fracture neck of femur in adults only

1. FRACTURE NECK OF FEMUR
IN ADULTS
DIRECTOR & HOD
PROF. DR. K. PRAKASAM
M.S.ORTHO., D.ORTHO., DSc(HON).,
MODERATOR: DR. HARI
PRESENTOR: DR. SANJOO

2. ANATOMY
• Femoral neck is
located between
femoral head,
greater and lesser
trochanter
• Upper femoral
epiphysis closes –
16 years.

3. TRABECULAR PATTERN
Presence or absense of
trabecular lines indicates
the stages of osteoporosis
Ward’s triangle: formed by
primary tensile, primary
compressive and secondary
compressive group of
trabeculae

4. BLOOD SUPPLY OF
FEMORAL HEAD
1. Extracapsular arterial ring
2. Ascending cervical branches
3. Artery of ligamentum teres

5. BLOOD SUPPLY
• The extracapsular
arterial ring is formed
posteriorly by a large
branch of medial
femoral circumflex
artery and anteriorly
by a branch of lateral
femoral circumflex
artery

6. BLOOD SUPPLY
• Ascending
cervical branch
or retinacular
vessels arise
from the
extracapsular
arterial ring

7. BLOOD SUPPLY
• Ascending cervical branch ascends
over the femoral neck in anterior,
posterior, medial and lateral groups
• Lateral vessels provide more blood
supply to head and neck of femur
• Their proximity to the surface makes
them vulnerable to injury in femoral
neck fractures

8. BLOOD SUPPLY OF
FEMORAL HEAD
• Ascending cervical
arteries forms a
subsynovial intra-
articular arterial ring
• At the subsynovial
intra-articular ring,
epiphyseal arterial
branches arise that
enter the femoral
head

9. BLOOD SUPPLY OF
FEMORAL HEAD
• Epiphyseal artery forms 2 groups of
vessels
1.lateral epiphyseal arteries
2.Inferior metaphyseal arteries

10. BLOOD SUPPLY OF FEMORAL
HEAD
• Most important is,
lateral epiphyseal
arterial group
supplying the
lateral weight
bearing portion of
the femoral head

11. BLOOD SUPPLY OF
FEMORAL HEAD
• The artery of the
ligamentum teres
is a branch of the
obturator artery

12. FRACTURE NECK OF FEMUR
• Intra capsular fracture
• Femoral neck fracture occurs
mainly in the elderly people with
osteoporosis
• fracture can occur in people with
normal bone density with high
force (Road Traffic Accident)
• Stress fracture occasionally seen
in athletic people (increased
cyclic loading)

13. RISK FACTORS
1.Age:female – 65yrs; Male – 60yrs
2.Sex-Females, secondary to senile
osteoporosis (Female to male ratio 2:1)
3.Alcoholic

14. MECHANISM OF INJURY
• Old age:
1.fall with lateral rotation strain of lower
limb
2. fall producing a direct blow over the
greater trochanter
• Young individuals – high energy trauma

15. CLINICAL FEATURES
• History of trivial trauma
• Pain
• Swelling
• Tenderness

16. CLINICAL FEATURES
• In undisplaced/impacted fracture
1. Ambulatory
2. Minimal pain

17. CLINICAL FEATURES
In displaced fractures:
1. External rotation deformity
2. Shortening
3. Unable to ambulate
4. Echymosis
5. Restricted movements.

18. INVESTIGATIONS
1.Xray Antero
Posterior view of
pelvis
2.Traction &
internal rotation
view of affected
hip joint

19. INVESTIGATIONS
• Cross table lateral view
– to assess posterior
comminution
• CT scan
• MRI

20. ANATOMICAL
CLASSIFICATION
• 1.Subcapital
• 2.Transcervical
• 3.Basicervical

21. GARDEN’S CLASSIFICATION
• Based on degree of displacement before
reduction of fracture fragments

22. GARDEN CLASSIFICATION
• Type1
Incomplete fracture
(impacted fracture)
• Intact inferior neck
trabeculae

23. GARDEN CLASSIFICATION
• Type 2
complete fracture
without displacement
• Distal fragment
trabeculae are in
normal alignment

24. GARDEN CLASSIFICATION
• Type 3
Complete fracture with
partial displacement
• Intact posterior retinaculum
• Trabecular pattern of
femoral head does not line
up with that of acetabulum

25. GARDEN CLASSIFICATION
• Type 4
Complete fracture
with full
displacement
(trabeculae of the
head realign
themselves with the
trabeculae of the
acetabulum)

26. PAUWEL’S CLASSIFICATION
(RADIOLOGICAL)
• Post reduction
classification
• Based on inclination
angle of fracture line
• Type I - fracture
Line 30* from the
imaginary horizontal
line

27. PAUWEL’S CLASSIFICATION
• Type II -
fracture Line
50* from the
imaginary
horizontal line

28. PAUWEL’S CLASSIFICATION
• Type III –
fracture line 70*
from the
imaginary
horizontal line

29. TREATMENT
• Treatment depends on,
1.Age of the patient
2.Duration of fracture
3.Geometrical pattern of the fracture

30. TREATMENT EVOLUTION
• 1.Whitman – hip spica cast
• 2.Smith Petersen - triflanged
nail
• 3.Charnley – spring loaded
compression screw with a
lateral plate fixation
• 4.Smythe – combination of 2
screws joined by a plate to
form a triangular fixation

31. TREATMENT EVOLUTION
• 5.Garden – used a 2
crossed screws
• 6. Three cannulated
screw fixation
• 7. Prosthetic
replacement

32. Garden type 1# < 60yrs
> 60yrs
Closed reduction with
cancellous screw fixation
Prosthetic replacement
Garden type 2# < 60yrs Closed reduction with
cancellous screw fixation
> 60yrs Prosthetic replacement
Garden type 3# < 60yrs
> 60yrs
Osteotomy with Dynamic
Hip Screw fixation
Prosthetic replacement
Garden type 4# < 60yrs
> 60yrs
Osteotomy with Dynamic
Hip Screw fixation
Prosthetic replacement

33. CLOSED REDUCTION
WHITMAN TECHNIQUE
• The fractured extremity is tied to footplate in
an externally rotated position
• With the extremity externally rotated, it is
abducted approximately 20*
• Traction is applied
• The extremity is internally rotated until the
patella is internally rotated 20 - 30*.

34. LEADBETTER TECHNIQUE
• Hip is flexed to 90*
• Traction along long axis of femur
• Thigh is internally rotated &
abducted
• Reduction is evaluated by “heel
palm” sign

35. HEEL- PALM SIGN:
• patient's heel is placed in the palm of
the surgeon's outstretched hand
• If reduction is complete, the limb
does not externally rotate
spontaneously

36. FLYNN METHOD:
• Hip is flexed to 90*
• Traction is applied laterally in the
axis of femoral neck
• Limb is extended & internally
rotated while the lateral traction is
maintained

37. GARDEN’S INDEX
• Post reduction evaluation
• X rays – Anteroposterior &
Lateral view of hip
• Based on trabecular pattern
alignment

38. GARDEN’S INDEX
In Xray antero posterior
view
• Angle formed by the
central axis of the medial
trabecular system in the
head fragment and the
medial cortex of the
femoral shaft should be
160-180*

39. GARDEN’S INDEX
• In X ray lateral
view
• Major trabeculae
are in the same
axis as axis of
femoral neck or
lie at an angle of
180*

40. GARDEN’S INDEX
• Angle < 160* denotes
varus reduction
• Angle > 180* denotes
valgus reduction
• Alignment index <
155* or > 180*
increases incidence of
Avascular necrosis

41. RADIOLOGICAL EVALUATION
• Convex outline
of head meeting
concave outline
of neck produces
an “S” curve –
(fracture
reduced)

42. RADIOLOGICAL EVALUATION
• If femoral neck
is tangent to
head,it forms an
unbroken “c”
curve- (fracture
not reduced)

43. CLOSED REDUCTION &
CANNULATED SCREW
FIXATION
• Stab incision – 3cm distal to the
greater trochanter
• After manipulating head into
anatomical position, guide pins
passed from lateral aspect of femoral
shaft parallel with the neck

44. CLOSED REDUCTION &
CANNULATED SCREW
FIXATION
• Screws are fixed in Inverted
triangle configuration
• 1st screw: inferior aspect of
head to prevent neck varus
• 2nd screw: placed posteriorly
• 3rd screw: placed anteriorly

45. CLOSED REDUCTION &
CANNULATED SCREW
FIXATION
• compress the
anterior screws
first and the
posterior screws
last to prevent
collapse of the
posterior aspect of
the femoral neck

46. OPEN REDUCTION &
CANNULATED SCREW
FIXATION
Indications:
1.Failed closed reduction
2.Neglected fracture
• Watson – Jones approach
• Hip in 20* – 30* flexion helps good exposure
& reduction
Complication:
• Avascular necrosis of femoral head

47. COMPRESSION HIP SCREW
WITH PLATE FIXATION
Indications:
• Displaced fracture
• Osteoporotic bone
• Comminuted lateral cortex

48. COMPRESSION HIP SCREW
WITH PLATE FIXATION
• Applies compression at fracture site
• Permits controlled collapse leading
to,
1.progressive increase in bony contact
2.continuous increase in stability
3.constant decrease in stress on plate

49. COMPRESSION HIP SCREW
WITH PLATE FIXATION
Site of screw placement
• Postero inferiorly on
Antero Posterior view
• posteriorly on lateral view
- permits impaction and
prevents cutting out

50. COMPRESSION HIP SCREW
WITH PLATE FIXATION
• Tip should be advanced
within 5mm of articular
surface of femoral head
• Derotation screw
prevents the rotation of
neck while inserting the
large lag screw in to
head

51. HEMIARTHROPLASTY
• 1.Austin moore prosthesis
• 2.Thompson prosthesis
• 3.Bipolar

52. AUSTIN MOORE PROSTHESIS
Indications:
1.Non union
2.Age - > 60yrs
3.Adequate
femoral calcar

53. THOMPSON PROSTHESIS
• Indications
1.Non union
2.Age - > 60yrs
3.Inadequate femoral
calcar
4.Pathological fracture
5.Osteoporosis

54. BIPOLAR
HEMIARTHROPLASTY
• Indications
1.Non union
2.Young patient(50-55yrs)
acetabular erosion is less,
compared to unipolar
hemiarthroplasty

55. TOTAL HIP
ARTHROPLASTY
• INDICATIONS
1.Pre existing acetabular
disease
2.Displaced fracture in old age
- >60yrs
3.Avasular necrosis of femoral
head
4.Neglected fracture

56. COMPLICATIONS OF
PROSTHETIC REPLACEMENT
IMMEDIATE EARLY LATE
1.Neurovascular
injury
2.Bleeding
3.Fracture
Femur
1.Fat embolism
2.Deep Vein
Thrombosis
3.Dislocation
4.Infection
1.Thigh pain
2.Periprosthetic
loosening
3.Periprosthetic
fracture
4.Infection
5.Protrusio
acetabulum

57. COMPLICATIONS OF
FRACTURE NECK OF FEMUR
NON UNION:
• Absence of cambium layer of
periosteum. fracture heals through
endosteal callus
• Diminished blood flow
• Synovial fluid washes away the
hematoma formation
• Shearing and distraction forces

58. TREATMENT OF NON UNION
YOUNG AGE:
1.Mc-murray’s osteotomy
2.Pauwel’s Y osteotomy
3.Valgus osteotomy
OLD AGE:
1.Prosthetic replacement

59. MC-MURRAY’S OSTEOTOMY
• Oblique medial displacement
intertrochanteric abduction
osteotomy

60. MC-MURRAY’S OSTEOTOMY
PRINCIPLE
• Converts the shearing
force into compressing
force
• Site- just below the base
of Greater
Trochanter,extends
upwards to a point above
the Lesser Trochanter
• Plane- 10 – 15* oblique

61. MC-MURRAY’S OSTEOTOMY
• Proximal
fragment rotated
externally
• Distal fragment
displaced
medially

62. PAUWEL’S Y OSTEOTOMY
PRINCIPLE
• Vascular
proximal end of
shaft displaced
medially to
bridge the non
union site

63. VALGUS OSTEOTOMY
PRINCIPLE
• Converts the
mechanical
loading of non
union site from
shear force into
compressive force

64. Avascular necrosis
• Common in Garden’s grade 4
fractures
• Presents with groin,buttock and
proximal thigh pain
• Bone scan determine the healing
process
• Core decompression/ prosthetic
replacement is the treatment of
choice