1.Fracture neck of Femur: Diagnosis and TreatmentPresented By S.Renuga Devi BME,Final year 31510121035 110/16/2013

2. What is a femoral neck fracture? A fracture through the intra articular part of the femoral neck is usually referred to by the term femoral neck fracture. Another term is intracapsular proximal femoral fracture. About 80% of these fractures are displaced.210/16/2013 3. Anatomical factors The structure of the head and neck of femur isdeveloped for the transmission of body weight efficiently, with minimum bone mass, by appropriate distribution of the bony trabeculae in the neck. The tension trabeculae and compression trabeculae along with the strong calcar femorale on the medial cortex of the neck of the femur form an efficient system to withstand load bearing and torsion under normal stresses of locomotion and weight bearing. In old age, osteoporosis of the region occurs. The incidence of fracture neck of femur is higher in old age. 310/16/2013 4. ANATOMY OF NECK OF FEMUR Neck connects head with shaftand is about 3.7 cm long. It makes angle with the shaft 130+/- 7 degree( less in female due to their wider pelvis). It facilitate movements of hip joint. It is strengthened by calcar femorale (bony thickening along its concavity). 410/16/2013 5. 2 borders and 2 surfacesUpper border concave and horizontal meets the shaft at greater trochanter. Lower border straight and oblique meet the shaft at lesser trochanter. Anterior surface- flat .meet shaft at intertrochanteric line . Entirely intra capsular. Posterior surface- convex from above downwards and concave from side to side.meets shaft at intertrochanteric crest.it is crossed by horizontal groove for tendon of obturator externus. 510/16/2013 6. Blood supply Crock described the arteries of the proximal end of the femur in three groups (a) an extracapsular arterial ring located at the base of the femoral neck; (b) ascending cervical branches of the extracapsular arterial ring on the surface of the femoral neck (known as retinacular arteries) (c) the arteries of the ligamentum teres610/16/2013 7. a)The extracapsular arterial ring is formed posteriorly by a large branch of the medial femoral circumflex artery and anteriorly by branches of the lateral femoral circumflex artery . The superior and inferior gluteal arteries also have minor contributions to this ring b) The ascending cervical arteries can be divided into four groups (anterior, medial, posterior, and lateral) based on their relationship to the femoral neck. lateral group provides most of the blood supply to the femoral head and neck.7 10/16/2013 8. c)8The artery of the ligamentum teres is a branch of the obturator or the medial femoral circumflex artery only small & variable amount of femoral head is nourished by artery of ligamentum teres. 10/16/2013 9. PATHO-ANATOMY Most fracture are displaced withdistal fragment externally rotated, adducted, and proximall migrated. These displacement are less marked than in intertrochanteric fracture because the capsule of hip joint is attached to distal fragment and prevent extreme rotation and displacement of distal fragment.910/16/2013 10. CLASSIFICATION ANATOMICAL LOCATION Subcapital Transcervical Basicervical (base of the neck fracture)1010/16/2013 11. 1110/16/2013 12. PAUWEL This is based on the angle of fracture from the horizontal Type I: 30 degrees Type II: 50 degrees Type III: 70 degrees1210/16/2013 13. As the fracture progresses from type 1 to type 3, theobliquity of the fracture line increases, thus the shear force at the fracture site increases.1310/16/2013 14. GARDEN 14This is based on the degree of valgus displacement Type I: Incomplete/valgus impacted Type II: Complete and nondisplaced on AP and lateral views Type III: Complete with partial displacement; trabecular pattern of the femoral head does not line up with that of the acetabulum Type IV: Completely displaced; trabecular pattern of the head assumes a parallel orientation with that of the acetabulum 10/16/2013 15. 1510/16/2013 16. 1610/16/2013 17. Orthopaedic Trauma Association (OTA) Classification B1 group fracture is nondisplaced to minimallydisplaced subcapital fracture B2 group includes transcervical fractures through the middle or base of the neck B3 group includes all displaced nonimpacted subcapital fractures1710/16/2013 18. 1810/16/2013 19. MECHANISM OF INJURY Low-energy trauma (most common in older patients)- Direct: A fall onto the greater trochanter (valgus impaction) or forced external rotation of the lower extremity impinges an osteoporotic neck onto the posterior lip of the acetabulum (resulting in posterior comminution). - Indirect: Muscle forces overwhelm the strength of the femoral neck1910/16/2013 20. High-energy trauma- accounts for femoral neckfractures in both younger and older patients, such as motor-vehicle accident or fall from a significant height. Cyclical loading-stress fractures: These are seen inathletes, military recruits, ballet dancers; patients with osteoporosis and osteopenia are at particular risk.2010/16/2013 21. Diagnosis Situations in which femoral neck fracture may be missed Stress fractures- elderly patient with unexplained pain in the hip should be considered to have stress fracture until proven otherwise. Undisplaced fracture-impacted fracture may be difficult to visualise on plain x-ray. Painless fracture-a bed ridden patient may develop a silent fracture.2110/16/2013 22. Multiple fractures-patient with a femoral shaftfracture may also have a hip fracture which is easily missed unless the pelvis is x- rayed.2210/16/2013 23. Radiography Radiography is the preferred initial imaging modality in evaluating femoral neck fractures because of its near universal availability, ease of acquisition, and documented correlation with surgical results over many years of use. 2310/16/2013 24. limitations: Spiral fractures are difficult to assess on a single view. Comminution is also not as easily demonstrated as it is with CT. Some stress fractures are simply not visible on plain images at all. However, radiography will likely remain the mainstay in the evaluation of these injuries in the near future, and cross-sectional imaging will play an increasing but supplementary role. 2410/16/2013 25. COMPUTED TOMOGRAPHY CT plays an increasingly important role in evaluating thehip after a fracture. CT is exquisite useful for imaging abnormalities of the bone itself. Because of its superior resolution, cross-sectional capabilities, and amenability to image reconstruction in the coronal and sagittal planes, CT is useful for assessing fracture comminution preoperatively and in determining the extent of union (or lack thereof) postoperatively.2510/16/2013 26. Degree of Confidence: CT is the most useful test for evaluating bony injury. However, axial fractures in the plane of the images can on occasion be missed with CT. This potential is decreased with the use of images reconstructed in orthogonal planes and newer multidetector CT scanners2610/16/2013 27. MRI MRI is both sensitive and specific in the detection offemoral neck fractures, because it can show both the actual fracture line and the resulting bone marrow edema. The superior contrast of MRI when appropriate pulse sequences are used, the intrinsic spatial resolution, and the ability to image in multiple planes (coronal, axial, and less commonly, sagittal) makes MRI the premiere imaging modality, especially in the setting of stress fractures, which can appear normal on initial plain images. The fracture line can be visualized as linear low-signalintensity areas surrounded by bone marrow edema, which is hypointense relative to normal marrow on T1-weighted images or hyperintense on T2-weighted images. 2710/16/2013 28. Drawbacks Drawbacks of MRI include its longerimaging time, its relative lack of widespread availability, Its higher costs, and the exclusion of patients with cardiac pacemakers and certain metal hardware in their body. .2810/16/2013 29. Nuclear Medicine Approximately 80% of fractures can be visualized 24 hours after trauma, as seen by diffusely increased tracer uptake. By 3 days after trauma, 95% of fractures are visualized, and maximal fracture sensitivity is found at 7 days; this knowledge may be helpful in equivocal cases. Nuclear medicine studies with technetium-99m methylene diphosphonate (99mTc-MDP) have also been found to be effective in predicting healing complications related to femoral neck fractures.2910/16/2013 30. TREATMENTS Conservative TreatmentFractures at this level have a poor capacity for union due to the following factors. Interference with the blood supply to the proximal fragment. Difficulty in controlling the small proximal fragment. The lack of organisation of the fracture haematoma due to the presence of the synovial fluid.3010/16/2013 31. Surgical Treatment : Two essential principles to be followed in the surgical management of this fracture are (a) perfect anatomical reduction. (b) rigid internal fixation. The earlier method of stabilising the fracture was by internal fixation with Smith Petersen Trifin nail. The fracture is reduced by manipulation with the patient in a special orthopaedic table. The fracture is internally fixed with an S.P. Nail under radiological control. The more recent method of internal fixation of the fracture is the use of multiple compression screws. 3110/16/2013 32. Fracture neck of femur in older patients In older patients above 60 years, such fractures are treated by removing the head of the femur and replacing it by metal prosthesis like Austin Moore's prosthesis. This enables the patient to be ambulant and start early weight bearing. Fracture neck of femur in Children The fracture is reduced by manipulation and the leg immobilised in full plaster spica in abduction for 8-10 weeks. When indicated internal fixation could be done with multiple thin Austin Moore's Pins. 3210/16/2013 33. Dynamic Hip Screw: Most commonly used device for both stable and unstable fracture patterns. Plate angle is variable 130 to 150 degrees. Has to be positioned centrally in the femoral head. Use of radiological views to know the exact position. 3310/16/2013 34. Austin Moore'sprosthesis34Total hip joint Replacement10/16/2013 35. Broad treatment guidelines Age groupundisplaced More than 70 yearsDHS Young adultsDHS ChildrenHIP spica Multiple Moore`s pinning35 DHS = dynamic hip screws THR = total hip replacementDisplaced Prosthesis THR DHS Osteotomy or prosthesis Multiple Moore`s pinning Osteotomy arthrodesis 10/16/2013 36. Complications Thromboembolism : - leading cause of death withinfirst 7 days ( 40 % ) Nonunion Avascular necrosis3610/16/2013 37. Nonunion Failure of union of this fracture still occurs due toimproper reduction of imperfect internal fixation. Nonunion rate 85 95 % If there is no evidence of radiological healing taking place between 6 and 12 months at treatment on a radiograph , it is declared as nonunion.3710/16/2013 38. Causes : Inaccurate reduction Poor internal fixation Avascularity of femoral headClinical features : Unable to bear the weight on the affected side Wasting of the muscles Minimal shortening of the affected lower limb3810/16/2013 39. Avascular Necrosis Avascular necrosis of the head of the femur is an 39unpredictable complication met with after any type of internal fixation. The patient presents with pain in the hip and limping. There is limitation of all movements of the hip with muscle spasm. Radiography shows patchy areas of increased density in the head of the femur. Treatment in the early stages is by rest, traction and weight relieving caliper. When indicated, osteotomy or replacement arthroplasty is done. 10/16/2013 40. 4010/16/201 THANK YOU