Neck of Femur Fractures
Wayne Hoskins
Background
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NOF #’s common with advancing age
High morbidity & mortality
Only 1/3 return to living environment
Death: 20-35% at 1 year in patients
aged 82 +/-7
Anatomy
Fracture location
Head blood supply
• Profunda femoris gives off medial &
lateral circumflex femoral arteries
– Extracapsular anastomosis at base of neck
– Ascending cervical branches
– Intracapsular branches
• Majority via MCFA, ↓ via ligamentum
teres
Garden classification
1. Incomplete impacted #
2. Complete # undisplaced
3. Displaced capsule intact
4. Displaced
Fracture classification
• Garden classification: poor interobserver reliability:
– displaced = 1 & 2
– undisplaced = 3 & 4
Shenton’s Line
Mechanism of #
• Direct or indirect:
1. Direct blow to GT
2. ER: impinging posterior cortex on rim
3. Bending torque – major trauma
4. Violent muscle contraction
5. Cyclical loading / insufficiency #
NOF # complications
• AVN
– Undisplaced 5-10%
– Displaced 10-20%
– RFs: displacement, velocity of injury, delay in
reduction, non-anatomical reduction
• Non-union
– Undisplaced 5-10%
– Displaced 20-30%
– RFs - initial displacement, non anatomical
reduction, instability, no compression across #,
vascularity
Presentation
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Typically elderly female
Low energy fall
Hip pain
Short & ER leg
Unable to weight bear
NOF # risk factors
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Osteoporosis
Co-morbidities
Dementia
Poor mobility / vision
Work up – not just a #
• History
– Mechanism of injury
– Cause of fall - exclude medical cause: TIA, UTI,
MI, arrythmia, electrolyte imbalance etc
– Other injuries from fall
– Risk factors for osteoporosis
– Co-morbidities/medications: ?anaesthetic review
pre-op, ?choice of operation
• ? Gen Med vs. Ortho admission
– Ortho Geri’s consult
Work up
• Examination: pain, unable to weight
bear, short ER leg, ?delirium
• Investigations:
– ECG, FWT, urine MCS
– Bloods: FBE, UEC, CMP, albumin, ESR, Vit
D, Coags, G&H
– DEXA bone scan
Imaging
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Pelvis & hip XR
?undisplaced # - gold standard = MRI
CT if MRI unavailable
Bone scan less useful, changes take up
to 1week in elderly
• Pre-op CXR
Medical management
• Treat co-morbidities whilst await OT:
- electrolyte imbalances
- anemia
- pneumonia / UTI / infection
- arrythmia / MI etc
• Post-op manage co-morbidities, RFs
falls & osteoporosis: consider Vit D, Ca,
bisphosphonates
Surgical management
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Surgical option based on:
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Displaced vs. undisplaced
Age of patient
Mobility/independence
Bone stock
Aim perfect anatomical reduction and
rigid fixation
Anti-coagulants
• Operate if on clopidogrel / aspirin
• If on warfarin: Vit K / FFP to reduce INR
<1.5
Time to surgery
• Aim: surgery < 24 hours
• Jain JBJS Am 2002: significant
reduction in AVN if fixed <12 hours
Surgical results
• Best results with healed # in anatomical
position without AVN
• Quality of reduction is best predictor
Undisplaced subcapital #
• Cannulated screws  used in young
– 1 x inferior screw, 2x superior screws,
ensure threads cross # site, 5mm from
surface, inferior screw above LT
• DHS + derotation screw  used in old,
independent walker
Displaced subcapital #
• Expected life > prosthesis survival
(<65): aim to preserve the joint
• DHS + derotation screw
– Closed or open anatomical reduction
• Union rates ↑ with anatomical reduction:
accept no varus, <15 valgus, <10 AP
plane
DHS technique
• Set up on traction table
• Lateral incision: divide fascia lata
• Ensure 2 guide wires centrally in femoral
heard
1. Allows reaming for DHS
2. Derotation screw
• Screws to attach plate
• DHS Blade noe being used with osteoporotic
bone  ↑ rotational stability
X-rays
Post-operative Mx
• DHS/Screws/Nail – admit to med ward
– Surg ward: Hemi/THR/High energy trauma
• Young patients – PWB
• Elderly – WBAT to prevent
complications
• Watch for AVN in subcapital #’s (usually
8-12 weeks, but up to 2 years)
Displaced subcapital #
• Expected life < prosthesis survival (>65)
• Hemiarthroplasty < 5 year survival
– Bipolar no better than unipolar, difficult to reduce if Ds
– No difference cemented vs uncemented outcome measures
– Cemented hemi: ↑ operative time, blood loss, cement
pressurization complications, difficult revision
• Moore’s if severe comorbidities/non walker – 30%
revision at 2 years
• Gjertsen JBSB 2010 cf ORIF: both 25% mortality, 3
vs. 22% reoperation, more pain, lower QoL with ORIF
Displaced subcapital #
• Expected life < prosthesis survival (>65)
• THR 5-15 year survival  young,
active, mobile, associated joint disease
(RA, OA, etc)
– better ROM & pain relief vs hemi
– Higher early Ds rate & early loosening
– Long term Ds rate equal to hemi
Hemi/THR approach
• Posterior approach
- preserves gluteus medius
- observe sciatic n. ? ↓/↑damage
- ? ↓ Ds rate with bone anchors
• Hardinge/anterolateral approach
- Trendelenburg gate
- Previous data ↓ Ds rate
• Surgeon preference
Complications
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Infection
Dislocation
GT or Femoral shaft #
Leg length discrepancy
Loosening / pain
Revision
Summary
• Full medical history and work up 
think medical admission with ortho
consult
• Time to theatre
• Surgical choice based on age, # type,
mobility, comorbidities
• High morbidity and mortality