's program. In addition, sport-specific training should be incorporated so
that the athlete can maintain muscle balance.

H. Medication
As with all fractures, pain management should be a primary concern. Often,
acetaminophen or an NSAID is prescribed for the acute pain of a fracture. However,
additional pain relief may be necessary if the patient does not have relief with
acetaminophen or NSAIDs alone. In this case, an opiate may be required, particularly for
breakthrough pain. Adjustment of pain medications may be necessary, especially in the
acute phase.

Analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort,
promote pulmonary toilet, and have sedating properties, which are beneficial for patients
who have sustained injuries.
Acetaminophen (Tylenol, Feverall, Tempera, Aspirin-Free Anacin, Tylenol-3)
Indicated for mild to moderate pain. DOC for pain in patients with documented
hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral
anticoagulants.

Ibuprofen (Motrin, Ibuprin)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and
pain by decreasing prostaglandin synthesis.

Oxycodone (OxyContin, Percocet, Roxicet, Roxilox, OxyIR, Tylox, Roxiprin)

Analgesic with multiple actions similar to those of morphine; may produce less
constipation, smooth muscle spasm, and depression of cough reflex than similar
analgesic doses of morphine.
I. Follow-up
Complications
Treatment of neck of femur fractures is important. Significant complications
such as avascular necrosis and non-union are very common without surgical
intervention. The treatment options include non-operative management, internal
fixation or prosthetic replacement.
Internal fixation can be performed with multiple pins, intramedullary hip
screw (IHMS), crossed screw-nails or compression with a dynamic screw and plate.
Replacing the femoral head is achieved with either hemiarthroplasty and total hip
arthroplasty.
 As a general rule, internal fixation is recommended for young, otherwise fit
patient with small risk for AVN. While prosthetic replacement is reserved for
fractures with high risk of AVN and the elderly.

Prognosis
The high morbidity and mortality associated with hip and pelvic fractures
after trauma has been well documented. Prognosis is varied, but is complicated by
advanced age, as hip fractures increase the risk of death and major morbidity in the
elderly.
Depending on the nature of the fracture, the athlete may or may not return to
premorbid functioning. A displaced stress fracture of the femoral neck may end the
career of an elite athlete even if correctly treated. Early diagnosis and treatment may
prevent displacement of the fracture and thus improve the prognosis.

Education
The patient with a femoral neck fracture should have a good understanding of
his or her diagnosis and the benefits and risks of treatment. Completing education
throughout the rehabilitation process is very important for patients to obtain the most
optimal results and to possibly to return to their previous level of activity.
Patients should take an active role in their care and understand what is
necessary for proper healing, in addition to being instructed in a home exercise
program for regaining their strength and range of motion of the affected lower
extremity. Patient education is crucial to the prevention of recurrent neck stress
fractures.
CHAPTER IV
DISCUSSION

Diagnose of femoral neck fracture obtained by history that the patient complains of pain
in the hip joint and can not walk after fall in eldery or a sifnificant trauma in younger patient.
A comprehensive training history should be obtained, and recent changes in activity level,
equipment, intensity levels, and technique should be noted. A careful menstrual history should
be obtained from all female patients. Amenorrhea is often associated with decreased serum
estrogen levels. Lack of protective estrogen leads to decreases in bone mass. The examiner
should inquire whether these symptoms have occurred in the past, and, if so, whether the
patient tried using ice or heat or any medications (eg, acetaminophen, aspirin, nonsteroidal
anti-inflammatory drugs [NSAIDs]). Questions should be asked about previous participation
in a physical therapy program, and the physician should attempt to understand the treatment
plan used.
Based autoanamnesis of Ny. Ruci (eldery patient with 70 years old in age) is known that
patients vomiting blood since more about six hours ago after patient drink some drug to lessen
her pain. Patient felt pain because of fall in the bathroom since more about one month. Patient
falls with the upper right thight hit the floor. Patient complaining a pain on his right hip joint,
swollen and hard to move it.
From the results of physical examination, we found abnormalities in the right femoral.
Localist status check on legs below the visible not presence of edema, pale and wrinkled skin
around, but the right femoral presence a eksorotation and flexion deformity. There is
tenderness on palpation, the dorsalis pedis arterial pulsation is normal, the difference true
right and left leg length 78 cm / 80 cm, the differences apparent right and left leg length 82
cm / 84 cm and the same anatomical right and left leg length 37 cm / 37 cm. In the active
movement of patients were not able to minimal endorotation, exorotation, and flexion. While
in the passive movement, the patient were not able to perform the minimal flexion, minimal
endorotation, minimal exorotation. At the neurovascular distal examination (NVD) it was not
obtained for pathological reflexes and motor examination is weak in right leg.
Patients with displaced femoral neck fractures are usually unable to stand or ambulate.
Observe the iliac crest for any difference in height, which may indicate a functional leg-length
discrepancy. Alignment and length of the extremity is usually normal; however, the classic
presentation of patients with displaced fractures is a shortened and externally rotated
extremity. The most common physical feature of stress fractures in general is local bony
tenderness; however, the neck of the femur is relatively deep and bony pain or tenderness may
be absent. Additionally, evaluate the dynamic stabilizers of the pelvis, including hip flexors,
extensors, and abductors. A Trendelenburg gait pattern is indicative of hip abduction
weakness. Test hip flexion (L2, L3), extension (L5, S1, S2), abduction (L4, L5, S1), and
adduction (L3, L4). Upon sensory examination, a dermatomal decrease or loss of sensation
can indicate or exclude any specific nerve damage. Muscle stretch reflexes are helpful in the
evaluation of patients presenting with hip pain. Abnormal reflexes can indicate nerve root
abnormality. The asymmetry of reflexes is most significant; therefore, a patient's reflexes
must be compared with the contralateral side.
The radiographs in this patient, we can found a right femoral neck fracture. Radiographs
may show a fracture line on the superior aspect of the femoral neck, which is the location for
tension fractures. Tension fractures must be distinguished from compression fractures, which,
according to Devas and Fullerton and Snowdy, are usually located on the inferior aspect of the
femoral neck. The standard radiographic examination of the hip includes an anteroposterior
view of the hip and pelvis and a cross-table lateral view. If a hip fracture is suggested but not
seen on standard x-ray films, a bone scan or magnetic resonance imaging (MRI) study should
be performed.
As with all fractures, pain management should be a primary concern. Often
acetaminophen or an NSAID is prescribed for the acute pain of a fracture, but in this patient
with a vomiting blood because of gastropathy NSAID, acetaminophen is indicated for pain in
patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or
who are taking oral anticoagulants. Also in this patient use sucralfat to protect the mucous of
gaster.
Treatment of neck of femur fractures is important. Significant complications such as
avascular necrosis and non-union are very common without surgical intervention. The
treatment options include non-operative management, internal fixation or prosthetic
replacement. Internal fixation can be performed with multiple pins, intramedullary hip screw
(IHMS), crossed screw-nails or compression with a dynamic screw and plate. Replacing the
femoral head is achieved with either hemiarthroplasty and total hip arthroplasty.

CHAPTER V
CONCLUSION

Femoral neck fracture most commonly in eldery with a various mechanism of fall on the
hip joint because of post-menopausal osteoporosis.
Femoral neck fractures are a subset of proximal femoral fractures. The femoral neck is
the weakest part of the femur. Since disruption of blood supply to the femoral head is
dependant on the type of fracture and causes significant morbidity, diagnosis and
classification of these fractures is important.
Diagnose of femoral neck fracture obtained by history that the eldery patient complains
of pain in the hip joint and can not walk after fall, physical examination, such as look, feel,
move and measurement. The radiograph can help some information to diagnose femoral neck
fracture.
In patient with hipersensitivity to NSAID or a Gastropathy NSAID, acetaminophen is a
choise to pain management, and sucralfat can protect the mucous of gaster in this patient.
Treatment of neck of femur fractures is important. Significant complications such as
avascular necrosis and non-union are very common without surgical intervention. The
treatment options include non-operative management, internal fixation or prosthetic
replacement. Internal fixation can be performed with multiple pins, intramedullary hip screw
(IHMS), crossed screw-nails or compression with a dynamic screw and plate. Replacing the
femoral head is achieved with either hemiarthroplasty and total hip arthroplasty.

REFERENCES

1. Konetsky M, Miller J, Tripp C. Femoral neck stress fracture. J Orthop Sports Phys
Ther. 2013 Apr. 43(4):275. [Medline].
2. Koval KJ, Zuckerman JD. Hip fractures: I. Overview and evaluation and treatment of
femoral-neck fractures.J Am Acad Orthop Surg. 1994 May. 2(3):141-149. [Medline].
3. Sachse D, Beiter C, Bludau F et-al. Fractures of the neck of the femur in younger
patients (15-50 years old). Outcome 4 years after surgery. Z Orthop Unfall. 2014;152
(01): 20-5. doi:10.1055/s-0033-1360243 - Pubmed citation
4. Maitra RS, Johnson DL. Stress fractures. Clinical history and physical
examination. Clin Sports Med. 1997 Apr. 16(2):259-74. [Medline].
5. Markey KL. Stress fractures. Clin Sports Med. 1987 Apr. 6(2):405-25. [Medline].

6. Sachse D, Beiter C, Bludau F et-al. Fractures of the neck of the femur in younger
patients (15-50 years old). Outcome 4 years after surgery. Z Orthop Unfall. 2014;152
(01): 20-5. doi:10.1055/s-0033-1360243 - Pubmed citation

7. Schwappach JR, Murphey MD, Kokmeyer SF et-al. Subcapital fractures of the

femoral neck: prevalence and cause of radiographic appearance simulating pathologic
fracture. AJR Am J Roentgenol. 1994;162 (3): 651-
4.doi:10.2214/ajr.162.3.8109516 - Pubmed citation

8. Monteleone GP Jr. Stress fractures in the athlete. Orthop Clin North Am. 1995 Jul.
26(3):423-32. [Medline].
9. Devas MB. Stress fractures of the femoral neck. J Bone Joint Surg Br. 1965 Nov.
47(4):728-38. [Medline].[Full Text].
10. Fullerton LR Jr, Snowdy HA. Femoral neck stress fractures. Am J Sports Med. 1988
Jul-Aug. 16(4):365-77.[Medline].
11. Shin AY, Morin WD, Gorman JD, Jones SB, Lapinsky AS. The superiority of magnetic
resonance imaging in differentiating the cause of hip pain in endurance athletes. Am J
Sports Med. 1996 Mar-Apr. 24(2):168-76.[Medline].
12. Holder LE, Schwarz C, Wernicke PG, Michael RH. Radionuclide bone imaging in the
early detection of fractures of the proximal femur (hip): multifactorial
analysis. Radiology. 1990 Feb. 174(2):509-15. [Medline].[Full Text].
13. Quinn SF, McCarthy JL. Prospective evaluation of patients with suspected hip fracture
and indeterminate radiographs: use of T1-weighted MR images. Radiology. 1993 May.
187(2):469-71. [Medline]. [Full Text].
14. Blomfeldt R, Tornkvist H, Ponzer S, Soderqvist A, Tidermark J. Internal fixation
versus hemiarthroplasty for displaced fractures of the femoral neck in elderly patients
with severe cognitive impairment. J Bone Joint Surg Br. 2005 Apr. 87(4):523-
9. [Medline].
15. Stappaerts KH. Early fixation failure in displaced femoral neck fractures. Arch Orthop
Trauma Surg. 1985. 104(5):314-8. [Medline].
16. Scheck M. The significance of posterior comminution in femoral neck fractures. Clin
Orthop Relat Res. 1980 Oct. 152:138-42. [Medline].
17. Heetveld MJ, Raaymakers EL, van Eck-Smit BL, van Walsum AD, Luitse JS. Internal
fixation for displaced fractures of the femoral neck. Does bone density affect clinical
outcome?. J Bone Joint Surg Br. 2005 Mar. 87(3):367-73. [Medline].

18. Moroni A, Hoque M, Waddell JP, Russell TA, Wippermann B, Digiovanni G. Surgical
treatment and management of hip fracture patients. Arch Orthop Trauma Surg. 2011
Dec 6. [Medline]