Fracture of the femoral neck

Question 1

what is the vascular supply of the femur ?

Answer 1

proximal shaft of the femur supplied by medial and lateral circumflex artery of the deep femoral artery

medial circumflex artery responsable for majority of the supply

Question 2

what causes femoral neck fractures ?

Answer 2

in young - high energy trauma

old - low energy fall into the greater trochanter

can also be stress fracture due to overuse and overloading of the hips

women > men

Question 3

the femoral neck lacks what ?

Answer 3

a periosteal layer so callus formation is limited

Question 4

what is the anatomic classification of femoral neck fracture ?

Answer 4

subcapital - near the formal head
transcervical
basicervical

Question 5

femoral neck are further classified from the anatomic classification into what ?

Answer 5

GARDEN classification

garden 1 classification - incomplete and non displaced
impacted

2 - complete and non displaced

3 - complete fracture and partially displaced

4 - complete displacement

pauwels classification
based on vertical line of the fracture
less than 30 degrees = stable
30-50 digress from horizontal = less stable
more than 50 degrees from horizontal = unstable highest risk for nonunion and AVN

Question 6

clinical presentation of femoal neck fractures ?

Answer 6

impacted and stress fractures
slight pain in the groin or pain referred along the medial side of the thigh and knee
no obvious clinical deformity
minor discomfort with active or passive hip range of motion, muscle spasms at extremes of motion

displaced fractures
pain in the entire hip region
displaced fractures leg in external rotation and abduction with shortening

Question 7

femoral neck fracture treatment depends on ?

Answer 7

activity of the patient

age of fracture - there is improved outcome if the fracture is treated within 48 hours and the surgical urgency of the fixing the fracture in young is very important

degree of osteoporosis present

Question 8

what are is the treatment in femoral neck fracture

Answer 8

even in undisplaced fracture open reduction and internal fixation is still done

cannulated screw fixation
- acts as a lag screw - 3 screw inverted triangle formation
try to insert the screw above or at the lesser trochanter to avoid refractures
in garden 1,2 of elderly
displaced trasncervical in young

order of screw placement (this varies)
1-inferior screw along calcar
2-posterior/superior screw
3-anterior/superior screw
obtain as much screw spread as possible in femoral neck

sliding hip screw - in basicervical fracture and vertical fractures in young patients
acts like a big lag screw
and side plate fixes it to the femur with self tapping cortical screws
consider placing another cannulated screw above the sliding hip screw to prevent raton

approach
limited anterior Smith-Peterson

Watson-Jones
used to gain improved exposure of lower femoral neck fractures

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hemiarthroplasty in debilitated elderly patients

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total hip arthroplasty - older active patients
or degenerative arthritis in joints
garden 3/4 in less than 85 years old

improved functional hip scores and lower re-operation rates compared to hemiarthroplasty and internal fixation

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benefits of early mobilization cannot be overemphasized in elderly patients
improved outcomes in medically fit patients if surgically treated less than 4 days from injury

Question 9

complications of femoral neck fractures ?

Answer 9

patient mortality
increases when surgery is delayed for more than 4 days

avascular necrosis
risk : with increased displacement
treatment - vascularised fibular bone grafts in young
prosthetic in old - hemiarthorplasty or total hip arthroplasty

nonunion
treatmnet :
- valgus intertrochanteric osteotomy
can be done even in presence of AVN
turns vertical fx line into horizontal fx line and
with vascularised fibular bone grafts
- free vascularized fibula graft (FVFG)
indicated in young patients with a viable femoral head
- arthroplasty
indicated in older patients or when the femoral head is not viable

Dislocation
higher rate of dislocation with THA (~ 10%)
about seven times higher than hemiarthroplasty

Question 10

femoral neck fracture prognosis depends on ?

Answer 10

pre-injury mobility is the most significant determinant for post-operative survival

patients with chronic renal failure, rates of mortality at 2 years postoperatively, are close to 45%

Question 11

what is the first aid in femoral neck fracture ?

Answer 11

thomas bed knee splint
or
in treating any femoral fracture splint the whole leg as soon as possible, before transport of the patient. For that purpose you need two firm boards or along the leg, suitably padded, one on the inside and one along the leg and the body on the outside.
splints should then be kept in place by bandages around

before surgery

bucks skin traction is used for TEMPORARY UNTIL OPERTION for femora neck fractures
UNDISPLACED FRACTUREOF ACETABULUM
after reduction of hip dislocation