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Fracture neck of femur is one of the most |   observed in the 



leading
to morbidity and mortality among them. With increased standards of   and the resulting
longevity, this type of fracture is becoming increasingly common. The fracture can be a
major cause of morbidity in the elderly as it leaves many patients immobile and confined to
their bed.  
in these patients can take months. Immobility makes them more prone to pressure sores (bed
sores) and chest infections. The early mortality of this fracture is about 10%. If untreated,
these fractures fare very poorly.

It is estimated that in the United States 320,000 people -- mostly elderly and women --
sustain this fracture that results in their hospitalization. These fractures mostly occur due to a
low-energy fall. In one study from the UK it was noted that  
over age 82 (± 7 years)
fared badly after this fracture and the mortality was estimated to be between 20 and 35% in
one year. Majority of these patients (80%) were women.

The rounded head of the femoral bone and the hollow socket in the hip bone called the
acetabulum works in a 'ball and socket' arranegement. In fracture of the neck of the femur,
and the head and neck of the femur is often replaced by 



and this is termed as Hemi-arthroplasty of the hip. When both head and the hollow socket
(acetabulum) of the hip  are replaced by prostheses it is called 'Total     
.'

If the fracture is below the neck of femur (inter-trochanteric), a sliding compression screw
maybe used to fix the fracture.

Fracture of the femur neck is also called Ñ   | |  Ñamong the   
fraternity, in other words it is a kind of fracture that needs to be operated upon for optimal
results.

 | |  

[  |
 |  
The structure of the head and neck of femur is developed 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.

r
 
    |  
The profunda femoris artery arising from the femoral artery gives off medical circumflex
femoral artery. This gives off the lateral epiphyseal and superior and inferior metaphyseal
arteries. The lateral epiphyseal arteries are important and supply the laterial 2/3 of the
femoral head. The superior metaphyseal artery supplies the superior aspect of the femoral
neck. The inferior metaphyseal artery supplies the inferior part of the neck and the adjacent
part of the head derived from the metaphysis.
The medial epiphyseal artery supplies a circumfoveal sector of the head. It is a continuation
of the artery of the ligamentum teres which arises from the acetabular branch of the obturator
artery.

Femoral neck fractures that are intracapsular and may threaten any or all of the three sources
of blood to the femoral head:

c the cervical vessels in the retinaculum of the joint capsule - usually damaged if the
fracture is displaced
c intramedullary vessels - always torn
c from the ligamentum teres - usually contributes minimally in the elderly and not
uncommonly, may be non-existent

In addition to the damage to the blood supply, the intracapsular nature of the fracture hinders
recovery from the injury:

c intra-articular bone has only a thin periosteum and has no contact with soft tissues -
the response to injury - callus formation - is weak
c blood remains inside the joint capsule, increasing intracapsular pressure and further
damaging the femoral head; synovial fluid hinders clotting

×| |  |  


The fracture of the neck of femur is common in the elderly. It does occur occasionally in
young adults and even in children. It occurs more frequently in women. In India, the
incidence of fracture neck of femur in children is higher than in the Western countries.
The fracture may result either from rotation violence at the hip due to tripping over
something on the floor and falling or a direct violence over the lateral aspect of the hip by a
fall on the side.


 |  

Two broad groups of fractures are recognised in the neck of femur

(1) Intracapsular fractures (2) Extracapsular fractures.

× |  
 | 
This is diveded according to the level of the fracture line in the neck as follows.

1) Subcapital
2) Transcervical
3) Basal

 |  
 | 
There are all grouped as Trochanteric fractures of various types.

× [[[[ 
This is also called a high fracture neck of femur. In this group, the proximal fragment often
loses part of its blood supply and hence, the union of this fracture is difficult. This is a
serious injury in the elderly patient. In the very old and debilitated person, it can precipitate a
crisis in the precarious metabolic balance. It can become a terminal illness due to uremia,
lung infection, bed sores etc, and be fatal.


 |    
This classification relies only upon the appearance of the hip on the AP radiograph. It is used
to determine the appropriate treatment.

c stage I : incomplete fracture of the neck (so-called abducted or impacted)


c
c stage II : complete without displacement

c
c stage III: complete with partial displacement: fragments are still connected by
posterior retinacular attachment; there is malalignment of the femoral trabeculae

c
c stage IV : this is a complete femoral neck fracture with full displacement: the
proximal fragment is free and lies correctly in the acetabulum so that the trabeculae
appear normally aligned

c
Subcapital fractures are classified along two continuums: the Pauwels and Linton
classifications.

Pauwels Classification:
Type I has an obliquity ranging from 0 to 30 degrees
Type II has an obliquity ranging from 30 to 50 degrees
Type III has an obliquity of 70 or more degrees

The greater the obliquity in the fracture, the higher the chances of either delayed or nonunion.
This woman's fracture is Pauwels Type II and therefore has an intermediate chance of
delayed or nonunion.

Linton Classification:
Stage I: Incomplete fracture
Stage II: Complete but undisplaced fracture
Stage III: Complete, partially displaced fracture
Stage IV: Displaced and totally free fracture


|
  
The patient is usually an elderly person with a history of a fall and inability to walk. On
inspection, the injured led lies in a position of external rotation and there is shortening of the
leg. The attachment of the capsule to the distal fragment prevents excessive external rotation
of the leg. On palpation, there is tenderness over the anterior and lateral aspects of the hip
joint. The greater trochanter is elevated on the injured side. All movements are extremely
painful except in the rare case of an impacted type of fracture.

 
|
  
An anteroposterior view of Y   to show both the hips must be taken. It shows
the level and the type of fracture. The subcapital and transcervical fractures are divided into
three types according to the obliquity of the line of fracture (Pauwel). This is expressed as
the angle formed by the line of the fracture with the horizontal line (Pauwel's angle).

Type I: Pauwel's angle is less than 30 degrees, the fracture line is nearer the horizontal.
Type II: The angle is between 30 and 70 degrees.
Type III: The angle is more than 70 degrees and the fracture line is nearer the vertical.
In the more vertical fractures, the action of the gluteal and adductor museles produces a

   on the fracture line and hence nonunion is commoner. Thus, prognosis is
worse in Type III and good in Type I.

(Following imaging info from http://www.emedicine.com)

    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.
However, radiography has some 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.

False Positives/Negatives: Some femoral neck fractures are not visible on radiographs
obtained during the initial evaluation. If the clinical suspicion is strong, these cases can be
further evaluated with MRI, which shows bone marrow edema, or nuclear medicine bone
scanning, which shows increased tracer uptake. The latter is much less expensive than MRI
and nearly as sensitive. The major drawback of bone scanning is in the first 48-72 hours after
trauma, when its sensitivity is lower than that of MRI.

 plays an increasingly important role in evaluating the hip 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.

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 scanners.

×is both sensitive and specific in the detection of femoral 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.

Popular pulse sequences include coronal and axial T1-weighted and T2-weighted fat-
suppressed sequences, although several other bone marrow sequences can also be used. In
practice, a large field of view is usually used so that both hips and the bony pelvis can be
imaged simultaneously. Intravenous contrast enhancement is not routinely used in the
assessment of fractures. The fracture line can be visualized as linear low-signal-intensity
areas surrounded by bone marrow edema, which is hypointense relative to normal marrow on
T1-weighted images or hyperintense on T2-weighted images.

Drawbacks of MRI include its longer imaging 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. With continued technological advances the imaging
time has decreased, as have the costs, making MRI more cost-effective.

MRI is the most sensitive modality in detecting bone marrow changes related to avascular
necrosis, even when radiographic findings are normal; therefore, MRI is the imaging
modality of choice in this regard. When avascular necrosis is detected after surgical fixation
for a femoral fracture, the patient can become a candidate for placement of a prosthesis. More
importantly, MRI can be used to detect early stages of ischemic necrosis in the femoral head,
where interventions can be initiated before further damage can occur. Such damage may
include femoral head collapse, secondary osteoarthritis, or fragmentation.

MRI is currently the best imaging modality for detecting femoral neck fractures. Several facts
must be kept in mind, however. The normal bone marrow of the pelvis and hips can have a
patchy intermediate-signal-intensity appearance corresponding to the persistence of red
marrow. Also, the subchondral area of the femoral head can sometimes have a thin rim of red
marrow. These normal variants should not be confused with fractures.

Fractures and contusions should not be confused with idiopathic transient osteoporosis of the
hip. This is an uncommon, self-limited disease that affects middle-aged men and pregnant
women. It appears as osteopenia on plain radiographs and as areas of decreased T1 signal
intensity and increased T2 signal intensity which generally extends from the femoral head to
the intertrochanteric line on MRI. Usually, only one hip is affected at a given time. To
complicate matters, transient osteoporosis can predispose patients to a fracture if proper care
(eg, protected weight bearing) is not implemented. ULTRASOUND Section 7 of 12
Author Information Introduction Differentials X-ray Cat Scan MRI Ultrasound Nuclear
Medicine Angiography Intervention Pictures Bibliography


    does not play a significant role in the routine evaluation of hip fractures.
However, it has been used in research to evaluate the degree of distention of the hip joint
capsule after fractures and in the study of elevated intracapsular pressures. Sonograms can
also depict the presence of an intracapsular hematoma, which is mildly echogenic, as
distinguished from synovial fluid, which is anechoic

|
  |
Findings: 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. Given the high sensitivity of nuclear medicine studies, they can be used to diagnose
suspected femoral neck fractures not confirmed by means of plain radiography.
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. Stromqvist et al have demonstrated that 99mTc-MDP bone scans of the hips
performed within 2 weeks after fixation surgery for femoral neck fractures have an excellent
prognostic value for future fracture redisplacement, nonunion, or segmental femoral head
collapse.
Although sensitive, bone scintigraphy is not specific for fractures. Other processes such as
infection, inflammation, or tumor formation can also demonstrate increased uptake. However,
in the right clinical setting (eg, known trauma), it is highly sensitive for the detection of
fractures.

  

    


Fractures at this level have a poor capacity for union due to the following factors.
a) interference with the blood supply to the proximal fragment.
b) difficulty in controlling the small proximal fragment.
c) the lack of organisation of the fracture haematoma due to the presence of the synovial
fluid.

|
 
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

Dynamic Hip Screw


.
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.

 ||  

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.

 
|     | | 
The important complications are: a) Non-union b) Avascular necrosis of head of femur.

 
Failure of union of this fracture still occurs due to improper reduction of imperfect internal
fixation. When this occurs, the patient complains of pain and develops instability on
walking. The condition is treated by intertrochanteric osteotomy (McMurray) in the younger
age group and replacement arthroplasty in the elderly.

In the  
Y Ywith poor general condition, the only treatment possibly may be to
keep the leg between sand bags and attend to the general care of the patient. As soon as the
general condition is restored and the local pain relieved, physiotherapy is started.
Movements of the hip are encouraged and the patient is got up on crutches about three weeks
after the injury. Gradual weight bearing will lead to painless nonunion. This end result is
practicable and is still useful in our country, in places where good surgical and hospital
facilities are not available

[ |
 |  
Avascular necrosis of the head of the femur is an unpredictable 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.

[ ×[

   
 ||  
These are also called low fractures and are again classified as (i) Stable, (ii) Unstable
fractures. In this group, the blood supply to the proximal fragment is not interfered with and
there is a greater area of contact between the two fragments; hence the fractures unite easily.
While union is the rule, it is common to see these fractures malunited with a coxa vara
deformity.

The normal neck shaft angle is about 115 degrees. When the angle is reduced to nearer
90 degrees, the deformity is called Coxa Vara

These fractures occur in the elderly and the nature of the violence is the same as in the
intracapsular fracture.


|
  
On examination, the injured leg lies externally rotated and is obviously shorter. The degree
of external rotation is greater than in the intra capsular fracture. There is marked local
swelling and echymoses over the trochanteric area. All movements of the hip are extremely
painful and limited. This has to be differentiated from intracapsular fracture. 
  Intracapsular Extracapsular

Incidence Less common More common


Causative violence Minimal rotation violence Lateral violence
Clinical features
External rotation Minimal Fully externally
rotated
Local swelling Nil Marked local swelling
Treatment Difficult Easy
Complications
Non Union Common Does not occur
Malunion Rare Common

 
|
   
Stable Type: There is a single fracture line and it is a two piece fracture.
Unstable Type: This is a comminuated fracture with multiple fractures at the trochanteric

level

  
The principle of the treatment is reduction of the fracture and maintenance of the fragments
in good position till union occurs .

    


This consists of the application of continuous Y
Y
Y . For cases with marked coxa
vara, continuous skeletal traction through the upper tibia is applied and the leg is immobilised
in the Bohler Braun splint and the foot end of the bed is raised. Traction with 12 to 15 Ibs is
sufficient. The coxa vara gets corrected and the fracture unites in about 12 weeks. When the
coxa vara is not marked,  Y
Y in Thomas' splint will be sufficient. Excepting the fact
that the patient occupies a hospital bed for about 3 months, there is no other serious defect in
this conservative method and the results are highly satisfactory.

  


This consists of manipulative reduction and internal fixation. The internal fixation is done by
a nail plate as shown in the figure. The McLauglin two piece nail plate has been commonly
used. The use of a single piece angled nail plate (Jewett) has been found to be mechanically
superior and gives good results. More recently the use of compression hip screw and plate
system has enabled earlier mobilisation of the hip and weight bearing.

 
|   
The main complication is malunion with coxa vara and shortening. If the coxa vara is gross,
it can be corrected by osteotomy.
The death rate within one year of fractured neck of femur is typically reported as between
20% and 35%.Performance indicators based on mortality after hospital admission for such
fractures have been promoted.The only measure of mortality in routine hospital statistics,
however, is ³in-hospital mortality´²death during the initial admission for the fracture.
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