Fracture Neck Femur

Prof. Sadeq Al-Mukhtar

Consultant Orthopaedic Surgeon

Epidemiology
occurs in patients more than 50 years 97%
.old. The incidence increases with age
occurs in under 50 years age(20-40) due 3%
to high energy trauma, sports, industrial &
motor vehicle accidents. In 20-40 years most
hip fractures are subtrochanteric or basicervical. Fractures in elderly are serious
injuries, about 250,000 fractures per year in
USA & the number is projected to double by
the year 2050 & the cost exceeds 6 billion $
per year

Anatomy
The femoral side of the hip is made of
the femoral head with its articular
cartilage & the femoral neck which
connects the head to the shaft in the
region of intertrochanteric area. The
synovial membrane incorporates the
entire head &the anterior neck but only
the middle part of the neck posterior
.The neck shaft angle is 130(+_7)
.degree. The Ante version is 10(+_7)

The diameter of femoral head ranges from

40-60 mm. The thickness of the articular
cartilage ranges from 4mm in the apex to
.1mm in the periphery
:Blood supply of the head from
Artery of ligamentum teres that usually- 1
originates from anterior obturator artery but
it supplies only small area of the head near
.the attachment of the ligament

Lateral, medial, anterior & posterior- 2

.Capital vessels
Lateral, medial, anterior &posterior- 3
.cervical vessels
All these 2&3 vessels groups comes from
.intertrochanteric ring
Accumulation of intracapsular hematoma
interferes with the venous outflow &perhaps
the vascular inflow. After 12 hours necrosis
.of the head starts

Biomechanics
Falling from standing position leads to direct blow
on the greater trochanter. Osteoporosis is the
.precipitating factor
In young& middle aged high velocity trauma is
.needed to induce fracture
Postmenopausal& senile osteoporosis predisposes
to fracture .By the age of 65 years, 50% of women
show bone mineral content below the threshold for
fracture. By the age of 85 year this will reaches 100%
In elderly it can occur with minor trauma on an
externally rotated thigh or the bone is so weak that
.powerful muscle contraction can lead to fracture

Classifications
:Anatomical classification- 1
:A- Intracapsular
Subcapital (high risk)
Tran cervical (moderate risk)
Basal (less risk) intracapsular anteriorly, extra
.capsular posteriorly
Sometimes, high energy fracture occur in young
which involve the shaft of femur then to the base
of the neck then to the sub capital area. Usually
.these are undisplaced

:B- Extra-capsular
Inter-trochanteric fractures
Per-trochanteric
Notes:Intracapsular fractures carry poor
prognosis because of poor blood supply
which lead to avascular necrosis & nonunion while extracapsular fractures carry
good prognosis due to the good blood
supply

:Gardens classification- 2
They are classified according to the degree of
.displacement of the fracture fragment
Incomplete fracture(abduction& impacted)- 1
.making the neck in valgus
Complete fracture without displacement; the- 2
.neck alignment looks normal
.Complete fractures with partial displacement - 3
.Complete fractures with complete displacement- 4

are considered as undisplaced 2&1

fractures& have good prognosis while
3&4 are displaced fracture& have poor
prognosis. Stage 1 can slowly progress
.to stage 4 if untreated

:Pauwels classification
They are classified according to the
:direction of the fracture
Pauwel s 1: The angle from the
.horizontal line is 30-49 degree
Pauwel s 2: The angle from the
horizontal line is 50-69 degree
.
.Pauwel s 3: The angle is 70& more

All the available classifications can not

determine the exact displacement that
occurred at the time of accident, the
degree of vascular damage & the
condition of the posterior femoral
.neck

Clinical features
Patient is usually old with history of
trauma. The patient is unable to stand
or walk. On examination the limb is
shorter, externally rotated & he is
unable to move it. Movement of the hip
.is tender &limited

Diagnosis
It is achieved by history,Examination, &
X-Ray of the hip, A.P& Lateral views are
.required
:Differential diagnosis
Non-traumatic fractures of the neck of
:-femur
Pathological fractures: Multiple
.myeloma, Secondary bone tumors

.Post-irradiation fractures
Stress fractures: Hair-line
fracture with no
.shortening or deformity

Treatment
According to the treatment required,
the complications likely to occur & the
prognosis; patient are divided into
;three age groups
.Fractures in elderly; over 70 years
.Fractures in young & middle aged
.Fractures in children

Each group has its own problems but there is one

common factor to them ( the danger of injury to the
retinacular vessels with end result of avascular
.necrosis)
This can sometimes be the cause of non-union
whatever the method used for immobilization &even
in cases where union has occurred late avascular
necrosis. Changes in the weight bearing segment of
the head can result in a stiff& painful joint .IT IS NOT
WITHOUT REASON THAT THE INJURY HAS BEEN
.LABELLEDE THE UNSOLVED FRACTURE
There must be rigid lines of demarcation, each
.fracture must be carefully& individually assessed

The Aim of treatment

.Accurate reduction
Rigid fixation
Early mobilization to avoid
.complications

Causes of avascular necrosis

.Interference with blood supply of the head
No periosteum( some believe there is very
thin one) so only endosteal healing will
.occur resulting in poor callus
Dissolution of the fracture hematoma by
.synovial fluid

Treatment of patients above 70

years
Because of high incidence of AVN &non-
union& complications of prolonged
.immobilization, the treatment is Arthroplasty
Partial Arthroplasty: Using Austen Moore or
.Thompson's prosthesis
Total hip replacement (THR): Indications
includes delayed union &secondary
.osteoarthritis involve acetabulum

Treatment of young &middle

aged patients
:-Accurate reduction by
Closed reduction under anesthesia.or
)Open reduction
Rigid fixation by screws( at least 3
screws), using DHS(dynamic hip
.screws), or Smith-Petersons nail..ect

Treatment in Children
Some prefer conservative but the best
method of fixation by multiple pins
&immobilization by hip spica for 6
weeks &weight bearing after 8-12
.weeks
Notes: Even undisplaced fractures are
not immune from complications like
.AVN

Complications
:General
DVT& Pulmonary embolism: It is due to prolonged- 1
immoblication, treated by prophylactic early
.mobilization, if happens give Anticoagulants
Bed sores: It is due to prolonged immobilization, - 2
bad nursing &pressure on the skin& bony
prominence leading to necrosis that may be followed
by infection. It is treated by prophylactic frequent
turning of the patient, talk powder& pneumatic
.bedes
.Pneumonia, chronic UTI- 3
..Psychological trauma- 4

Local complications
:Avascular necrosis AVN
Incidence is 10-30% ( 10% in undisplaced
fractures, &30% in displaced fractures). It
may be partial or complete with consequent
collapse of the bone structure leading to
fragmentation. It takes months or even 2-3
years to occur. If involved the fracture site it
may lead to failure to union whereas collapse
at the articular surface leads to O.A & the
patient complains of hip pain & inability to
walk X-Rays reveal increased bone density,
.collapse & later an O.A changes

NON UNION- 2
:-Causes are
.Interference with blood supply- 1
Inadequate immobilization& early- 2
.mobilization
Dissolution of the hematoma by synovial- 3
.fluid
:Pathology of non-union
When there is failure to unite, the fracture
undergoes absorption& if it is associated
.with AVN the head will collapse

Clinical features: Hip pain, lateral rotation of

.the limb& inability to walk with shortening
:-Treatment
In young patient: If the head is viable to make
:the fracture line horizontal, the treatment is
.Subtrochanteric valgus osteotomy
.Rigid fixation &bone graft
.In elderly, Arthroplasty
.Osteoarthritis- 3

Fractures of the Trochanteric region

These fractures occur in the region between the
greater &lesser trochanters. They are common in
elderly especially in women, more than the fracture
.of neck femur
Compared to patients with fractured femoral neck,
patients with intertrochanteric fractures are
significantly older, more likely to be limited to home
ambulation& more dependant in their activities of
daily living: therefore they tend to have overall
poorer prognosis .Because the region is a vascular
area so we note blood supply is excessive & AVN is
.less than 1%

Classification
Stable fracture:-The the postero-- 1
medial buttress remains intact or
minimally comminuted& therefore
collapse of the fracture fragment is
.unlikely
Unstable fracture: The large segment- 2
of postero-medial wall is fractured
free& comminuted& therefore tends to
.collapse in varus

KYLE Classification
Non-displaced stable fracture: without- 1
comminution (stable) 21%
Minimal comminution but displaced- 2
fracture: once reduced become (stable) 36%
Large postero-medial comminuted area- 3
.This is a problem fracture (unstable) 28%
Intertrochanteric & subtrochanteric- 4
fracture: It is uncommon (unstable) 15%

Treatment
;Types
.Conservative; Traction for 6-8 weeks- 1
Surgical; Because patients are elderly&- 2
complications of such fractures are high so
.surgery is indicated
:-Principles
Reduction either closed under screen or
.open reduction
Rigid fixation by pin& plate, DHS ,angled
.plate etc

Complications
General; The same as complications of
.fracture neck femur

;Local
Malunion; Varus deformity or external- 1
rotation which is treated by corrective
.osteotomy& fixation
Non-union; rare due to soft tissue- 2
.interposition, treated by ORIF & bone graft

Subtrochanteric fracture
These are fractures in the area between
lesser trochanter & the junction between
proximal and middle 3rd of femur. It occur in
all age groups but there are two peak ages of
;incidence
Late adolescence & early adulthood; here- 1
.high energy trauma is needed
Geriatric; minor trauma to bone lesion like-2
metastatic tumor lung, breast cancer)
causing pathological subtrochanteric
.fracture

The upper fragment is flexed due to

spasm of the iliopsoas& abducted by
gluteal muscle while the distal segment
is adducted by adductor muscles

Thank you