Femoral Neck Fractures Flashcards
1
Q
femoral neck is ______, bathed in synovial fluid
A
intracapsular
2
Q
femoral neck lacks _____ layer
A
periosteal
3
Q
____ formation limited, which affects healing
A
callus
4
Q
mechanism of injury
A
high energy in young patients
low energy in older patients
5
Q
associated injuries
A
femoral shaft fracture
6
Q
do you treat the neck or the shaft first?
A
neck
7
Q
what percentage of femoral neck fractures have an associated femoral shaft fracture?
A
6-9%
8
Q
what is the normal neck shaft angle
A
130 +/- 7
9
Q
what is normal anteversion
A
10 +/- 7 degrees
10
Q
major contributor to blood supply of femoral head is _____ (lateral epiphyseal artery)
A
medial circumflex femoral
11
Q
some contribution to anterior and inferior head from ____ femoral circumflex
A
lateral
12
Q
some contribution to blood supply of head from ____ artery
A
inferior gluteal
13
Q
displacement of femoral neck fracture will disrupt the blood supply and cause an ______
A
intracapsular hematoma
14
Q
where is the pain in impacted and stress fractures?
A
slight pain in the groin or pain referred along the medial side of the thigh and knee
15
Q
where is the pain in displaced fractures
A
pain in the entire hip region
16
Q
physical exam of impacted and stress fractures
A
no obvious clinical deformity
minor discomfort with active or passive hip range of motion, muscle spasms at extremes of motion
pain with percussion over greater trochanter
17
Q
no obvious clinical deformity
minor discomfort with active or passive hip range of motion, muscle spasms at extremes of motion
pain with percussion over greater trochanter
A
impacted and stress fractures
18
Q
pain in the entire hip region
A
displaced fracture
19
Q
slight pain in the groin or pain referred along the medial side of the thigh and knee
A
impacted and stress fractures
20
Q
leg in external rotation and abduction, with shortening
A
displaced fracture
21
Q
displaced fracture physical exam
A
leg in external rotation and abduction, with shortening
22
Q
Xray views
A
AP
cross table lateral
full length femur
23
Q
_____ AP hip is best for defining fracture type
A
traction-internal rotation
24
Q
CT is useful for what
A
helpful in determining displacement and degree of comminution in some patients
25
helpful in determining displacement and degree of comminution in some patients
CT
26
why is MRI useful
helpful to rule out occult fracture
not helpful in reliably assessing viability of femoral head after fracture
27
helpful to rule out occult fracture
not helpful in reliably assessing viability of femoral head after fracture
MRI
28
do this to rule out DVT if delayed presentation to hospital after hip fracture
duplex scanning
29
non op/observation indications
may be considered in some patients who are non-ambulators, have minimal pain, and who are at high risk for surgical intervention
30
ORIF indications
displaced fractures in young or physiologically young patients
ORIF indicated for most pts <50 years of age
31
displaced fractures in young or physiologically young patients
indicated for most pts <50 years of age
ORIF
32
____ sex has highest reoperation rate
female
33
nondisplaced transcervical fx
Garden I or II in the physiologically elderly
displaced transcervical fx in young patient
cannulated screws
34
indications for cannulated screws
nondisplaced transcervical fx
Garden I or II in the physiologically elderly
displaced transcervical fx in young patient
35
indications for sliding hip screw
basicervical fracture
vertical fracture pattern in a young patient
36
basicervical fracture
vertical fracture pattern in a young patient
sliding hip screw
37
are sliding hip screws or cannulated screws biomechanically superior?
sliding
38
consider placement of additional cannulated screw above sliding hip screw to prevent ____
rotation
39
controversial
debilitated elderly patients
metabolic bone disease
hemiarthroplasty
40
indications for hemiarthroplasty
controversial
debilitated elderly patients
metabolic bone disease
41
decreased fracture rates
improved short and medium term mobility
cemented hemiarthroplasty
42
cemented hemiarthroplasty pros
decreased fracture rates
improved short and medium term mobility
43
indications for total hip arthroplasty
older active patients
patients with preexisting hip osteoarthritis
Garden III or IV in patient < 85 years
44
older active patients
patients with preexisting hip osteoarthritis
Garden III or IV in patient < 85 years
total hip arthroplasty
45
does a hemi or total hip have more predictable pain relief and better functional outcome
total hip
46
_____ has more pronounced effect on healing than surgical timing
reduction method and quality
47
elderly patients with hip fractures should be brought to surgery as soon as _____
medically optimal
48
the benefits of early ____ cannot be overemphasized
mobilization
49
improved outcomes in medically fit patients if surgically treated less than _____ days from injury
4
50
preoperative ____ have been shown to delay the time to surgery without any effect on treatment decisions
echocardiograms
51
treatment approach based on:
degree of displacement
physiologic age of the patient (young is < than 50 years old)
ipsilateral femoral neck and shaft fractures
52
priority goes to fixing femoral neck because anatomic reduction is necessary to avoid complications of _____
AVN and nonunion
53
permit dynamic compression at fx site during axial loading
can cause shortening of femoral neck
fixation with implants that allow sliding
54
fixation with implants that allow sliding can lead to
permit dynamic compression at fx site during axial loading
can cause shortening of femoral neck
55
multiple closed reduction attempts are associated with higher risk of _____ of the femoral head
osteonecrosis
56
10cm skin incision made beginning just distal to AIIS
incise deep fascia
develop interval between sartorious and TFL
external rotation of thigh accentuates dissection plane
LFCN is identified and retracted medially with sartorius
identify tendinous portion of rectus femoris, elevate off hip capsule
open capsule to identify femoral neck
anterior smith Peterson approach
57
steps in anterior smith Peterson approach
10cm skin incision made beginning just distal to AIIS
incise deep fascia
develop interval between sartorious and TFL
external rotation of thigh accentuates dissection plane
LFCN is identified and retracted medially with sartorius
identify tendinous portion of rectus femoris, elevate off hip capsule
open capsule to identify femoral neck
58
anterior approach interval
sartorius and TFL
59
steps to Watson approach
used to gain improved exposure of lower femoral neck fractures
skin incision approx 2cm posterior and distal to ASIS, down toward tip of greater trochanter
incision curved distally and extended 10cm along anterior portion of femur
incise deep fascia
develop interval between TFL and gluteus medius
anterior aspect of gluteus medius and minimus is retracted posteriorly to visualize anterior hip capsule
capsule sharply incised with Z-shape incision
capsulotomy must remain anterior to lesser trochanter at all times to avoid injury to medial femoral circumflex artery
60
used to gain improved exposure of lower femoral neck fractures
skin incision approx 2cm posterior and distal to ASIS, down toward tip of greater trochanter
incision curved distally and extended 10cm along anterior portion of femur
incise deep fascia
develop interval between TFL and gluteus medius
anterior aspect of gluteus medius and minimus is retracted posteriorly to visualize anterior hip capsule
capsule sharply incised with Z-shape incision
capsulotomy must remain anterior to lesser trochanter at all times to avoid injury to medial femoral circumflex artery
Watson approach
61
Watson approach interval
TFL and gluteus medius
62
screw fixation: inverted triangle along the calcar (not central in the neck) has stronger fixation and higher ____
load to failure
63
where is the first screw placed when doing cannulated screw fixation?
inferior screw along calcar
64
where is the second screw placed when doing cannulated screw fixation?
posterior/superior screw
65
where is the third screw placed when doing cannulated screw fixation?
anterior/superior screw
66
how many screws are normally placed?
3
67
four screws considered for ____
posterior comminution
68
cannulated screw fixation starting point at or above level of ____ to avoid fracture
lesser trochanter
69
cannulated screw fixation: avoid multiple cortical perforations during guide pin or screw placement to avoid development of _____
lateral stress riser
70
posterior hemi approach has higher risk of
dislocation
71
anterolateral approach to hemi has increased ____ weakness
abductor
72
total hip-should consider using the _____ approach and selective use of larger heads in the setting of a femoral neck fracture
anterolateral
73
complications of total hip
5x higher rate of dislocation compared to hemi
74
complications of femoral neck fractures
osteonecrosis
nonunion
dislocation
failure
loss of independence
75
osteonecrosis incidence
10-45%
76
increased risk of osteonecrosis associated with _____
increase initial displacement
nonanatomical reduction
sliding hip screw
77
treatment of osteonecrosis in a young patient
>50% involvement treat with FVFG vs THA
78
treatment of osteonecrosis in an older patient
prosthetic replacement (hemiarthroplasty vs THA)
79
nonunion incidence
5-30%
80
increased incidence of nonunion in ____ fractures
displaced
81
_____ malreduction most closely correlates with failure of fixation after reduction and cannulated screw fixation
varus
82
treatment of nonunion options
valgus intertrochanteric osteotomy
FVFG
arthroplasty
revision ORIF
83
turns vertical fx line into horizontal fx line and decreases shear forces across fx line
valgus intertrochanteric osteotomy
84
FVFG nonunion fixation indications
indicated in young patients with a viable femoral head
85
indicated in young patients with a viable femoral head
FVFG
86
indicated in older patients or when the femoral head is not viable
also an option in younger patient with a nonviable femoral head as opposed to FVFG
arthroplasty
87
arthroplasty as nonunion treatment indications
indicated in older patients or when the femoral head is not viable
also an option in younger patient with a nonviable femoral head as opposed to FVFG
88
are overall failure rates higher in fixation or arthroplasty?
fixation
89
important to mitigate risks of hospital ____ which may lead to increased length of stay
delirium
90
the _____ test has been identified as a reliable predictor of a patient's need for post-operative assistive devices
timed up and go (TUG)
91
Normal TUG is <_____ seconds in all age groups
12
92
Persistent use of ambulatory aids is predicted if TUG > _____ seconds
26
93
loss of independence associated factors
age >80 years
ASA class >1
prior walking aid use
current tobacco use
implant placement quality
nondisplaced fracture
not requiring revision surgery
94
mortality rate
25-30% at 1 year
95
_____ is the most significant determinant for post-operative survival
pre-injury mobility
96
in patients with chronic renal failure, rates of mortality at 2 years postoperatively, are close to ____%
45
97
mortality risk is decreased at 30 days and at 1 year post-op when surgical intervention is performed within ____
24 hours of admission
