PROXIMAL FEMUR

FRACTURES
Sulita Turaganiwai
s130364
 AK 62yo IF Male Referred from VHC;
• Hx fall x 1/7
• Rt hip pain x 1/7
 HPC: O/E : comf, elderly male. GCS 15/15
Had been attempting to board the  T 36 HR 85 BP 105/58 RR 20 Sp02 100%
bus when he fell and landed on his  HEENT : N Conj and Sclera, moist oral mucosa
Rt Hip.
Denies LOC, weakness  CHEST: s1s2 NAD LF Clear Abd : soft non tender
Nil Bleeding, other injuries  Ext: Rt LL ext rotated and flexed at Rt knee
ROS : Unremarkable . Community + Rt Hip pain Neurovascular intact. Lt LL Normal
ambulatory
 Nil prev admissions, Nil
LAB INVESTIGATIONS
comorbidities  FBC WCC 14100 Hb 6.3 P/M 21/65 Plt 744000
 Smokes 5 rolls/day. Occ Grog +  UECr Na 134 K 4.3 U 5.7 Cr 74 Cl 105 eGFR 120
Alco  Coag : PT C/T 12/13 APTT 26/38
 Xmatch: A+ . 1 PRBC G&H
ASSESSMENT :

RT SUBCAPITAL PROXIMAL
FEMUR FRACTURE:
GARDEN GRADE IV
 MANAGEMENT
1) OPTIMISE THE PATIENT
Anemia : 2 ʘ PRBC TF (9.8)
Mebendazole 100mg PO bd x 3/7
2) ANESTHETIC RV : CXR
Coag and Anemia corrected
3) PLANNED FOR OT:
Consented for Hemiarthroplasty
NBM 12mn
IVF 3L/24 H
FBC + Xmatch done
 ORTHOPAEDIC OT REGISTER
EPIDEMIOLOGY (May 2017-July 2018)
 48 pt with DHS
Lautoka Hospital (2009-2013) Dr.Madhukar:  79% > 60yo
 54 pts. with fractured neck of femur  60% were Females
 72% in 7th decade of life  70% were FoID; of which ¾ were ladies >60yo
 69% were females
 39% had some comorbidity (DM, HPT, RF)
 Mortality: 7.4% at 1 month, 27.8% at 1 year
 Only 13% return to level of pre-morbid
mobility
 AETIOLOGY
Neck of femur fractures are typically caused
either by:
 Low energy injuries – such as a fall in frail
older patient; or
 High energy injuries – such as a road traffic
collision, affecting the ipsilateral side
 Chronic stress injuries
BLOOD SUPPLY
OF THE
PROXIMAL
FEMUR
CLASSIFICA
TION
Stable
(Garden I and II)

Intracapsular Unstable
PROXIMAL (Garden III and
IV)
FEMUR
FRACTURE
Intertrochanteric
Extracapsular
Subtrochanteric
GARDEN CLASSIFICATION
PAUWELS CLASSIFICATION
 Pauwels observed that the obliquity of the
fracture line with the horizontal plane
significantly affected the prognosis of the
fracture.
 The angle formed by extending the
fracture line upwards to meet an
imaginary horizontal line drawn through
the transtubercular (iliac crest) plane on
AP film is described as "Pauwels’ angle."
 The higher the value of this angle, the
greater is the instability of the fracture.
CLINICAL PRESENTATION PHYSICAL EXAM:
 Leg in external rotation and abduction, with
HISTORY : shortening
 Elderly person  Pain on pin-rolling the leg and axial loading,
pain with percussion over greater trochanter
 Recent fall or trauma.
 Unable to straight leg raise.
 Pain (in the groin, over the hip, in the thigh, or
 Distal neurovascular deficits are rare in
the knee)
isolated neck of femur fractures.
 Inability to weight bear.
 Hx of chronic metabolic problems such as
osteoporosis or renal failure.
 Vertigo, dementia, malignancy, and
cardiopulmonary disease in the elderly.
IMAGING STUDIES
WHAT TO LOOK FOR ?
 Shenton’s line disruption: loss of contour
between normally continuous line from
medial edge of femoral neck and inferior
edge of the superior pubic ramus
 lesser trochanter is more prominent due to
external rotation of femur
 femur often positioned in flexion and
external rotation (due to unopposed
iliopsoas)  
 asymmetry of lateral femoral neck/head
 cortex interruption and/or fracture gap 
 a vague dense (‘white’) line in an impacted
fracture
 OPERATIVE
MANAGEMENT
CONSERVATIVE
 non-ambulators, minimal pain
 Analgesiscs , physiotherapy

CONTRAINDICATIONS FOR SURGERY:

RELATIVE
 Process where rapid destruction of bone
 Insufficient musculature
 Progressive neurological d/o
PRE OPERATIVE CHECKLIST
1) OPTIMISE THE PATIENT
Correct anaemia , treat infection, Hypovolemia? coagulopathy?, Electrolyte?
Glycaemic Control? BP Control?
2) GAIN CONSENT: adv on procedure, benefits, risk and prognosis, need for blood
3) ANESTHETIC RV : Allergies, comorbid, current meds , CXR
4) PROPHYLACTIC ANTIBIOTICS: max. serum concentration at time of incision
5) CROSS MATCH BLOOD
6) ANTI-THROMBOTICS
7) INSERT IDC + NBM
CANNULATED HIP SCREW
 Three non-parallel screws in an inverted
triangle formation. Are also used in valgus-
impacted fractures
INDICATIONS
 Non displaced trans cervical #
 G I/II in elderly
 G III/IV Trans cervical in Young
Surgical emergency
Reduce to limit vascular insult
DYNAMIC HIP SCREW
 Consists of a lag screw into the neck, a
sideplate, and cortical screws. The lag screw is
able to slide through the sideplate, allowing
for compression and primary healing of the
bone.
INDICATIONS
 Basicervical #
 Vertical # pattern in Young
 + Cannulated Screw: prevent rotation
HIP ARTHROPLASTY TOTAL HIP ARTHROPLASTY
Replacing both the femoral head and neck
(via a femoral component) and the
HEMIARTHROPLASTY acetabulum (via an acetabular cup).
Replacement of the femoral head and neck via a INDICATIONS
femoral component fixed in the proximal femur
 Older active patients
INDICATIONS
 Pre existing hip osteoarthritis
 Debilitated elderly
 G III/IV <85yo
 Metabolic bone disease
 POST OPERATIVE CHECKLIST
1) POST OP XRAY
2) EARLY IMMOBILISATION
3) PREVENT COMPLICATIONS
4) ADEQUATE PAIN RELIEF
5) RETURN TO PRE MORBID LEVEL OF AMBULATION

POSTOPERATIVE COMPLICATIONS • Infection – Monitor surgical site, patient

ONS
PREOPERATIVE
 Hemorrhage – iatrogenic vascular damage during
reduction
 Avascular Necrosis of the Femoral Head – due
to vascular compromise  Allergic reaction – to anesthesia, equipment,
implant
 Fat Embolus – dislodged from fracture
 Secondary to pt. comorbidity – Cardiac arrest
 Hemorrhage – fracture edge cuts vessel
 Infection (Compound Fractures ++) -
Osteomyelitis
AVASCULAR NECROSIS OF THE
FEMORAL HEAD Radiologic characteristics of AVN of the
femoral head
 stage I: normal/mild osteopenia as a sign of
bone resorption
 stage II: mixed picture of osteopenia/sclerosis
and/or subchondral cysts
 stage III: crescent sign (linear subchondral
lucency) and/or cortical collapse
 stage IV: secondary osteoarthritis of the hip
joint
TAKE HOME MESSAGE
Importance of Early Mobilization after
Fracture Intervention

“Movement is Life”
 REFERENCES
 Medscape – Femoral Neck Fractures (http://emedicine.medscape.com/article/86659-overview)
 Orthobullets – Neck of Femur Fractures (
http://www.orthobullets.com/trauma/1037/femoral-neck-fractures)
 Teach Me Surgery - Neck of Femur Fracture
(http://teachmesurgery.com/orthopaedic/hip/neck-femur-fracture/)
 Wheeless Textbook of Orthopaedics
(http://www.wheelessonline.com/ortho/cannulated_screws_for_femoral_neck_fracture)
 Radiopedia
(https://radiopaedia.org/articles/femoral-neck-fracture)
 Start Radiology
(http://www.startradiology.com/internships/emergency-medicine/hip/x-hip/)
 “Outcomes Following Fractured Neck of Femur at Lautoka Hospital” – Dr. Madhukar Prasad –
Orthopaedic Unit