Fracture Neck Of Femur
ANATOMICAL FEATURES OF FEMUR
• 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.
Blood Supply To Head & Neck Of Femur
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.
Blood Supply To Head & Neck Of Femur
Blood Supply To Head & Neck Of Femur
 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.
Summary to Blood Supply to Head & Neck of Femur
• The epiphysis and metaphysis receive their blood supply from
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separate sources.
Epiphysial arteries named medial and lateral
Metaphysial arteries named superior and inferior.
The lateral Epiphysial and both Metaphysial arteries usually
arise from the medial femoral circumflex artery.
The medial Epiphysial is a continuation of the artery within the
ligamentum teres which comes from the acetabular branch of
the obturator artery.
Lateral Epiphysial arteries predominate in the epiphysis &
inferior Metaphysial arteries predominate in the Metaphysis.
The artery of the ligamentum teres--a secondary blood source
for the femur head-- supplies the medial third of the femoral
head
Blood Supply To Head & Neck Of Femur
Blood Supply To Neck Of Femur
Incidence & Mechanism
 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.
 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.
Classification of Neck of Femur #
(1) Intra capsular fractures
(2) Extra capsular fractures.
• Intra capsular Fractures
from subcapital area to the middle of the neck. This is divided
according to the level of the fracture line in the neck as follows.
1) Subcapital
2) Transcervical
3) Basal (at the junction of neck and shaft )
• Extra capsular Fractures
from base of the neck to the pertrochanteric region.There are all
grouped as Trochanteric fractures of various types.
Gardens classification of fracture
• This classification relies only upon the appearance of
the hip on the AP radiograph.
• It is used to determine the appropriate treatment.
 grade I : Incomplete fracture of the neck (so-called
abducted or impacted)
 grade II : complete # without displacement
 grade III: complete # with partial displacement:
 grade IV : Complete femoral neck fracture with full
displacement
grade -1
grade -2
grade -3
grade -4
Clinical features
• Pain
• Restriction of movements of the affected hip
• On examination : • Tenderness over the anterior hip joint line
• Minimal shortening and external rotational deformity
of the affected limb due to the fracture being
intracapsular
• Active straight leg raising is difficult
• In impacted # complains : • Groin pain , restriction of hip movement
Clinical Features
• Inability to walk
• The injured leg 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.
Investigations
X-ray: Anteroposterior (AP) and lateral view of the
whole pelvis 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).
Investigations
Pauwel's angle
Type I: Pauwel's angle is less than 30 degrees (0-30),
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 muscles produces a shearing force on the
fracture line and hence nonunion is common. Thus,
prognosis is worse in Type III and good in Type I
Pauwels classification however refers to the angle the
fracture line makes with the horizontal
MANAGEMENT
• CONSERVATIVE MANAGEMENT:
• 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 organization of the fracture
haematoma due to the presence of the synovial
fluid.
MANAGEMENT
CONSERVATIVE MANAGEMENT:
• In the very old patient with 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.
Surgical Management
• 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 stabilizing the fracture was
by internal fixation with Smith Petersen Trifin nail.
• The more recent method of internal fixation of the
fracture is the use of multiple compression screws
• Dynamic hip screws (DHS)
• Total hip replacement (THR )
Dynamic hip screws
Dynamic hip screw- DHS
• Most commonly used
device for both stable and
unstable fracture patterns.
• Plate angle is variable 130
to 150 degrees.
• Has to be positioned
centrally in the femoral
head.
• Use of radiological views
to know the exact position.
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
Joint replacement surgery
• 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.
Austin moore’s prosthesis
Total Hip Replacement
Complications of neck of femur fracture
• The important complications are:
• a) Non-union
• b) Avascular necrosis of head of femur.
• Non-union
Failure of union of this fracture still occurs due to
improper reduction of imperfect internal fixation.
 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.
Complications of neck of femur fracture
• Avascular Necrosis
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
Extra capsular fracture
These are also called low fractures and are 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.
Clinical features
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.
All movements of the hip are extremely painful
and limited.
Trochanteric Fracture
Conservative Management
• Skeletal Traction:
In cases with marked coxa vara, continuous skeletal
traction through the upper tibia is applied and the leg
is immobilized 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.
• Skin Traction:
When the coxa vara is not marked, skin traction in
Thomas' splint will be sufficient.
Bohler Braun splint
Surgical Management
• This consists of manipulative reduction and internal
fixation.
• The internal fixation is done by a nail plate
• Compression hip screw and plate system has been used
to enable earlier mobilization of the hip and weight
bearing
• If the Coxa vara is more, it can be corrected by
Osteotomy.
complications
The main complications are
Malunion
Coxa vara
o(It is common to see these fractures Malunited with a
Coxa vara deformity)
oThe normal neck shaft angle is about 115
degrees. When the angle is reduced to nearer
90 degrees, the deformity is called Coxa Vara
Shortening.