femoral neck fractures n.
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Femoral neck fractures

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Femoral neck fractures

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Femoral neck fractures

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  1. Femoral neck fractures Re-written by: Daniel Habashi

  2. Anatomy • Physeal closure at the age of 16 • Neck-shaft angle 130° +/- 7 ° . • Anteversion 10 degr +/- 7 degr • Calcarfemorale • Posteromedial • Dense plate of bone

  3. Blood Supply • Greater fracture displacement = greater risk of vascular disruption to femoral head • Revascularization of the head • Intact vessels • Vascular ingrowths across the fracture site

  4. Epidemiology • 250 thousand hip fractures annually

  5. Classification • Pauwels • Angle describes vertical shear vector • Type 1 = 30° • Type 2 = 50° • Type 3 = 70 °

  6. Classification • Garden (1961) • I • Valgus impacted or incomplete • II • Complete non displaced • III • Complete partial displacement • IV complete full displacement • ** portends risk of AVN and nonunion

  7. Classification • Functional classification • Stable • Impacted Garden I • Non-displaced Garden II • Unstable • Displaced Garden III and IV

  8. Treatment • Non-Operative • Very limited role • Activity modification • Skeletal traction • Operative • ORIF • Hemiarthroplasty • Total hip replacement

  9. Decision making variables • Patient characteristics • Young (under 65) • High energy injuries • Often multi-trauma • High Pauwels angle (vertical shear pattern) • Elderly • Lower energy injury • Comorbidities • Pre-existing hip disease • Fracture characteristics • Stable • Unstable

  10. Young patients • Non-displaced fractures • At risk for secondary displacement • Urgent ORIF recommended  OPEN REDUCTION INTERNAL FIXATION • Displaced fractures • Patients native femoral head best • AVN related to duration and degree of displacement • Irreversible cell death after 6-12 hours • Emergent ORIF recommended

  11. Pre-operative considerations • Regional vs general anesthesia • Mortality / long term outcome • No difference

  12. Pre-operative considerations • Surgical timing • Surgical delay for medical clearance in relatively healthy patients probably not warranted • Increased mortality, complications, length of stay • Surgical delay up to 72 hours for medical stabilization warranted in unhealthy patients

  13. Non-displaced fractures • ORIF – standard of care • Predictable healing • Nonunion under 5% • Minimal complications • AVN under 8% • Infection under 5% • Relatively quick procedure • Minimal blood loss • Early mobilization • Unrestricted weight bearing with assistive device PRN

  14. Approach for open reduction • SMITH-PETERSON • Anterior approach • Best for transcervical

  15. Sliding compression screw fixation • Compression hip screws • Sacrifices large amount of bone • May injure blood supply • Biomechanically superior in cadavers • Anti-rotation screw often needed • Increased cost and operative time • No clinical advantage over parallel screws • May have role in high energy / vertical shear fractures

  16. HemiarthroplastyUnipolar vs. Bipolar • Bipolar theoretical advantages • Lower dislocation rate • Less acetabular wear / protrusio • Less pain • More motion

  17. Hemiarthroplasty cemented vs. non-cemented • Cement (PMMA) • Improved mobility, function, walking aids • Most studies show no difference in morbidity / mortality • Sudden intra-op cardiac death risk slightly increased:

  18. Cemented vs. non-cemented • Conclusion • Cement gives better results • Function • Mobility • Implant stability • Pain • Cost-effective • Low risk of sudden cardiac death • Use cement with caution

  19. Pre-operative considerations • Surgical approach • Posterior approach to hip • 60% higher short-term mortality vs. anterior • Dislocation rate • No significant difference

  20. ORIF or Replacement • Prospective, randomized study ORIF vs. cemented bipolar hemi vs. THA • Ambulatory patients > 60 years of age

  21. Stress Fractures • Patient population • Females 4-10 times more likely

  22. Stress fractures • Clinical presentation • Activity weight bearing related • Anterior groin pain • Limited ROM at extremes • +/- antalgic gait • Must evaluate back, knee, contralateral hip

  23. Stress fractures • Imaging • Plain radiographs are negative in up to 66% • Bone scan • Sensitivity 93-100% • Specificity 76-95% • MRI 100% sensitive / specific • Also differentiates synovitis, etc

  24. Stress fractures - complications • Tension sided and compression sided fx’s over 50% treated non-operatively • Varusmalunion

  25. Femoral neck nonunion • Definition: not healed by one year • 0-5%

  26. And then he just finished it and that’s it….