13/5/2013

INTRACAPSULAR FRACTURE

NECK OF FEMUR

BHAGEERATH REDDY PR NO 11

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• Anatomy of Hip Joint• Fracture femur neck Aetiology Mechanism of Injury Classification Clinical features Investigations Treatment

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HIP JOINT

• Articular Capsule• Iliofemoral ligament• Pubofemoral ligament• Ischiofemoral ligamnet

Ligaments :

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Trabecular pattern of proximal hip

Principal compressive group

Ward’s triangle

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Blood supply:

Femoral artery Profunda femoris artery

Lateral circumflex arteryMedial circumflex artery

EXTRACAPSULAR ARTERIAL RINGEXTRA CAPSULAR ARTERIAL RING

Retinacular arteries

SUBSYNOVIALINTRACAPSULAR ARTERIAL RING

Epiphyseal branchesMetaphyseal branches

Artery of ligament teres

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• Older patients – Osteoporosis or Osteomalacia

• Elderly women • Major trauma in young adults like RTA,fall etc.

FRACTURE NECK OF FEMURAETIOLOAETIOLOGY

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• Trivial fall – direct blow over the greater trochanter

• Lateral rotation of the extremity posterior communition of the neck.

• Cyclical loading due to muscle force and torsion

Mechanism of injury

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CLASSIFICATION

Broad classification:Fracture neck of femur

INTRACAPSULAR EXTRACAPSULAR

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Structural classificationIMPACTEDUNDISPLACED

DISPLACED

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causatively

STRESS FRACTURES

TRAUMATIC FRACTURES

PATHOLOGICAL FRACTURES

POSTIRRADIATION FRACTURES

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Based On Fracture Character

Anatomical location

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Fracture angle:

PAUWEL’S CLASSIFICATIONPrerequisites : Traction Internal rotation

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GARDEN’S CLASSIFICATION

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DELBET’S CLASSIFICATION

Transepiphyseal fracture

Inter trochanteric fracture

Sub trochanteric fracture

Transcervical fracture

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CLINICAL FEATURES

PainRestriction of movements

Minimal shorteningExternal rotation deformity

h/o fall

Tenderness over ant.hip jt lineO/E

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Active straight leg rising is difficult

Groin painAntalgic gait

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Investigations

Radiography

1.EXTENT OF FRACTURE COMPLETE

INCOMPLETE2.FRACTURE ANGLE3.BREAK IN SHENTON’S LINE4.POSTERIOR WALL COMMUNITION5.PROMINENT LESSER TROCHANTER6.DEGREE OF OSTEOPOROSIS

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Shenton’s line

It is the line drawn from the superior margin of the obturator foramen to the margin of neck.

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Singh’s indexDegree of osteoporosis

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Other investigations• Oxygen tension measurement• Venography• Intraosseous pressure recording

• Isotope scanning• Bone scan with Tc-99m, sulphur colloid, etc.

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TreatmentTREATMENT

Aims of treatment

• Early anatomical reduction – prevents further vascular damage.

• Impaction of fracture fragments• Rigid internal fixation: enables the vascularization from the surrounding soft tissues and uninjured bones – early callus formation.

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Fracture neck of femur

Undisplaced Displaced

Physiologically <60 years Physiologically >60 years

Closed reduction under x-ray control Prosthetic replacement

Reduction possible Reduction not possible Normal hip Hip with pre existing arthritis

Multiple screw fixation

Open reduction screw fixation

hemiarthroplasty THR

ConservativeMultiple screws

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Garden I: Conservative Hip Spica for -old fracture. -unfit for surgery. surgical multiple pins by Moore,Knowles cannulated screws.Garden II: fracture fixed with DHS, multiple cannulated AO screws.Gardens III/IV: conservative treatment rarely indicated. SURGERY – anatomical reduction impaction stable internal fixation

Treatment plans as per Garden’s Classification

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Reduction techniques

Closed reduction with hip in extension• Whitman’s method

• Massie• Mc Elevenny• Deyerle

Closed reduction with hip in flexion

• Lead better method

• Smith Peterson• Flynn

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INTERNAL FIXATION for fracture neck of femurChoices of implants for internal fixation:Multiple pins (Knowles,Moore): - - impacted fractures - medically unfit persons - fractures in children.ASNIS: - provide improved pullout and bending and torque strengths.*Fixed angle nailSliding or Telescopic nails (Dynamic Hip Screws): nail offers collapsibility continuous impaction at the fracture site lessen the chances of nail penetration.

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DHSMS

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Blade plate fixation:

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Complications of Internal Fixation

InfectionNonunionAvascular necrosisLoose fixation

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Meyer’s Muscle Pedicle Graft:

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COMPLICATIONS OF FEMORAL NECK FRACTURE

Thromboembolism

Non union:1/3 cases heal with OR+IFRate – 85-95% *Causes:• Inaccurate reduction• Poor Internal Fixation• Lack of Cambium layer in periosteum.• Avascularity of femoral head• Posterior wall communition

Incidece; 40%

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Clinical features:• Unable to bear weight on affected side• Trendelenberg test +ve• Telescopic test +ve• Wasting of muscles• Minimal shortening of affected limb.

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Treatment

Head is viable

Head is not viable

Osteotomy Acetabular cartilage viable

Acetabular cartilage not viable

THRHemireplacement arthroplastyBipolar arthroplasty

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AVASCULAR NECROSIS

Due to actual AVN: 2˚ to ischemiaLate segmental collapse: due to collapse of subchondral and articular cartilage.

INCIDENCE: Aseptic necrosis: 66-84%Late segmental collapse: 7-27%Survival of head depends upon:• Uninjured vascular supply• Revascularization

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Investigations: RadiographyBonescan

Treatment: • Symptomatic treatement: bed rest, NSAIDS.• Displacement or Angulation Osteotomy in early stages.

• Hemireplacement arthroplasty• THR.

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Osteotomy

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Hemiarthroplasty

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• An unsolved problem• Fracture in elderly• Majority due to trivial fall.• Garden’s classificatio is widely accepted.

• It is an Orthopaedic Emergency.• Speed is the watchword in management.

• Early anatomical reduction,impaction and rigid internal fixation are the aim of treatment.

• DHS and Multiple cannulated cancellous screws is the currently accepted method of fixation.

• Nonunion ad AVN are very common.

Fracture neck of femur at a glance

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