FRACTURES OF THE FEMORAL NECK

• The femoral neck is the commonest site of fractures in the

elderly.
• The vast majority of patients are Caucasian women in the
seventh and eighth decades, and the association with
osteoporosis is so manifest that the incidence of femoral neck
fractures has been used as a measure of age-related
osteoporosis in population studies.
• Other risk factors include bone-losing or bone-weakening
disorders such as osteomalacia, diabetes, stroke (disuse),
alcoholism and chronic debilitating disease.
• Fractures of the neck of the femur occur predominantly in the elderly,
typically result from low-energy falls, and may be associated with
osteoporosis.
• Fractures of the femoral neck in the young are a very different injury
and are treated in very different ways.
• Femoral neck fractures in young patients typically are the result of a
high-energy mechanism, and associated injuries are common.
• Most fractures of the femoral neck are intracapsular and may
compromise the tenuous blood supply to the femoral head.
• Basicervical femoral neck fractures are extracapsular femoral
neck
fractures and ofen are considered with intertrochanteric femoral
fractures
• Extracapsular ring—formed at the base of the femoral neck primarily from branches of MFCA and
LFCA
• Subsynovial intracapsular arterial ring—formed at the base of the femoral head
• CLASSIFICATION
• Femoral neck fractures can be classifed by the location of
the fracture line
• subcapital,
• transcervical, or
• basicervical
• The Garden classifcation is the most commonly used
classifcation system and is based on the degree of
displacement
• Stage I is an incomplete impacted fracture, including the so-
called abduction fracture in which the femoral head is tilted
into valgus in relation to the neck.
• Stage II: complete fracture line; nondisplaced
• Stage III: complete fracture line; partially displaced
• Stage IV: complete fracture line; completely displaced
• Stages III and IV can be differentiated radiographically
by carefully scrutinizing the trabecular patterns of the femoral
head and acetabulum.
• Stage III femoral neck fractures maintain contact between the
femoral neck and femoral head, and the trabecular patterns
between the head and acetabulum are no longer aligned.
• Stage IV fractures do not maintain contact between the femoral
neck and femoral head, and the trabecular patterns between
the head and acetabulum have realigned.
• Healing of femoral neck fractures is bedevilled by two problems: the threat of
bone ischaemia and tardy union.
• The femoral head gets its blood supply from three sources:
• (1) intramedullary vessels in the femoral neck;
• (2) ascending cervical branches of the medial and lateral circumflex anastomoses, which
run within the capsular retinaculum before entering the bone at the articular margin of
the femoral head; and
(3) the vessels of the ligamentum teres.
• The intramedullary supply is always interrupted by the fracture; the
retinacular vessels, also, may be kinked or torn if the fracture is displaced.
• In elderly people, the remaining supply in the ligamentum teres is at best
fairly meagre and, in 20 per cent of cases, nonexistent.
• Hence the high incidence of avascular necrosis in displaced femoral neck
fractures.
• Transcervical fractures are, by definition, intracapsular.
• They have a poor capacity for healing because:
• (1) by tearing the retinacular vessels the injury deprives the head of its main
blood supply;
• (2) intra-articular bone has only a flimsy periosteum and no contact with
soft tissues which could promote callus formation; and
(3) synovial fluid prevents clotting of the fracture haematoma.
• Accurate apposition and impaction of bone fragments are therefore of more
importance than usual.
• There is evidence that aspirating a haemarthrosis increases the blood flow in
the femoral head by relieving tension in the capsule, and the practice is
encouraged at the time of surgery
• Clinical features
• There is usually a history of a fall, followed by pain in the hip.
• If the fracture is displaced, the patient lies with the limb in lateral rotation and
the leg looks short.
• Beware, not all hip fractures are so obvious.
• With an impacted fracture the patient may still be able to walk, and debilitated
or mentally handicapped patients may not complain at all – even with bilateral
fractures.
• In contrast, femoral neck fractures in young adults result from road traffic
accidents or falls from heights and are often associated with multiple injuries.
• A good rule is that young adults with severe injuries – whether they
complain of hip pain or not – should always be examined for an
associated femoral neck fracture.
• X-ray
• Two questions must be answered: is there a fracture, and is it displaced?
• Usually the break is obvious, but an impacted fracture can be missed by
the unwary.
• Displacement is judged by
• abnormal shape of the bone outlines and
• degree of mismatch of the trabecular lines in the femoral head and neck
and the supra-acetabular (innominate) part of the pelvis.
• This assessment is important because impacted or undisplaced fractures
do well after inter nal fixation, whereas displaced fractures have a high
rate of non-union and avascular necrosis.
• In Garden II fractures the femoral head is normally placed and the
fracture line may be difficult to discern.
• In Garden III fractures the anteroposterior x-ray shows that the
femoral head is tilted out of position and the trabecular markings are
not in line with those of the innominate bone; this is because the
proximal fragment retains some contact with the neck stump and is
pushed out of alignment.
• In Garden IV fractures the femoral head trabeculae are normally
aligned with those of the innominate bone; the reason is that the
proximal fragment has lost contact with the femoral neck and lies
in its normal position in the acetabular socket.
(c) Stage III: complete with partial displacement – thefragments are still connectedby the posterior
retinacularattachment; the femoral head trabeculae are no longer in with those of theinnominate bone. (d) Stage IV:
complete withfull displacement – theproximal fragment is free andlies correctly in the acetabulumso that the trabeculae
appear normally aligned with those of the innominate.
• Diagnosis
• There are four situations in which a femoral neck fracture may
be missed, sometimes with dire consequences.
• Stress fractures
• The elderly patient with unexplained pain in the hip should be
considered to have a stress fracture until proved otherwise.
• A similar cautionary note is raised for young athletes who do regular
impact-loading sports and military personnel on marching routines.
• The x-ray is usually normal but a bone scan, or better still an MRI, will
show the lesion
• Undisplaced fractures
• Impacted fractures may be extremely difficult to discern on plain x-ray.
• If there is a fracture it will show up on MRI or a bone scan after a few days.
• Painless fractures
• A bed-ridden patient may develop a ‘silent’ fracture.
• Even a fit patient occasionally walks about without pain if the fracture is
impacted.
• If the context suggests an injury, investigate –
whether the patient complains or not.
• Multiple fractures
• The patient with a femoral shaft fracture may also have a hip fracture, which
is easily missed unless the pelvis is x-rayed.
• Treatment
• Initial treatment consists of pain-relieving measures and simple splintage
of the limb.
• If operation is delayed, a femoral nerve block may be helpful.
• A case for non-operative treatment of undisplaced (Garden Stages I and
II) fractures can be made in treating patients with advanced dementia
and little discomfort.
• For all others, operative treatment is almost mandatory.
• Displaced fractures will not unite without internal fixation, and in any case
elderly people should be got up and kept active without delay if
pulmonary complications and bed sores are to be prevented
• Impacted fractures can be left to unite, but there is always a risk
that they may become displaced, even while lying in bed, so fixation
is safer.
• Another indication for non-operative management is an impacted
Garden
• I fracture that is an ‘old’ injury, where the diagnosis is made only
after the patient has been walking about for several weeks without
deleterious effect on the fracture position.
• When should the operation be performed?
• In young patients operation is urgent; interruption of the blood supply will
produce irreversible cellular changes after 12 hours and, to prevent this,
an accurate reduction and stable internal fixation is needed as soon as
possible.
• In older patients, also, the longer the delay, the greater is the
likelihood of complications.
• However, here speed is tempered by the need for adequate
preparation, especially in the very elderly, who are often ill and
debilitated.
• What if operation is considered too dangerous? Lying in bed on
traction may be even more dangerous, and leaving the fracture
untreated too painful; the patient least fit for operation may need
it most.
• Fractures of the femoral neck are displaced in 85% of cases
at presentation, and 97% of patients are older than 60 years
• Nonoperative Treatment of Undisplaced Femoral Neck
Fractures
• Nonoperative treatment is an option in undisplaced femoral
neck
fractures, and some authors have recommended this method of
treatment and reported good results.
• Patients can be mobilized touch weight-bearing with
crutches, and the fracture can b expected to heal in 4 to 6
weeks.
• The advantage of this method is that it avoids surgery, but most
studies show that there is a signifcant risk of displacement
during nonoperative treatment
• Internal fixation
• Notwithstanding the advances in joint replacement, for most patients
the principles of treatment are as of old: accurate reduction, secure
internal fixation and early activity.
• Displaced fractures must first be reduced: with the patient under
anaesthesia, the fracture is disimpacted by applying traction with
the hip held in 45 degrees of flexion and slight abduction; the limb is
then slowly brought into extension and finally internally rotated; as
traction is released, the fracture re-impacts in the reduced position.
• The reduction is assessed by x-ray.
• The femoral head should be positioned correctly with the stress trabeculae in the femoral
head and those in the femoral neck aligned close to their normal position in both
anteroposterior and lateral views
• In the AP x-ray the trabeculae in the femoral head and a line along the medial border of
the
femoral shaft should subtend an angle of 155–180 degrees.
• To fix an imperfectly reduced fracture is to risk failure. If a stage
III or IV fracture cannot be reduced closed, and the patient is
under 60 years of age, open reduction through an anterolateral
approach is advisable.
• However, in older patients (and certainly in those over 70) this
may not be justified; if two careful attempts at closed reduction
fail, prostheticreplacement is preferable.
• Some may even argue that prosthetic replacement is always a
preferable option for this older group as it carries a much lower
risk of needing revision surgery.
• Fixation of Undisplaced Intracapsular Femoral Neck
Fractures
• In the majority of patients, fxation is the treatment of choice for
the undisplaced intracapsular hip fracture.
• There are a large number of implants available to choose from.
• In modern orthopedic practice, the usual choice is either a
• cannulated screw system or
• sliding hip screw device with a short plate
sliding hip screw fixation
• Operative Treatment of Displaced Femoral Neck Fractures
• Most surgeons believed reduction and fxation was the
treatment of choice for displaced fractures in patients younger
than 60 years.
• Almost all surgeons preferred arthroplasty in patients older
than 80 years.
• There was much more variation in patients between the age of
60 and 80 years, with surgeons using
• reduction and fxation,
• unipolar hemiarthroplasty,
• bipolar hemiarthroplasty, and
• THR to differing extents.
• POSTOPERATIVE CARE
• Patients with high-energy femoral neck fractures are kept at
touch-down (weight of leg) weight bearing for 10 to 12 weeks.
• Older patients are allowed protected weight bearing with a
walker if their balance and other medical comorbidities allow.
• Patients who cannot safely ambulate are encouraged mobilize
to a chair to minimize pulmonary complications.
• Avascular necrosis
• Ischaemic necrosis of the femoral head occurs in about 30 per cent of
patients with displaced fractures and 10 per cent of those with
undisplaced fractures.
• There is no way of diagnosing this at the time of fracture.
• A few weeks later, an isotope bone scan may show diminished
vascularity.
• X-ray may not become apparent for months or even years.
• Whether the fracture unites or not, collapse of the femoral head will
cause pain and progressive loss of function.
• In patients over 45 years, treatment is by total joint replacement.
• In younger patients, the choice of treatment is controversial. Core
decompression has no place in the management of traumatic
osteonecrosis.
• Realignment or rotational osteotomy is suitable for those with a
relatively small necrotic segment.
• Arthrodesis is often mentioned in armchair discussions, but in
practice it is
seldom carried out.
• Provided the risks are carefully explained, including the likelihood of
at least one revision procedure, joint replacement may be justifiable
even in this group.
• Non-union
• More than 30 per cent of all femoral neck
fractures fail to unite, and the risk is particularly high
in those that are severely displaced.
• There are many causes: poor blood supply, imperfect reduction,
inadequate fixation, and the tardy healing that is characteristic of intra-
articular fractures.
• The bone at the fracture site is ground away, the fragments fall apart
and the screw cuts out of the bone or is extruded laterally.
• The patient complains of pain, shortening of the limb and difficulty with
walking. The x-ray shows the sorry outcome.
• The method of treatment depends on the cause of
the non-union and the age of the patient. In the relatively young,
three procedures are available: (1) if the
fracture is nearly vertical but the head is alive, subtrochanteric
osteotomy with internal fixation changes
the fracture line to a more horizontal angle; (2) if the
reduction or fixation was faulty and there are no signs
of necrosis, it is reasonable to remove the screws,
reduce the fracture, insert fresh screws correctly and
also to apply a bone graft across the fracture, either a
segment of fibula or a muscle pedicle graft; and (3), if
the head is avascular but the joint unaffected, prosthetic replacement
may be suitable; if the joint is damaged or arthritic, total replacement
is indicated.
• In elderly patients, only two procedures should be
considered: (1) if pain is considerable then the
femoral head, no matter whether it is avascular or not,
is best removed and (provided the patient is reasonably fit) total joint
replacement is performed; (2) if
the patient is old and infirm and pain not unbearable,
a raised heel and a stout stick or elbow crutch are
often sufficient.
• Osteoarthritis
• Avascular necrosis or femoral head collapse may lead, after several years,
to secondary osteoarthritis of the hip.
• If there is marked loss of joint movement and widespread damage to the
articular surface, total joint replacement will be needed.