2.4 Proximal Femur Fractures Flashcards
3 fracture patterns for proximal femur?
Who can get proximal femur fractures?
- intracapsular,
- intertrochanteric or
- subtrochanteric
Fragility fracture in the elderly
Rarely in young people in high energy
Have degree of suspicion for malignancy as mets can go here.
Where is the acetabulum?
yeah find a pic
What is the blood supply to the femoral head?
Three:
- Intramedullary vessels in the medullary canal of the bone.
- Anastomosis of the medial and lateral circumflex arteries. They run around the joint capsule and their blood supply passes proximally up the neck of femur to the the femoral head through he capsular retinaculum.
- Just 10% comes from the Ligamentum teres which in 20% of people doesnt contribute blood at all.
How is blood supply affected by a neck of femur fracture?
all neck of femur fractures will disrupt the intramedullary blood supply.
A displaced fracture will kink or disrupt supply from the capsular retinaculum. This leaves possible tenuous supply from ligaments teres.
Without supply the femoral head will undergo avascular necrosis (AVN).
Intracapsular (NOF) neck of femur classification?
Garden classification:
G1: incomplete fracture of the femoral neck where the head has tilted into the vagus position
G2:
complete fracture across the femoral neck but completely undisplaced
G3:
complete fracture which is displaced with some continuity between the fracture ends (as the head remains tilted)
G4:
complete fracture and no continuity between fracture end and the femoral head comes back to rest in its neutral position
Useful for exams but in practice it doesnt really change management. Degree of displacement guides treatment and fitness of patient.
Displaced should be replaced. “1 and 2 use a screw, 3 and 4 Austin Moore”
How do you fix an undisplaced NOF fracture?
Cannulated hip screws.
Hollow so use wires to guide the position and then the screw goes in over the top.
Usually use 3 screws, 2 superiorly and one lower.
What do you do for a displaced NOF fracture?
(over 60yrs)
Hemiarthropasty
Stem variants:
- cemented
- uncemented (uncommon)
Head variants:
- unipolar (single block with stem)
- bipolar (built in articulation between head and stem)
(under 60 then try and operate within 6hrs)
Young hip displaced NOF patients?
20-60yrs you should try and fix it within 6hours rather than replace. Otherwise you will need multiple revision surgeries as the replacement wears out.
What would you do for an intertrochanteric fracture?
(not worried about AVN)
Often a few fragments
Use CHS (compression hip screw) for example the:
- DHS (dynamic hip screw)
How does a DHS operation go and how does it work?
First you reduce the fracture on the traction table.
Then x-ray guide wire through neck into the head.
Hole is made here to fit a screw.
A plate goes over the top of the screw and attaches to the femur.
The place it not attached to the screw.
This means when weight is applied the head is compressed onto the fracture.
Subtrochanteric fracture treatment of choice?
Intramedullary nail with a hip screw such as the gamma nail.
Unlike DHS this is fixed and not ‘dynamic’
