بسم هللا الرحمن الرحيم

The National Ribat University

Faculty of Graduate Studies & Scientific Research

Types& Seasonal Relations of Proximal Femoral

Fractures in Sudanese Patients Admitted to Khartoum

Teaching Hospital During 2013

A thesis Submitted in Partial Fulfillment Required for

M.Sc in Human and Clinical Anatomy

By:

Yousif Adballa Fadlelmoula Balla

Supervisor:

Dr. Abbas Gareeb-alla

August 2014

بسم هللا الرمحن الرحمي

ال هو احلي القيوم ال تأ خذه س نة وال هوم هل ما يف الساموات وما يف هل ا )هللا ال ا

ذهه يؼمل ما بني أ يدهيم وما خلفهم وال حييطون ال ب ال رض من ذا اذلي يشفع غنده ا

ال مبا شاء وسع كرس يه الساموات وال رض وال يؤوده حفظهام وهو بشئ من ػلمه ا

س522. سسور الققر االيية صدق هللا الؼظميالؼيل الؼظمي.(

Chapter One

INTRODUCTION AND OBJECTIVES

Chapter Two

LITERATURE REVIEW

Chapter Three

MATERIALS& METHODS

Chapter Four

RESULTS

Chapter Five

DISCUSSION

Chapter Six

CONCLUSION& RECOMMENDATIONS

Chapter Seven

REFERENCES

ANNEX

1.1 INTRODUCTION:

The Acetabulum (cotyloid cavity).The acetabulum is a deep, cup-shaped,

hemispherical depression with lunate surface, for articulation with the head of

the femur. Acetabular foramen transmits nutrient vessels and nerves to the head

through ligamentum teres (1)

.The Head (caput femoris): is directed upward,

medialward, and a little forward. Fovea capitis femoris, which is situated a

little below and behind the center of the head, and gives attachment to the

ligamentum teres (1)

. The Neck (collum femoris) Connecting the head with the

body. The neck forms an angle of about 125° with the body. In the female, in

consequence of the increased width of the pelvis, the neck of the femur forms

more nearly a right angle with the body than it does in the male. The neck also

projects somewhat forward, but on an average is from 12° to 14° (1)

. In the

anterior surface there is a groove lodges the orbicular fibers of the capsule of

the hip-joint, these fibers hold-down the arteries to the head and their rupture

may result in AVN (avascular necrosis) of the head of the femur in

intracapsular fracture of the neck(2)

. Revascularization of the head depends on

new vessels crossing the fracture line not on any within the ligament of the

head (1)

. The Trochanters are prominent processes which afford leverage to the

muscles that rotate the thigh on its axis. They are two in number, the greater

and the lesser. Inter-trochanteric line (spiral line of the femur) running

obliquely on the anterior surface. The inter-trochanteric crest on the posterior

surface of the neck is a prominent ridge (1)

.

Although the artery in the ligament of the head of the femur (from the

obturator artery) is important in the young child, it is usually considered to

have atrophied by the age of about 7 years (but bleeding from it at adult hip

operations suggests that it may often remain patent for much longer) (2)

.

Epidemiology of the proximal femoral fractures is increasingly common due

to aging population. Its more common among women and whites United States

has highest incidence of hip fractures rates worldwide most expensive fracture

to treat on per-person basis. In low energy trauma Osteoporosis causes thinning

or weakening of the bone due to loss of bone mass. This condition affects the

elderly population of the society, particularly women. With thinner, weaker

bones, people with osteoporosis are at much greater risk for developing a hip

fracture from even a trivial fall. Spontaneous fracture without a fall may occur

if the area of bone is involved with cancer or infection and this type of fracture

is called a pathologic fracture. High energy trauma in the younger patients the

cause of this fracture is high energy impact injuries such as vehicle accidents

(3). Proximal femoral fractures are divided into four types; first type (Femoral

head fracture) involving the femoral head is usually the result of high impact

trauma such as motor accidents and often results in the dislocation. Second

type (Femoral neck fracture, also called Fracture Neck of Femur) denotes a

fracture in the neck region between the femoral head and the greater (or) upper

trochanter. The neck is narrow between the head and the shaft of the bone and

at an angle making it the weaker part of the bone that is prone to fracture.

Fracture of the neck disrupts the blood supply to the head of the femur. It is

also referred to as trans-cervical (cervical for neck) fracture. The fracture may

or may not displace the bone involved. The third type (Inter-trochanteric

fracture) is the most common type of hip fracture and refers to a fracture line

between the greater and lesser trochanter. The prognosis for this type of

fracture is fairly good, especially in a healthy patient. The fourth type (Sub-

trochanteric fracture) occurs in the shaft (body) of the femur, below the lesser

trochanter (3)

.

The symptoms in impacted and stress fractures are slight pain in the groin

or pain referred along the medial side of the thigh and knee but in displaced

fractures there is a pain in the entire hip region. On Physical examination of

impacted and stress fractures there is no obvious clinical deformity with minor

discomfort with active or passive hip range of motion, muscle spasms at

extremes of motion and pain with percussion over greater trochanter. On

displaced fractures; leg is in external rotation and abduction, with shortening.

Recommended view of radiographs (X-ray) is AP pelvis and cross-table lateral,

and full length femur film of ipsilateral side with consideration of obtaining

dedicated imaging of uninjured hip to use as template intraop. Traction-internal

rotation AP hip is best for defining fracture type .Garden classification is based

on AP pelvis. CT scan is helpful in determining displacement and degree of

comminution in some patients.MRI is helpful to rule out occult fracture but not

helpful in reliably assessing viability of femoral head after fracture. Bone scan

is helpful to rule out occult fracture and in reliably assessing viability of

femoral head after fracture (3)

. Osteonecrosis is common complication with

incidence of 10-45%. Recent studies fail to demonstrate association between

time to fracture reduction and subsequent avascular necrosis (4)

. Increased risk

with increased initial displacement but avascular necrosis can still develop in

non-displaced injuries. The Incidence of Non-union is 5 to 30% and it is

increased in displaced fractures. There is no correlation between age, gender,

and rate of nonunion. Varus mal-reduction most closely correlates with failure

of fixation after reduction and cannulated screw fixation (5)

.

Pre-injury mobility is the most significant determinant for post-operative

survival (Several studies have shown that only patient age and pre-injury

functional independence measure scores were independent predictors of

functional outcome after hip fracture. Mortality rates equal to age-matched

population thereafter in patients with chronic renal failure, rates of mortality at

2 years postoperatively, are close to 45% (3)

.

Because fracture neck of femur is commonest among elders and associated

with great morbidity and mortality (3)

; measurement of the incidence among

this group is of value for heath policies targeting this group. The diagnosis of

which type of proximal femoral fractures and the age of the patient are major

determinants of which surgical or medical treatment is suitable. By

determining of which age group and sex, this can be helpful in focusing on it

and decreasing the prevalence and determining of which side is commonly

affected can be a key-point for other researches; why? And is manipulation of

left-sided fracture by right-handed or left handed surgeons can be deferent in

the outcome? If the fracture is commonest during specific season of the year,

this can be studied later on; why? How we can prevent it?

1.2. RESEARCH OBJECTIVES:

1.2.1. General objective:

To determine the distribution of types and seasonal relations of proximal

femoral fractures in Sudanese patient admitted to Khartoum Teaching Hospital

during 2013.

1.2.2. Specific objectives:

1. To determine the occurrence of proximal femoral fractures in different age

groups.

2. To determine the occurrence of proximal femoral fractures in different sex

groups.

3. To determine the distribution of types of proximal femoral fractures in the

Sudanese patients.

4. To determine the distribution of sides on proximal femoral fractures.

5. To determine the effect of season on the prevalence of proximal femoral

fractures.

6. To identify the distributions of types among different age groups.

7. To identify the distributions of types among different sex groups.

2. LITERATURE REVIEW

2.1. Anatomical view:

The Acetabulum (cotyloid cavity).The acetabulum is a deep, cup-shaped,

hemispherical depression with lunate surface, for articulation with the head of

the femur (1)

.The Head (caput femoris): is directed upward, medialward, and a

little forward. Fovea capitis femoris, which is situated a little below and behind

the center of the head, and gives attachment to the ligamentum teres (1)

. The

Neck (collum femoris) Connecting the head with the body. The neck forms an

angle of about 125° with the body(1)

.Revascularization of the head depends on

new vessels crossing the fracture line not on any within the ligament of the

head (1)

. The Trochanters are prominent processes which afford leverage to the

muscles that rotate the thigh on its axis. They are two in number, the greater

and the lesser. Inter-trochanteric line (spiral line of the femur) running

obliquely on the anterior surface. The inter-trochanteric crest on the posterior

surface of the neck is a prominent ridge (1)

.

Although the artery in the ligament of the head of the femur (from the

obturator artery) is important in the young child, it is usually considered to

have atrophied by the age of about 7 years (but bleeding from it at adult hip

operations suggests that it may often remain patent for much longer) (2)

.

2.2. Proximal femoral fracture:

Epidemiology of the proximal femoral fractures is increasingly common due

to aging population. Its more common among women and whites United States

has highest incidence of hip fractures rates worldwide most expensive fracture

to treat on per-person basis. In low energy trauma Osteoporosis causes thinning

or weakening of the bone due to loss of bone mass. This condition affects the

elderly population of the society, particularly women. With thinner, weaker

bones, people with osteoporosis are at much greater risk for developing a hip

fracture from even a trivial fall. Spontaneous fracture without a fall may occur

if the area of bone is involved with cancer or infection and this type of fracture

is called a pathologic fracture. High energy trauma in the younger patients the

cause of this fracture is high energy impact injuries such as vehicle accidents

(4). Proximal femoral fractures are divided into four types; first type (Femoral

head fracture) involving the femoral head. Second type (Femoral neck fracture,

also called Fracture Neck of Femur) denotes a fracture in the neck region

between the femoral head and the greater (or) upper trochanter. The third type

(Inter-trochanteric fracture) is the most common type of hip fracture and refers

to a fracture line between the greater and lesser trochanter(4)

.

Osteonecrosis is common complication with incidence of 10-45%. Recent

studies fail to demonstrate association between time to fracture reduction and

subsequent avascular necrosis (4)

.

2.3. Previous studies:

In a prospective 12-year study by Chang KP, Center JR, Nguyen TV,

Eisman JA- 2004(6)

in men and women 60 years of age and older, there was a

4-6% per year reduction in the incidence rate of overall osteoporotic fractures,

but the study was unable to exclude any change in the hip fracture incidence

rate. Approximately one-half of hip fractures occurred before 80 years in men

and two-thirds before 85 years in women.

Another study was done by Has B et al (7)

to, in accordance with the

presented theoretical presumptions; analyze the possible reasons for hip

fractures of the older population in the north-eastern part of Croatia. A group of

2,696 persons (1,936 women and 760 men) with hip fractures were analyzed

during a 12 year period (from 1993. until 2005. year) in the Clinical Hospital

Osijek. The dates of admittance, age, gender and fracture location were

recorded. In men, the incidence of total hip fracture number on the left side was

greater 23.5% compared to the right side, while in women this difference does

not exist. Men have a greater incidence of trochanteric fractures than fractures

of femoral neck on both sides, while in women this difference could be shown

on the right side only. In women, a 30.5% higher fracture incidence occurred in

the winter compared to the summer.

Patients of 50 years and older, with a diagnosis of hip fracture, discharged

from two local acute care hospitals over a 5 year period were analyzed as a

function of age and gender to explore the relative proportions of inter-

trochanteric and subcapital fractures, and the change in relative proportion in

the two genders with age. This study was done by David A .T et al (8)

from

2002 to 2006 Associations between ages, gender and fracture type were

explored. Analysis of the proportion of hip fracture types across the age groups

and across gender was conducted using the Chi-Square method. This was

followed by logistic regression to test for a significant interaction between age

and gender on the likelihood of sustaining one fracture type compared to the

other. The results showed that for all patients, age and fracture type were

significantly related, with the proportion of inter-trochanteric fractures

increasing from 41.5% to 50% across age groups. A significant interaction was

found by logistic regression analysis, the relative proportion of the two types of

hip fracture changing with age in a different manner in the two genders. In

women the proportion of the hip fractures which occurred at the inter-

trochanteric site raised significantly with age across the four age groups

whereas the proportion of inter-trochanteric hip fractures among men

decreased with age. The mean age of women with inter-trochanteric fractures

is significantly older than those with subcapital fractures whereas men with

inter-trochanteric fractures were younger than men with subcapital fractures (8)

.

Riis BJ et al did a study which published in 1996. The aim of the study

was to examine the role of peak bone mass and rate of postmenopausal bone

loss for the subsequent risk of osteoporotic fracture. 182 women within 3 years

of menopause were followed longitudinally for 15 years. Over the first 2 years,

forearm bone mass (single photon absorptiometry) was measured nine times,

the rate of bone loss was calculated, and the women were stratified into a group

of "fast bone losers" (n = 49) and a group of "normal bone losers" (n = 133).

Later, bone mass was also measured in the lumbar spine and hip with dual

energy X-ray absorptiometry. At 15 years, the fast losers had significantly

lower body weight than the normal losers. Furthermore, the fast losers had

significantly increased values of bone turnover (osteocalcin and C-terminal

type I collagen breakdown products). In both groups the forearm, spine, and

hip, the fast bone losers had at all sites significantly less bone mass than the

normal bone losers. 23 women had experienced a peripheral (Colles') fracture

and 25 a spinal fracture. The fracture groups had generally significantly less

bone mass than the group without fracture, both in the forearm, spine, and hip

and they also had the highest rate of bone loss after menopause. Baseline bone

mass and rate of loss predisposed to the same extent to fractures with ODDs

ratios of about 2. If both low bone mass and rate of loss were present, the

ODDs ratio increased to about 3.they concluded that fast rate of bone loss and

low bone mass are equally important for the risk of fracture. The identification

of women at risk of osteoporosis should therefore consider both a measurement

of bone mass status, and a determination of the postmenopausal rate of loss (9)

.

Johnell O. and Kanis J. published a paper in March 2005 showed that

Lifetime risk of any osteoporotic fracture is very high and lies within the range

of 40-50% in women and 13-22% for men. Measuring the true burden of

osteoporotic fractures involves multiplying the morbidity of hip fractures

according to age group: for women aged 50-54 years, the disability caused by

osteoporotic fractures is 6.07 times that accounted for by hip fracture alone,

and for women aged 80-84 years, the incidence of hip fractures should be

multiplied by 1.55; for men aged 50-54 years, the incidence of hip fractures

should be multiplied by 4.48, and for those aged 80-84 years by 1.5. (10)

.

A referenced study by Holt et al was a prospective review of 1000 hip

fractures and reported that pre-injury mobility is the most significant

determinant for post-operative survival (11)

. Egol et al provided a review of the

factors involved in functional recovery of patients with femoral neck fractures.

They reported the successes of integrated care pathways and reviewed the risk

factors (institutionalization, co-morbidities, etc.) that go into the outcomes of

these patients. They recommend co-management of these patients with a

medical or geriatric service in order to improve patient outcomes (12)

.

3. MATERIAL AND METHODS:

3.1. Study design:

Retrospective Descriptive Cross-sectional.

3.2. Study area:

Khartoum Teaching Hospital.

3.3. Study population:

All patients admitted to Khartoum teaching hospital-department of

orthopedics & trauma during 2013.

Inclusion criteria:

Sudanese.

Admitted to Khartoum teaching hospital.

Diagnosed with fracture neck of femur by at least a registrar.

Diagnosis is done from obtained an AP pelvic X-ray at least.

Diagnosis must include the type (fracture head, fracture neck,

inter-trochanteric or sub-trochanteric fractures).

Operated at Khartoum teaching hospital.

Exclusion criteria:

Not Sudanese patient.

Not diagnosed by a registrar at least.

AP pelvic X-ray is not obtained at least.

Type of the fracture is not mentioned or reported in the

patient file.

3.4. Study instruments:

Checklist from hospital reports (patient’s file)

3.5. Sample size and sample technique:

Total coverage; all patients admitted to Khartoum teaching hospital-

department of orthopedics & trauma during2013, diagnosed with proximal

femoral fracture and operated at the same hospital.

3.6. Data analysis:

SPSS (16) software was used.

3.7. Pilot study and limitations:

Done at 3/2/2014 by meeting the medical administer of the hospital

and the head of statistics office reporting the following:

1. The total number of orthopedic additions during 2013 is 3346.

2. The files are arranged by a code numbers not by the departments

spatiality which making the reaching of specific files very

difficult.

Then I met the head of perpetrators in Orthopedics Theater at

9/2/2014 reporting that every patient operated during 2013 is reported

with his name and diagnosis. To solve that I added an inclusion criterion;

operated patients to reach their files easily and i removed determining of

prevalence from my objectives.

3.8. Ethical consideration:

From the medical administer of the hospital (annex).

4. RESULTS:

Form all patients admitted to Khartoum teaching hospital-department of

orthopedics trauma, diagnosed with proximal femoral fracture and operated

(167 patients) during 2013, only (88) patients their files were present and the

following results were obtained.

The Patients of age more than (65) years were most commonly affected

(70.45%) followed by the patients of age between (40 – 65) years (22.73%).

The patients of age between (40 -20) years or less than (20) years were less

commonly affected (4.55% and 2.27%) respectively (Figure 4.1).

Figure 4.1: Distribution of proximal femoral

fractures among different age groups in Khartoum

Teaching Hospital during 2013.

Majority of the patients was females (62.5%). The affected males were

(37.5%) (Figure 4.2).

Figure 4.2: Distribution of proximal femoral fractures among

both sexes in Khartoum Teaching Hospital during 2013.

The patients whose affected during the season of autumn (June – October)

were (55.68%) and those affected during summer (March – May) and winter

(November – February) seasons were (19.32%) and (25%) respectively (Figure

4.3).

Figure 4.3: Relation between proximal femoral fractures

and seasons in Khartoum Teaching Hospital during 2013.

The left side is commonly affected, (56.82%) less than it was right side

(43.18%). There was no patient with affected both right and left sides (Figure

4.4).

Figure 4.4: Distribution of proximal femoral fractures

among sides (right and left) in Khartoum Teaching Hospital

during 2013.

The most common type of proximal femoral fractures was inter-trochanteric

(47.73%) followed by fracture neck (42.05%).less common types were sub-

trochanteric (9.09%) and fracture head (1.4%) (Figure 4.5).

In the patients with an ages less than 20 years, neck and sub-trochanteric

fractures were commonest(50%) and (50%) respectively, while among those

with age group between (20 – 40) years fracture neck was commonest (75%)

and in age group between (45 -65) years inter-trochanteric and neck fractures

were commonest(45%)&(40%) respectively. Inter-trochanteric fractures were

Figure 4.5: Distribution of types of proximal femoral

fractures in Khartoum Teaching Hospital during 2013.

commonest in the patients with ages more than 65 years (53.2%) followed by

neck fractures (40.3%) (Table 4.1).

Age groups of the patients

Type of the

fracture

less than 20

years 20 - 40 years 40 - 65 years

More than 65

years

Count

Column

N %

Coun

t

Colum

n N %

Coun

t

Colum

n N % Count

Colum

n N %

Fracture head 0 .0% 0 .0% 0 .0% 1 1.6%

Fracture neck 1 50.0% 3 75.0% 8 40.0% 25 40.3%

Intertrochantric 0 .0% 0 .0% 9 45.0% 33 53.2%

Sub-trochanteric 1 50.0% 1 25.0% 3 15.0% 3 4.8%

In the males with proximal femoral fractures, neck fractures were

commonest(45.5%) followed by inter-trochanteric fractures(42.4%) then sub-

trochanteric fractures(12.1%) while in the females with proximal femoral

fractures, inter-trochanteric fractures were commonest(50.9%) followed by

neck fractures (40%) then sub-trochanteric fractures(7.3%) (Table 4.2).

Table 4.1: Distribution of types of proximal femoral fractures

among different age groups in Khartoum Teaching Hospital

during 2013.

Sex of the patient

Type of the fracture Male Female

Count

Column N

% Count Column N %

Fracture head 0 .0% 1 1.8%

Fracture neck 15 45.5% 22 40.0%

Intertrochantric 14 42.4% 28 50.9%

Sub-trochanteric 4 12.1% 4 7.3%

Table 4.2: Distribution of types of proximal femoral

fractures among both sexes in Khartoum Teaching Hospital

during 2013.

5. DISCUSSION

Hip) proximal femoral) fractures are regarded as the most common severe

type of fall-related injury among older and adults and the most serious of the

osteoporotic fractures because of their high morbidity, mortality and

impairment in quality of life (6, 10)

. The data were collected from 88 patients

with full criteria which mentioned in the objectives of this research.

In this study the most commonly affected age group was of more than 65

years. The epidemiological studies (in New York, 2001) showed an increase of

people aged over 65 years (13)

. In ethiopathogenesis of hip fractures, as the

outlined factors are cited osteoporotic and weak bones of older people (14)

. The

bone loss with increasing age is partially the effect of the accompanying

biochemical changes like lowering of serum sexual hormones (15,16)

and of 25-

OH-cholecalciferol levels(15)

and an increase of parathyroid hormone

concentration(17)

.

Previous studies (Center for Clinical and Basic Research, Ballerup,

Denmark) showed that females are more affected by proximal femoral

fractures than males (9)

. Our study also showed same results, this because

females are more affected by hormonal changes (15, 16)

. If the osteoporosis and

weak bones were the only reason of hip fractures, affected women should be

younger than affected men. However, the men with hip fractures are 6.6 years

younger than affected women (7)

.

Concerning the season of trauma and proximal femoral fractures, this study

showed that during autumn (June – October) the fractures are more, this may

be due to increased rates of trauma (falling down and RTAs). Other study in

the north-eastern part of Croatia showed that in women, a 30.5% higher

fracture incidence in winter, while in men the difference was not significant (7)

.

This study showed that the left side is more affected than the right but the

other pathological factors (neurological diseases and previous trauma) were not

considered in this study. In addition, several studies in Orebro, Sweden showed

that persons with neurological defects have a greater incidence of falls, and,

consequently, hip fractures, and that these fractures are predominantly located

on the diseased side (18, 19)

. Also, great majority of people are right – handed (or

footed), the supporting foot is the left one (i.e. jumping persons in athletics). Of

course, it does not mean that the left foot is weaker, or that the pelvi-

trochanteric muscles on the left side get more quickly tired. In other words, the

more frequent fractures of the left hip in males occur on the less skilled, and,

the most probably, on the stronger foot then the more frequent left hip fractures

in men, can be a consequence of the instability, caused by the weaker

neuromuscular function on the left body side(7)

.

There was also a study in the north-eastern part of Croatia at 2006 showed

that in the most patients (apart from the fractures on the left body side in

women) the greater incidence of inter-trochanteric fractures, compared to the

neck femoral fractures, such fractures are often multifragmental. It is well

known that trochanteric part of pelvis serves as the insertion of the strong

pelvi-trochanteric muscles (18)

. In this study the inter-trochanteric fractures

were most common followed by femoral neck fractures. Sub-trochanteric

fractures were not common there was study in New York City, 2006 showed

an increasing number of clinical reports suggested an association sub-

trochanteric and diaphyseal regions with long-term use of bisphosphonates (20,

21).

When different age groups were compared in this study, patients with ages

less than 20 years, neck and sub-trochanteric fractures were commonest while

in the patients aging between (20 – 40) years fracture neck was commonest and

among those aged between (40-65)years or more than 65 years Inter-

trochanteric fractures were commonest.

In this study, both sexes (males and females) were compared showing that

neck fractures were commonest while in females inter-trochanteric fractures

were commonest. Another study published at 10/2010 showed that In women

the proportion of Inter-trochanteric fractures rises from 24% in the youngest

group to almost 52% in the oldest group, while in men it falls from 59% to

42% although most of the change occurs early, with little change after 65(8)

.

There is evidence that the loss of trabecular and cortical bone with age may

differ between men and women, the significance of this is unclear (22)

but the

rising proportion of inter-trochanteric fractures in women may reflect greater

trabecular bone loss with age in women (8)

.

6. CONCLUSION AND RECOMMENDATIONS

6.1. Conclusion:

From the results which mentioned, the conclusions of this study about

proximal femoral fractures in Sudanese patients are:

Proximal femoral fractures are commonest among elders aged more than 65

years and females. More than halve of the patients were affected during season

of autumn. Left side was commonly affected. Intertrochantric fracture was

commonest type followed by femoral neck fracture. In age group more than 65

years, inter-trochanteric type is commonest while in age group between (40-65)

years inter-trochanteric and femoral neck types both were commonest. In age

group between (20-40) years femoral neck type is commonest. Males were

commonly affected by femoral neck fractures and females by inter-trochanteric

fractures.

6.2 Recommendation:

Proximal femoral fractures are associated with great morbidity and

mortality among elders; health policies must focus on this age group and

support further researches concerning this problem.

Post-menopausal care and hormonal therapy are important to decrease

the incidence of proximal femoral fractures among women.

Further researches are important about the outcome of operations on

different side (right and left) when done by same surgeon; training of

orthopedic surgeons (right-handed or left-handed) to perform operations

on both sides with same outcome.

Training of doctors medical staff assistants to deal with inter-

trochanteric type more than other types.

Increasing the efforts by health authorities concerning the health

education about trauma during autumn for elders.

Design a protocol for this type of fracture for the management especially

in the rural areas.

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The Bones of the Lower Extremity; femur. Philadelphia: lea& Febiger. 1918.

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7/2/2014.

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Orthopaedic Knowledge Update: Trauma 2. Rosemont, IL. American Academy

of Orthopaedic Surgeons. 2000. pp 115-124.

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Operative treatment of femoral neck fractures in patients between the ages of

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other osteoporotic fractures in elderly men and women. Dubbo osteoporosis

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7. B. Has1, A. Nagy, E. Has-Sch n, Roman , J. Kristek and B. Splavski.

Influence of Instability and Muscular Weakness in Ethiopathogenesis of Hip

Fractures. 30 (2006) 4: 823–827.

8. David A .T, M Kloseck, R G Crilly, B Chesworth, J Gilliland. Hip

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بسم هللا الرحمن الرحيم

كلية الدراسات العليا -جامعة الرباط الوطني

(1الدفعة)-ماجستير التشريح السريري

Check-list for research on:

Types& Seasonal Relations of Proximal Femoral

Fractures in Sudanese Patients Admitted to Khartoum

Teaching Hospital During 2013

by: YousifAbdallaFadlelmoula.

Supervissor: Dr/Abbas Gareeb-Alla,

No. Age Sex Month of trauma

Side of fracture

Type of fracture

1=less than 20 yrs 2=20-40 yrs 3=40-65 yrs 4=more than 65 yrs

1=male 2=femal

1=June – October 2=November- February 3=March- May

1=right 2=left 3=both

1=fracture head 2=fracture neck 3=intertrochantric 4=subtrochantric

1

2

3

4

5

6

DEDICATION

I want to dedicate this research work to my lovingly

respected parents.

To my Teachers

To my Students

And to my Friends.

ACKNOWLEDGEMENT

I would like to express my deepest gratitude to my supervisor Dr.

Abass Gareeb-Alla, for his excellent guidance, caring, patience, and

providing me with an excellent atmosphere for doing this research.

Special acknowledgement is for Dean of Faculty of Graduate

Studies & Scientific Research-National Ribat University, Prof. Al-

Tahir Osman, and Dr. Kamal Badawy for their great support during

this program and precious advice.

I would like to thank the team of Statistic Office and Theater of

Orthopedics Khartoum-Teaching Hospital for their support with the

information.

Finally, I would like to thank my friend Hasan Badawy and

appreciate all of those who in a way or another facilitated this study.

LIST OF CONTENTS

LIST OF FIGURES

Content Page No.

Dedication I

Acknowledgment II

Contents III

List of Figures IV

List of tables V

Abbreviations VI

Abstract(English)

Abstract(Arabic)

VII

IX

Chapter one: Introduction and Objectives

1.1 Introduction 1

1.2 Research objectives 5

1.2.1 General objectives 5

1.2.2 Specific objectives 5

Chapter Two: Literature review 6

Chapter Three: Materials and Methods 11

Chapter Four: Results 13

Chapter Five: Discussion 20

Chapter Six: Conclusion & Recommendations 23

Chapter Seven: References 25

ANNEX

Figure No. Title Page No.

4.1 Distribution of proximal femoral fractures among

different age groups in Khartoum Teaching

Hospital during 2013.

9

4.2 Distribution of proximal femoral fractures among

both sexes in Khartoum Teaching Hospital during

2013.

10

4.3 Relation between proximal femoral fractures and

seasons in Khartoum Teaching Hospital during

2013.

11

4.4 Distribution of proximal femoral fractures among

sides (right and left) in Khartoum Teaching

Hospital during 2013.

12

4.5 Distribution of types of proximal femoral fractures

in Khartoum Teaching Hospital during 2013.

13

LIST OF TABLES

Table No. Title Page

No.

4.1 Distribution of types of proximal femoral fractures among

different age groups in Khartoum Teaching Hospital during

2013.

14

4.2 Distribution of types of proximal femoral fractures among

both sexes in Khartoum Teaching Hospital during 2013.

14

ABBREVIATIONS

AP Anteroposterior

CT Computerized Topography

MRI Magnetic Resonance Imaging

n Number

SPSS Statistical Package for the Social Sciences

RTAs Road Traffic Accidents

AVN Avascular Necrosis

ABSTRACT

Arteries supplying head and intracapsular part of neck of the femur are mostly from the

trochanteric anastomosis and their rupture may result in avascular necrosis of the head of

the femur in intracapsular fracture of the neck. Hip) proximal femoral) fractures are

regarded as the most common severe type of fall-related injury among older and adults

and the most serious of the osteoporotic fractures because of their high morbidity,

mortality and impairment in quality of life.

The aims of this retrospective descriptive cross-sectional study were to determine the

distribution of types and seasonal relations of proximal femoral fractures in Sudanese

patients admitted to Khartoum Teaching hospital during 2013. From all patients

admitted, diagnosed with proximal femoral fracture and operated (167 patients) during

2013, only (88) patients their files were present and the following results were obtained

from them. The Patients of age more than (65) years were most commonly affected

(70.45%) followed by the patients of age between (40 – 65) years (22.73%).Majority of

the patients was females (62.5%), the males whose affected were less (37.5%). The

patients that affected during the season of autumn (June – October) were (55.68%). The

left side is commonly affected (56.82%). The most common type of proximal femoral

fractures was inter-trochanteric type (47.73%) but in the males with proximal femoral

fractures, neck fractures were commonest(45.5% of males). In the patients with an ages

less than 20 years, neck and sub-trochanteric fractures were commonest(50%)and (50%)

respectively, while among those with age group between (20 – 40) years fracture neck

was commonest(75%) and in age group between (45 -65) years inter-trochanteric and

neck fractures were commonest(45%)&(40%) respectively. Inter-trochanteric fractures

were commonest in the patients with ages more than 65 years (53.2%) followed by neck

fractures (40.3%).

In conclusion, proximal femoral fractures were commonest among elders aged more

than 65 years and females. More than halve of the patients were affected during season of

autumn. Inter-trochanteric type was commonest type followed by femoral neck fracture.

Therefore designing of a protocol for this type of fracture for the management especially

in the rural areas and increasing the efforts by health authorities concerning the health

education about trauma during autumn for elders are important to decrease the incidence

of proximal femoral fractures and their complications.

ملخص الدراسة

انذست يفبغشة ي ف يؼظب ػظى انفخز ي داخم انحفظت انشلبت يجضء انشأط ششا

داخم كسش انشلبت حبنت ف سأط ػظى انفخز ي الػبئ خش لذ ؤدي إنى ز انششاحضق

ببنسمط اإلصبببث انشحبطت أكثش األاع خطسة ب انذا( انفخزي( كسس انسن حؼخبش .انحفظت

انفبث اسحفبع يؼذالث انشاضت نب نب ي أخطش كسسشبشت انؼظبو انببنغ كببس انس ب

ة.إخمبض ف ػت انحب

نكسسانست انؼاللبث األاع ححذذ بأثش سجؼ انصفت انؼشضت ز انذساست أذاف

ي جغ2013 .انؼبو خشف انخشطو انخؼه خاللسف ي انشضى انسدا ف انذا انفخز

يشضب (167)حى إجشاء ػهبث جشاحت نى انذا انفخز بكسش حشخصى، انشضى انز حى إدخبنى

.يب انخبئج انخبنتحى انحصل ػهى يجدة يهفبحىي انشضى (88) فمظ كب ،3102انؼبو لخال

يب ف س انشضىهى %(45,57)األكثش حأثشا كبا ػبيب (65)أكثش ي أػبسى انشضى انز

انزكسانز %(5,,3)إبثبكبا انشضىانغبنبت انؼظى ي .%(33,42) ست (65 - 40) ب

-أكخبش( انخشف ف يسى لذ حأثشا انشضى ي%( 5,,55)كب%(. 24,5)حأثشا كبا ألم سبت

انع االكثش شػب ي كب%(. 53,,5) كبج األكثش سبت انجبب األسش.انكسس ف )

األكثش شػب كسسانشلبتكبج انزكسنك ف %( 74,42)ب انذست ع انذا كسسانفخز

ػبيب، كسس انشلبت ححج 31أػبسى ألم ي ي ب انزكس(. ف انشض انز كبج% 75)

ػهى انخان، ف ح ب ري انفئت انؼشت يب ب%( 51%( )51)انذست كبج األكثش شػب

يب ب تس (65- 45)ف انفئت انؼشت ب %( 45) كسشانشلبت األكثش شػب ست كب (40 - 20)

ػهى انخان. ف انشضى انز %( 71%( )75)انذست كسس انشلبت كبج األكثش شػب

هب كسس انشلبت %( 52,3) ػبيب، كبج انكسس ب انذست األكثش شػب 65أػبسى أكثش ي

(71,2)%.

ست 65أػبسى أكثش ي انز كببس انس ب األكثش شػب انذا انخخبو،كسسانفخز ف

األكثش شػب ب انذست انع انخشف. كب يسى خالل انشضى صف أكثش يلذ حأثش .اإلبد

انبطك خبصت ف نهؼبنجت انكسس نزا انع ي بشحكل حصى ببنخبن .كسشػك انفخز ه

خالل اإلصبببثػ انخثمف انصح بشأ ي لبم انسهطبث انصحت انجد انبزنت صبدة انشفت

.فبحبػيضب انذا كسسانفخزخمهم سبت حذد ن ي األشبء انت نهشخ انخشف ببنسبت