1. Fracture neck of femur
Dr. Shatrughna Ram
F.R.C.S., M.Ch. (Ortho), F.I.C.S.
Advanced Orthopaedic Centre
Patna 800016, INDIA
www.drshatrughnaram.com
2. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Introduction
• Relatively common fracture
• Increasing incidence due to
• High speed of travel
• Ageing population and osteoporsis
• High Morbidity and mortality
• 10% Hospital mortality in elderly
• 30% of the elderly die within one year of operation
• After one year resume their normal mortality rate
03/01/2016 Fracture neck of femur 2
3. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Introduction Contd...
• 10% surgical non-union, 20% avascular necrosis in fresh
displaced fracture fixation
• Much higher in old displaced fractures
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4. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
History
• Lagenbeck (1850)
• First internal fixation
• Whitman (1904)
• Closed reduction and hip spica
• Smith - Peterson (1931)
• SP Nail fixation
• Richard’s Hip screw (DHS)
• Physical pressure causes bone absorption
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5. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
History Contd…
• Asnis and other cannulated screws
• Osteogenic potency remains poor
• Fibular graft alone or with 1Asnis screw (1998)
• needs cumbersome of Hip Spica or flaper and prolonged bed rest
• Ram & Roshan (2006)
• Fibular graft with 2 Asnis screw
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6. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Type of Fracture of Neck of Femur
• Sub capital
• Trans cervical
• Basal
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7. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Basal Fracture Neck of Femur
• Vascularity
• plenty
• Non-union
• not a problem
• Treat like I.T. fracture
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8. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Displaced Sub-capital & Transcervical
Fracture (Gardens III & IV)
• Great challenges to Orthopaedic surgeons
• Prosthetic replacement
• For the elderly
• McMurray’s or abduction osteotomy
• For the younger
• Fibular graft alone
• Cumbersome of hip spica or flaper and prolonged bed rest
• Fibular graft with 2 cannulated screws
• Early return to function
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9. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Discussion
• Great challenges to Orthopaedic surgeons
• Unsolved fracture – treatment and results
• Results depend upon
• Extent of injury – displacement and comminution
• Adequacy of the reduction and fixation
• Time interval between injury and fixation: < 1day, < 3 days , < 1week, > 1 week
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10. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Garden’s classification
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11. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Results of Early Treatment
Garden’s
classification
Non-surgical Surgical (ORIF)
Non-union Non-union AVN
Grade I 10% 0% 0%
Grade II 50% 5% 10%
Grade III
100% 10% 20%Grade IV
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12. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Causes of Non-union
• Poor circulation
• Synovial fluid bathing the fracture
• Absence of Periosteum
• all healing is endosteal
• Temponad
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13. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Blood Circulation
Extra capsular arterial ring
Ascending cervical branches
Arteries of the Ligamentum teres
The poor blood supply further deteriorates with trauma and temponad
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14. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Blood Circulation Contd…
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15. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Treatment for Fresh Fracture Neck of
Femur
Garden’s type 1 & 2
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16. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Treatment for Fresh Fracture Neck of
Femur Contd…
Garden’s type 3 & 4
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17. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Encouraged with better results of late
treatment in neglected femoral neck
fracture in young adults
• Baksi
• ORIF + muscle pedicli graft - 100% union
• Nagi et al
• ORIF + Fibular graft - 100% union
• Ram et al
• ORIF + 2 Cannulated Screws & Fibular Graft - 91% union
• Clinical orthopedics 2006, No. 447
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18. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
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19. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Treatment for Fresh Fracture Neck of
Femur Contd…
• Strut free fibular graft with 2 cannulated screws
Garden’s type 3 & 4
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20. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Method
• Fracture reduced accurately on a traction table – closed or open
• 3 guide wires placed and reamed
• Whole fibular graft fixed in the centre
• 2 Asnis screws: 1 above and 1 below
• Radiological control: Image intensifier
• No plaster
• Walking in 3-5 days with crutches
• Partial weight to full weight bearing in 8 -20 wk
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21. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Advantages of Free Fibular Graft
• Easy to take and apply
• Practically no morbidity at donor site
• No cumbersome of hip spica or flaper
• Early mobilization
• Better fracture union rate (? 95%)
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22. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Treatment for Old Fracture Neck of Femur
Contd...
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23. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Treatment for Old Fracture Neck of Femur
Contd...
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24. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Treatment for Old Fracture Neck of Femur
Contd...
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25. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Treatment for Old Fracture Neck of Femur
Contd...
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26. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Treatment for Old Fracture Neck of Femur
Contd...
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27. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Treatment for Old Fracture Neck of Femur
Contd...
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28. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Treatment for Old Fracture Neck of Femur
Contd...
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29. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Treatment for Old Fracture Neck of Femur
Contd...
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30. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Treatment for Old Fracture Neck of Femur
Contd...
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31. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Treatment for Old Fracture Neck of Femur
Contd...
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32. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Treatment for Old Fracture Neck of Femur
Contd...
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33. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Conclusion
• Adequate reduction and fixation of displaced femoral neck
fracture with free fibular graft and 2 cannulated screws gives a
high union rate ( ? 95%).
• It eliminates the burden of hip spica, flaper or bed rest and
prolonged physiotherapy.
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34. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com
Thank you!