FRACTURE NECK OF FEMER

EPIDEMIOLOGY BIMODAL DISTRIBUTION

250,000 Hip fractures annually, expected to double by 2050, Elderly Doubles each decade beyond age 50, Young  high energy trauma

ANATOMY

BLOOD SUPPLY

GARDEN CLASSIFICATION

•Poor interobserver reliability

•Modified to:

–Non-displaced

•Garden I  (valgus impacted)

•Garden II (non-displaced)

–Displaced

•Garden III and IV

  I Valgus impacted or  incomplete   

II Complete

 Non-displaced

III  Complete

     Partial displacement

IV  Complete

      Full displacement

Pauwels Classification

                                            

                                      stable       less-stable      unstable

PATIENTS FACTOR

                    • Young (active)

       High energy injuries

Often multi-trauma 

• Elderly

Lower energy injury (falls)

Co-morbidities 

Pre-existing hip disease

TREATMENT GOALS

Geriatric Patients

•Mobilize

•Minimize surgical morbidity

Young patients

• Spare femoral head

•   Avoid deformity Improves union rate

•  Minimize vascular injury Avoid AVN

TREATMENT OPTION

•Non-operative

•Reduction and fixation

Open reduction

Closed reduction

•Arthroplasty

PRE-OPERATIVE CONSIDERATION

Timing of ORIF in Young
Surgical Urgency

•may unkink vessels

•Release tamponade in capsule

Surgical Timing Geriatric

•Surgical urgency healthy patients

•Surgical delay up to 72 hours for medical stabilization warranted in unhealthy patients

CLOSED REDUCTION AND OPEN APPROCH

•Flexion, slight adduction, slight traction

OPEN APPROCH

Smith-Peterson

Direct access to fracture

Second approach for fixation

 

Watson-Jones approach

 Anterolateral

Between TFL medius

Same approach for fixation Best for basicevical

FIXATION CONSTRUCTS

•3 Screws

•4 Screws

•Dynamic hip screw

•130° blade plate

COMPLICATIONS

Nonunion

•0-5%  in  Non-displaced fractures

•9-35%  in  Displaced fractures

•Clinical presentation

–Groin or buttock pain 

–Activity / weight bearing related

•Imaging

–Radiographs:

–CT:

–Bone Scan:

–MRI:

NONUNION TREATMENT

•Elderly patients 

–Arthroplasty

–Girdlestone Resection Arthroplasty

•Young patients

–Valgus intertrochanteric osteotomy (Pauwels)

AVN AND TRATMENT

•5-8% Non-displaced fractures

•20-45% Displaced fractures

•Increased incidence

•Clinical presentation

–Groin / buttock / proximal thigh pain

–May not limit function

–Onset usually later than nonunion

•Imaging

–Plain radiograph:

–Bone Scan:

–MRI diagnostic

•Treatment

–Elderly patients

•Arthroplasty

•Girdlestone Resection Arthroplasty

–Young Patients

•Proximal Femoral Osteotomy

•Arthroplasty

•Arthrodesis

** Prevention is the Key **