Femur Fractures

Proximal Femur Fractures

Classification

• Femoral Neck
  • Intra-capsular
• Inter-trochantric
  • Extra-capsular

Intra-capsular vs. Extra-capsular

• The capsule envelopes the femoral head and neck
• Intertrochanteric and sub-trochanteric fractures are extra-capsular

Mechanism of Injury

Elderly vs. Young Patients

• In elderly people 95%:
  • Low energy: slipping at home, pathological bones
• In young patients 5%:
  • High energy trauma like MVA, falls from heights

Types of Fracture

• Indirect injury:
  • Falls
  • Dash-board injury
  • Possibly with patellar fracture
• Types of fracture depend on:
  • Position of limb during impaction and
  • Magnitude of force

Holistic Approach

• Look at the patient as whole, not to injured limb alone!
  • In elderly: other diseases
  • In young: major trauma, other injuries
• Save life first, then save limb, then save function

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Femoral Neck Fractures

Epidemiology

• Most common in the elderly
• 53% of all fractures of proximal femur
• 1.7 million hip fractures annually world wide
• Expected to triple in the next 50 years

Vascular SupplyC ?

• Anterior View
  • The Lateral Femoral Circumflex Artery is shown supplying the femoral head.
• Posterior View
  • The Medial Femoral Circumflex Artery is depicted as the primary supplier to the femoral head.

Risk of Avascular Necrosis

• Risk of osteonecrosis (Avascular Necrosis)
  • More in near head (Sub-capital)
  • More in displaced fractures

Presentation and Investigations

• Presentation:
  • In elderly:
    • Mild trauma/fall
    • Pain in hip/ thigh
    • Inability to walk
      • May walk if impacted
  • In the young:
    • Major trauma
    • Pain in hip
    • Inability to walk
• Investigations:
  • In elderly:
    • X-ray: AP/?Lateral
    • May need MRI:
      • If X-rays inconclusive
    • Other diseases
  • In the young:
    • X-ray: AP/?Lateral
    • Other injuries

A 65 year old: slipped in the toilet

A 55 year old, tripped at edge of carpet

Treatment of Femoral Neck Fractures

Operative Treatment

• Operative
  • The treatment of choice
  • Surgery should be performed urgently

Internal Fixation and Replacement

• Internal fixation:

  • Multiple Screws
    • Young patient: Stable fracture
  • Dynamic Hip Screw

• Replacement:

  • Old patients
  • hemi or total

Complications

• Nonunion

  • 5% of non-displaced
  • 25% of displaced fractures

• Avascular necrosis

  • 0% of non-displaced
  • 27% of displaced fractures

Intertrochanteric Fractures

Characteristics

• Extra-capsular
• Good blood supply
• Heal well
  • Low risk for avascular necrosis

Demographics and Presentation

• Elderly, osteoporotic women
• Simple fall

Blood Supply Comparison

Intertrochanteric

Good blood supply maintained Good healing / no AVN

Femoral neck

Blood supply interrupted Non-union / AVN

Evaluation

• Clinical evaluation
  • Pain in the hip
  • Inability to bear-weight
  • Limb is short and externally rotated
  • c.f dislocated hip
    • Short, adducted, internally rotated

Radiological Evaluation

• Radiological evaluation
  • AP and ?Lateral (cross-table)
• Evaluation of medical condition

Treatment

• Usually operative
  • Dynamic hip screw (DHS)
  • Proximal femoral nail

Femoral Shaft Fractures

Mechanism and Complications

• Mechanism: high energy
• Bleeding:
  • Can easily loose 2L of blood
  • Need good resuscitation
  • Early fixation
• Inability to bear weight
• Risk of thrombo-embolism
• X-rays:
  • AP & lateral radiographs
  • Two joints (above and below)
    • Very important

Surgical Treatment

• IMN: Intramedullary nail / Locked(with screws)
  • The treatment of choice
  • Relative stability
  • Allows early weight-bearing

Intramedullary Nailing

• IMN: Intramedullary nail
  • The treatment of choice
  • Locked IMN (with screws)

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Plate Fixation

• Plate fixation
  • The second choice
  • Could use minimal invasive methods
  • No early weight-bearing