fraktur neck femur

8/13/2019 fraktur neck femur

1/16

FRACTURE NECK OF FEMUR

Patient : HBB

Age : Female

Sex : 70yrs

Race : Malay

General Hospital Kuala Lumpur

SUMMARY

Most common ractures seen among t!e el"erly are !ip ractures# $!ese ractures !a%e

a tremen"ous eect on our !ealt! care system an" "espite t!e "e%elopment in implant

"esigns& surgical tec!ni'ues an" patient care t!ey ten" to (e a ma)or consumption on

our !ealt! care resources# *n s!ort our attempt in treating t!ese patients +oul" (e

"irecte" to+ar"s optimi,ing patient-s !ealt!& early surgery& mo(ili,ation an"

"isc!arge# $!e a(o%e is case o a p!ysiologically young patient +it! close "isplace

racture nec. o emur +!ic! +as treate" +it! a unipolar !emiart!roplasty

CASE REPORT

A 70 year ol" Malay la"y +it! a !istory o all a(out a +ee. ago is ren"ering !er (e"

ri""en# S!e +as (roug!t in (y !er "aug!ter +it! t!e complaint o (eing una(le to

mo%e !er rig!t lo+er lim( an" constant pain# Her rig!t lo+er lim( +as note" to (e

slig!tly s!orter an" externally rotate"# $!ere +as also (ruising o%er t!e lateral aspect

o t!e rig!t t!ig!# S!e !a" no .no+n me"ically illness #$!e /ray o t!e rig!t !ip )oint

re%eale" a Gar"en type our racture nec. o emur# *t +as also note" t!at t!ere +as

no art!ritic c!anges o%er t!e emoral !ea" an" aceta(ular cup# S!e +as opte" or a

unipolar !emiart!roplasty 1uncemente"2# Patient +as put on s.in traction an"

sc!e"ule" or operation# *ntraoperati%ely an" postoperati%e perio"s +ere une%entul#

Ater a"e'uate p!ysiot!erapy patient +as "isc!arge" +ell +it! +al.ing rame support

or mo(ili,ation# S!e +as ollo+e" up in clinic in 3 +ee.s time an" note" t!at !er

36


2/16

+oun" !a" !eale" +ell# /ray re%eale" no apparent loosening o implants# Patient

+as a(le to am(ulate +ell (ut still nee"e" t!e ai" o t!e +al.ing rame# S!e +as gi%en

!er next ollo+ up in 4 mont!s time

DISCUSSION

Introduction

*n t!e treatment o racture nec. o emur t!ere !as (een speciic milestones t!at !as

(een passe" example rom re"uction (y "ynamic traction& t!e importance o

anatomical re"uction an" maintenance in plaster& t!e "e%elopment o sta(le internal

ixation "e%ices an" inally t!e "e%elopment o implant art!roplasty +!ic! t!en le" to

t!e era o total )oint replacement# 5espite t!e a"%ances in t!e management o emoral

nec. ractures& t!is con"ition is still reeree" to as 6t!e unsol%e" racture# A

compoun"ing pro(lem is t!e increase" inci"ence o emoral nec. ractures# $!is

racture is commonly seen at t!e age o 77 in +omen an" 73 in men# Men suer 809

o t!ese ractures an" t!e racture rate "ou(les or eac! "eca"e o lie ater t!e it!

"eca"e#

Incidence

Fracture nec. o emur oun" to primarily to aect t!e el"erly# ;< $!e inci"ence

steeply rises ater t!e sixt! "eca"e o lie& especially in emales# $!e el"erly usually

!a%e %isual pro(lems an" also associate" muscular +ea.ness +!ic! may (e

attri(uting actors increasing t!e ris. o alling#

Etiology factor

Most o t!ese ractures are seen among t!e el"erly an" are attri(ute" to a all o some

.in"# $!e ten"ency to all increases +it! age an" is "epen"ent on many actors +!ic!

inclu"e poor %ision& "ecrease muscle po+er& la(ile (loo"pressure an" coexisting

37


3/16


4/16

racture o t!e emoral nec.# A""itional source o (loo" supply to t!e emoral !ea" is

t!ro t!e ligamentum teres# $!ese usually enter t!ro t!e o%ea capitis an" are relati%ely

unimportant in a"ults as t!e only supply a small area o (one aroun" t!e o%ea# > surgically treate" patients +it! ;3conser%ati%ely treate" patients# All ;3 patients treate" conser%ati%ely sur%i%e" +it!out

43


9/16

complications (ut only one patient +as a(le +al.# Fortyt!ree percent o t!ose treate"

surgically "e%elope" signiicant complication (ut still orty our percent o t!em +ere

am(ulatory at t!e en" o treatment#

$!us conser%ati%e treatment +as opte" as an optional treatment or t!ose patients +!o

+ere poorly mo(ile or totally immo(ile prior to t!e racture#S!atan ;0< compare"

t!e results o ;0C patients treate" non operati%ely +it! >04 patients treate"

operati%ely# $!e criteria or nonoperati%ely +ere immo(ility or poor a(ility prior to

t!e all# on Ioperati%e treatment inclu"e" traction& analgesia an" mo(ili,ation as

early as patients tolerates#

$!e !ospital mortality rate +as 379 in t!e cases t!ose treate" nonoperati%ely

compare" +it! 439 or t!ose treate" surgically& (ut only ;C9 o t!e ormer (ecame

am(ulatory prior to "isc!arge compare" +it! @>9 o t!ose treate" operati%ely#

Most o t!ese cases s!oul" (e sta(ili,e" ast an" surgery carrie" out as soon as

possi(le to a%oi" complication suc! as pressure sores& urinary tract inection an"

pneumonia to +!ic! t!e (e" (oun" el"erly are prone an" +oul" increase t!e perio" o

pain prior to surgery#

Generally early surgery an" mo(ili,ation re"uces t!e ris. o t!rom(oem(olic

pro(lems# Most o t!e stu"ies con"ucte" a(out !ip ractures pro%e t!at t!e use o

eit!er +ararin& !eparin an" "extran 70 are eecti%e in re"ucing t!e inci"ence o

t!rom(oem(olic complications#

$!us to re"uce t!e mor(i"ity an" mortality cause" (y t!rom(oem(olic complications

one o t!e a(o%e antit!rom(otic agents is a"%ise"# t!er p!ysical antit!rom(otic

met!o"s are crepe stoc.ings& acti%e an.le exercises an" a%oi"ance o o%er transusion#

Prop!ylactic anti(iotics is a"%ise" prior to surgery an" proper aseptic measures ta.en

t!roug!out surgery to a%oi" inection o operati%e site# Most o t!ese patients are rail

el"erly an" t!eir immunity against an inection is oten ina"e'uate an" can pro%e to

44


10/16

(e atal# Burnett ;;< in a ran"omi,e" trail o prop!ylactic anti(iotic usage reporte" a

re"uction in ma)or +oun" inection to 0#79 compare" to t!e place(o usage +!ic! is

>#79

A re"uction in t!e operati%e time an" minimi,ation o intraoperati%e (loo" loss is

recommen"e"# Sta(le ixation +oul" also ena(le early mo(ili,ation o t!ese patients

t!us re"ucing postoperati%e mor(i"ity#

SPECIFIC TREATMENT

FACTORS INF$UENCIN) T%E C%OICE OF TREATMENT

a* Pat!ology

%ascular in gro+t! at t!e racture site is t!e main route (y +!ic!

re%asculari,ation occurs# $!e arteries o ligamentum teres maintains t!e

%ia(ility o a small area o (one aroun" o%ea capitis an" rom !ere %ascular in

gro+t! may e%entually occur# $!e "egree o racture "isplacement +oul"

"eci"e" t!e possi(ility o t!e lateral an" inerior metap!yseal arteries

remaining intact#

&* Factor influencing fe"oral !ead 'ia&ility

*n surgery +!ere preser%ation o t!e emoral !ea" is opte" or t!e actors t!at

inluences t!e %ia(ility o t!e emoral !ea" an" promote racture !ealing

s!oul" (e assesse"#

Ma)ority o stu"ies s!o+ t!at inci"ence o non union increases +it! age#

Barnes ;3< reporte" @09 non union among t!ose age" o%er 8> years

compare" to 449 in t!ose un"er C@ years# Bro+n an" A(rami ;4< reporte" an

increase inci"ence o non union among emales an" t!e Me"ical Researc!

=ouncil in ;7C a%ascular necrosis more among emales 13392 compare" to

1;C92 in males#

45


11/16

5alen an" Jaco(sson ;>< reporte" an increase inci"ence o non union

associate" +it! increase osteoporosis +!ic! +as assesse" using t!e Sing!

gra"e in t!eir series o > patients# Me"ical Researc! =ouncil ;3< !as s!o+n

t!e proximal ractures to !a%e an increase" ris. o non union# $!e "egree o

initial "isplacement o t!e racture strongly inluences t!e inci"ence o non

union an" a%ascular necrosis# Me"ical Researc! =ouncil ;3< reporte" @9 non

union an" ;09 a%ascular necrosis among t!e non "isplace" ractures an" 3;9

non union an" ;39 a%ascular necrosis among t!e "isplace" ractures#

Sc!ec. ;@< reporte" t!at posterior comminution resulting in angulation o t!e

racture site in 4@9 o cases# He recommen"e" re"ucing t!e racture to a

position o %algus to pre%ent "isplacement o t!e racture# Barnes ;3< stu"ie"

;0CC patients an" oun" t!at a "elay in surgery up to C "ays "o not increase

non union "ramatically# *n support to t!is Holm(erg ;@< stu"ie" ;3@; patients

an" oun" t!ere +as no signiicant increase in t!e inci"ence o non union an"

a%ascular necrosis among t!ose +!ose surgery is "elaye" or 7 "ays (ut ater

+!ic! t!e inci"ence increases rom 3>9 to @9#

n t!e AP %ie+ t!e angle (et+een t!e me"ial tra(eculae an" t!e line o t!e

emoral s!at is normally ;C0 "egrees an" on a lateral %ie+ t!e line passing

t!e axis o t!e emoral nec. an" passing t!ro t!e center o t!e emoral !ea" is

normally ;80 "egree# Barnes ;3< oun" t!at ractures internally ixe" +it! an

AP tra(eculae angle (et+een ;70"egrees an" ;7 "egrees !a" t!e !ig!est

union rate 17792# $!ose ixe" in %arus +it! a tra(eculae angle less t!an ;C0"egrees union rate +as only >>9# Among t!ose +it! a tra(ecular angle

greater t!at ;80 "egrees t!e rate o a%ascular necrosis +as !ig!# Barnes also

reporte" t!at more t!an 30 "egrees o in%ersions or retro%ersion increases t!e

inci"ence o non union rom >9 to 709

c* Prediction of fe"oral !ead 'ia&ility

Arteriograp!y among racture nec. o emur s!o+e" t!at in t!ose +!om t!e

posterior superior retinacular %essels +ere intact a%ascular necrosis "i" not

46


12/16

occur# $urner ;C< reporte" t!at out o ;@ patients +it! a normal preoperati%e

mtec!netium antimony colloi" scan only one "e%elope" a%ascular necrosis#

ut o ;3 patients +it! a(normal scan results ;; "e%elope" %ascular necrosis

C%OICE OF TREATMENT

Bot! t!e inci"ence o a%ascular necrosis an" nonunion are important actors in t!e

"ecision or t!e c!oice o treatment o racture nec. o emur# $!is "ecision is also

(ase" on +!et!er t!e racture is "isplace" or not#

UNDISP$ACED FRACTURE NECK OF FEMUR

+INTRACAPSU$AR,

Fracture nec. o emur +!ic! are impacte"& a("ucte"& in %algus or gar"en $ype ;

inclu"ing also Gar"en type ** ractures +!ic! are un"isplace" (ut not impacte"# $!e

c!oice o treatment o t!is type o racture is (asically conser%ati%e +it! suicient

immo(ili,ation or internal ixation (y means o scre+s or pins# Art!roplasty is not

really in"icate" as t!e initial treatment as t!e union ratein t!ese type o ractures are

relati%ely !ig!# it! t!e preexisting e%i"ence o art!ritis o !e !ip )oint t!en

art!roplasty is consi"ere"# Jenson an" Hog! ;7< "emonstrate" an increase" ris. o

non union among t!e Gar"en type ** ractures +!en compare" to t!e impacte"

patterns 1non union o C;9 in t!e Gar"en $ype ** ractures an" ;;9 in t!e impacte"

ractures2# $!e report suggests t!at t!e a(sence o impaction on t!e xray is an

in"ication or operati%e treatment# Lo+ell ;8< stu"ie" t!at any racture +it!

retro%ersion on t!e lateral xray +ill su(se'uently get "isplace" t!us early internal

ixation is recommen"e"#

=riteria or conser%ati%e treatment (ase" on ra"iological in"ings are t!e e%i"ence o

impaction o t!e racture in t+o planes& no e%i"ence o racture "isplacement& Pau+els

angle less t!an 70 "egree& clinical e%i"ence o sta(ility +it! a ull range o passi%e !ip

47


13/16


14/16

ray s!oul" e%i"ence o art!ritis or +ear# Bipolar !emiart!roplasty is use" in patients

+!o are expecte" to outli%e t!e prost!esis an" +ear aceta(ulum is note"# it! t!e use

o (ipolar t!e re%ision surgery at a later "ate is ma"e easy as only t!e aceta(ular

component is c!ange" an" t!e emoral component nee" not (e replace"#

*n (ipolar !emiart!roplasty t!e use o cement apparently re"uces post operati%e pain

ena(ling patient or early mo(ili,ation& pro%i"es sta(ility or t!e prost!esis (y

pre%enting sin.age o loosening o prost!esis# Ho+e%er t!e "isa"%antages o t!e use

o cemente" are t!e increase in t!e cost& increase in t!e ris. o "islocation re'uiring an

open re"uction an" t!e "isa"%antage o t!e cement it sel causing an increase" ris. in

car"io%ascular collapse#

REFERANCES

;< Martin A"& Sil%ert!orn KG& Ber!ar"son S& a")a A& rs LL# $!e inci"ence o

racture o t!e proximal emur in t+o million =ana"ians rom ;73;8># =lin

rt!op ;; 3CC: ;;;;;8

3< aterston JA# Falls in t!e el"erly uture strategies# Journal o social me"icine

;; 8>:;8;;

4< =laey $J# A%ascular necrosis o t!e emoral !ea" an anatomical stu"y# J

Bone a Joint Surg# ;C0 >3B: 80380#

>< Se%itt S& $!ompson RG# $!e "istri(ution an" anastomosis o arteries

supplying t!e emoral !ea" an" nec. #J Bone an" Joint Surg ;C@ >7B:@C0

@74@< ?ast+oo" H5H# 5elaye" "iagnosis in t!e emoral nec. ractures in t!e

el"erly# Age ageing ;87 ;C 478483#

C< ures!i K& Ho".inson HM# ?%aluation o a ten mental test in t!e

instutionalise" el"erly# Ageing ;7> 4: ;@3;@7

7< 5a%is Fm& oolner 5F& Frampton =& il.inson A& Grant A& Harrison P$&

Ro(ert M$S& $!a"a.a R# Prospecti%e multicenter trail o mortality ollo+ing

general or spinal anaest!esia or !ip racture surgery in t!e el"erly# Britis!

Journal o Anaest!esia ;87 @: ;080;088

49


15/16

8< unn 5# Sl"ing !ip scre+ an" me"ial "isplacement osteotomy# Journal o

social me"icine# ;88 8: ;>0;>3

< Lyon LJ& e%ins MA# Management o !ip ractures in nursing !ome patients&

to treat or not to treat Journal Am Geriartr Soc ;8> 43 4;4@

;0< S!atan G& Her(sman H& Pa%li"es =# Selecti%e conser%ati%e treatment in !ip

ractures# Surgery ;C7 C;: @3>@37

;;< Burnatt J& Gustilo RB& iliams 5& Kin" A=# Prop!ylactic anti(iotic * !ip

ractures : a "ou(le (lin" prospecti%e stu"y # J Bone an" Joint Surg ;80 C3A:

>@7>C3

;3< Barnes R& Bro+n J$& Gar"en RS& icoll ?A# Su(capital racture o t!e emur:

a prospecti%e re%ie+# J Bone an" Joint Surg ;7C @8B:33>

;4< Bro+ns J$& A(rami G# $ranscer%ical emoral racture: a re%ie+ o ;@

patients treate" (y sli"ing nail plate ixation# J Bone an" Joint Surg ;C> >CB:

C>8CC4

;>< 5alen & Joco(sson B# Factors inluencing t!e inci"ence o reoperation ater

emoral nec. ractures# *nt rt!op ;8@ : 34@347

;@< Sc!ec. M# *ntracapsular racture o emoral nec.: comminution o t!e

posterior nec. cortex as a cause o un sta(le ixation# J Bone an" Joint Surg

;@ >;A: ;;87;300

;C< $urner JH# Post Itraumatic a%ascular necrosis o t!e emoral !ea" pre"icte"

(y preoperati%e tec!netium m antimony colloi" scan# J Bone an" Joint

Surg ;84 C@A 78C77

;7< Jensen J& Haug! J# Fractures o t!e emoral nec.: a ollo+up stu"y ater non

operati%e treatment o Gar"en Stage * an" ** ractures# in)ury ;84 ;> 444>3

;8< Lo+ell J5# Results an" complications o emoral nec. ractures# =lin rt!op

;80 ;@3: ;C3;73

;< Martyn JP& Glyp AP# Hip racture management# $reatment o intracapsular

racture emur& xor"& Blac.+ell pu(lication

30< Bro"etti A# $!e (loo" supply o t!e emoral nec. an" !ea" in relation to t!e

"amaging eects o scre+s an" nails& J Bone an" Joint Surg ;C0 >3B 7>

80;

50


16/16

3;< icoll ?A# $!e unsol%e" racture# ) Bone an" Joint Surg ;C4 >B: 343>;

33< Gar"en RS # Selecti%e surgery in me"ial racture o t!e emoral nec.# *n)ury

;77 : @7

51

fraktur neck femur

Documents

Transcript of fraktur neck femur