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Neck of Femur Fractures

Neck of Femur Fractures. Wayne Hoskins. Background. NOF #’s common with advancing age High morbidity & mortality Only 1/3 return to living environment Death: 20-35% at 1 year in patients aged 82 +/-7. Anatomy. Fracture location. Head blood supply.

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Neck of Femur Fractures

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  1. Neck of Femur Fractures Wayne Hoskins

  2. Background • NOF #’s common with advancing age • High morbidity & mortality • Only 1/3 return to living environment • Death: 20-35% at 1 year in patients aged 82 +/-7

  3. Anatomy

  4. Fracture location

  5. Head blood supply • Profunda femoris gives off medial & lateral circumflex femoral arteries • Extracapsular anastomosis at base of neck • Ascending cervical branches • Intracapsular branches • Majority via MCFA, ↓ via ligamentum teres

  6. Garden classification 1. Incomplete impacted # 2. Complete # undisplaced 3. Displaced capsule intact 4. Displaced

  7. Fracture classification • Garden classification: poor inter-observer reliability: • displaced = 1 & 2 • undisplaced = 3 & 4

  8. Shenton’s Line

  9. Mechanism of # • Direct or indirect: 1. Direct blow to GT 2. ER: impinging posterior cortex on rim 3. Bending torque – major trauma 4. Violent muscle contraction 5. Cyclical loading / insufficiency #

  10. NOF # complications • AVN • Undisplaced 5-10% • Displaced 10-20% • RFs: displacement, velocity of injury, delay in reduction, non-anatomical reduction • Non-union • Undisplaced 5-10% • Displaced 20-30% • RFs - initial displacement, non anatomical reduction, instability, no compression across #, vascularity

  11. Presentation • Typically elderly female • Low energy fall • Hip pain • Short & ER leg • Unable to weight bear

  12. NOF # risk factors • Osteoporosis • Co-morbidities • Dementia • Poor mobility / vision

  13. Work up – not just a # • History • Mechanism of injury • Cause of fall - exclude medical cause: TIA, UTI, MI, arrythmia, electrolyte imbalance etc • Other injuries from fall • Risk factors for osteoporosis • Co-morbidities/medications: ?anaesthetic review pre-op, ?choice of operation • ? Gen Med vs. Ortho admission • Ortho Geri’s consult

  14. Work up • Examination: pain, unable to weight bear, short ER leg, ?delirium • Investigations: • ECG, FWT, urine MCS • Bloods: FBE, UEC, CMP, albumin, ESR, Vit D, Coags, G&H • DEXA bone scan

  15. Imaging • Pelvis & hip XR • ?undisplaced # - gold standard = MRI • CT if MRI unavailable • Bone scan less useful, changes take up to 1week in elderly • Pre-op CXR

  16. Medical management • Treat co-morbidities whilst await OT: - electrolyte imbalances - anemia - pneumonia / UTI / infection - arrythmia / MI etc • Post-op manage co-morbidities, RFs falls & osteoporosis: consider Vit D, Ca, bisphosphonates

  17. Surgical management • Surgical option based on: • Displaced vs. undisplaced • Age of patient • Mobility/independence • Bone stock • Aim perfect anatomical reduction and rigid fixation

  18. Anti-coagulants • Operate if on clopidogrel / aspirin • If on warfarin: Vit K / FFP to reduce INR <1.5

  19. Time to surgery • Aim: surgery < 24 hours • Jain JBJS Am 2002: significant reduction in AVN if fixed <12 hours

  20. Surgical results • Best results with healed # in anatomical position without AVN • Quality of reduction is best predictor

  21. Undisplaced subcapital # • Cannulated screws  used in young • 1 x inferior screw, 2x superior screws, ensure threads cross # site, 5mm from surface, inferior screw above LT • DHS + derotation screw  used in old, independent walker

  22. Displaced subcapital # • Expected life > prosthesis survival (<65): aim to preserve the joint • DHS + derotation screw • Closed or open anatomical reduction • Union rates ↑ with anatomical reduction: accept no varus, <15 valgus, <10 AP plane

  23. DHS technique • Set up on traction table • Lateral incision: divide fascia lata • Ensure 2 guide wires centrally in femoral heard 1. Allows reaming for DHS 2. Derotation screw • Screws to attach plate • DHS Blade noe being used with osteoporotic bone  ↑ rotational stability

  24. X-rays

  25. Post-operative Mx • DHS/Screws/Nail – admit to med ward • Surg ward: Hemi/THR/High energy trauma • Young patients – PWB • Elderly – WBAT to prevent complications • Watch for AVN in subcapital #’s (usually 8-12 weeks, but up to 2 years)

  26. Displaced subcapital # • Expected life < prosthesis survival (>65) • Hemiarthroplasty < 5 year survival • Bipolar no better than unipolar, difficult to reduce if Ds • No difference cemented vs uncemented outcome measures • Cemented hemi: ↑ operative time, blood loss, cement pressurization complications, difficult revision • Moore’s if severe comorbidities/non walker – 30% revision at 2 years • Gjertsen JBSB 2010 cf ORIF: both 25% mortality, 3 vs. 22% reoperation, more pain, lower QoL with ORIF

  27. Displaced subcapital # • Expected life < prosthesis survival (>65) • THR 5-15 year survival  young, active, mobile, associated joint disease (RA, OA, etc) • better ROM & pain relief vs hemi • Higher early Ds rate & early loosening • Long term Ds rate equal to hemi

  28. Hemi/THR approach • Posterior approach - preserves gluteus medius - observe sciatic n. ? ↓/↑damage - ? ↓ Ds rate with bone anchors • Hardinge/anterolateral approach - Trendelenburg gate - Previous data ↓ Ds rate • Surgeon preference

  29. Complications • Infection • Dislocation • GT or Femoral shaft # • Leg length discrepancy • Loosening / pain • Revision

  30. Summary • Full medical history and work up  think medical admission with ortho consult • Time to theatre • Surgical choice based on age, # type, mobility, comorbidities • High morbidity and mortality

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