| ID | 252 |
|---|---|
| Name | FRACTURE OF THE FEMORAL NECK |
| Cause | |
| Signs Symptoms | |
| Diagnosis | Diagnosis: X-Ray hip B/V: Fracture with or without displacement. Displacement is usually judged by the abnormal shape of the bone outlines and the degree of mismatch of the trabecular lines in the femoral head and neck and the supra-acetabular (innominate) part of pelvis. This assessment is important because displaced fractures have a high rate of non-union & avascular necrosis. There are four situations in which a femoral neck fracture may be missed: 1. Stress fractures 2. Undisplaced fractures 3. Painless fractures 4. Multiple fractures. |
| Investigations | |
| Management | |
| Introduction | In the elderly life, the femoral neck is the commonest site of fracture. The most of the patients are women in their seven & eight decades, and associated with osteoporosis, osteomalacia, diabetes, stroke (disuse), alcoholism, and chronic debilitating diseases. Mechanism of injury: 1. In elderly, where bone is osteoporotic- fall directly onto the greater trochanter, or, a less force or stress is enough to cause fracture. 2. In younger, mostly fall from a height, or, a blow sustained in a road accident. These patients often have multiple injuries and in about 20% there is an associated fracture of the femoral shaft. |
| History | |
| Etiology | |
| Clinical Features | Clinical features: 1. History of a fall. 2. Pain in the hip. 3. If the fracture is displaced, the patient lies with the limb in lateral rotation 4. Leg looks short. |
| Preventions | |
| Treatment | Treatment: Initial treatment: 1. Pain-relieving measures. 2. Surface traction- simple splintage of the limb. 3. Pulmonary complications and bed sores. Operative treatment: Operative treatment is mandatory in most of the femoral neck fracture. Non-operative management is only indicated for an ‘old’ impacted garden I fracture where the diagnosis is made after the patient has been walking about for several weeks without deleterious effect on the fracture position. In young patients, operation should be done urgently when interruption of the blood supply will produce irreversible cellular changes (after 12 hours). Principles of fracture treatment: Principles of fracture treatment are- i. accurate reduction, ii. internal fixation, iii. prosthetic replacement, and iv. total hip replacement. In case of stage III and IV fractures, prosthetic replacement is preferable specially in patients- i. the very old and the very frail, ii. patients in whom closed reduction fails, and iii. pathological fractures. 1. Reduction and fixation: In most patients specially aged under 75 years, treatment policy is- reduction and internal fixation. i. Reduction: Displaced fractures must first be reduced under general anesthesia, the fracture is disimpacted by applying traction with the hip held 45° of flexion & slight abduction. The femoral head should be positioned correctly so that the stress trabecule are aligned close. Fixation of an imperfectly reduced fracture is not possible. If Garden stage III or IV fracture cannot be reduced closed, and the patient age is under 60 years, open reduction is advisable. The method of reduction is assessed by x-ray. ii. Internal fixation: After completion of fracture reduction, it is held fixed with the femoral shaft by screw and side-plate, by giving a lateral incision to the upper femur. An impacted fracture can be left to unite, but there is always a risk of displacement, even while lying in bed, so internal fixation is essential. Displaced fractures will not unite without internal fixation. iii. Post-operative care: i. From the first day the patient should sit up in bed or in a chair; ii. Breathing exercises; iii. Encouraged to help herself and to begin walking. 2. Prosthetic replacement: In case of stage III and IV fractures prosthetic replacement is preferable specially in patients- i. the very old and the very frail, ii. patients in whom closed reduction fails, & iii. pathological fractures. 3. Total hip replacement: This may be preferable- i. if treatment has been delayed for some weeks and acetabular damage is suspected, or ii. in patients with metastatic disease or Paget’s disease. |
| Complications | Complications: 1. General complications: Deep vein thrombosis, pulmonary embolism, pneumonia and bed sores 2. Avascular necrosis: About 30% patients with displaced fractures and 10% with undisplaced fractures. 3. Non-union: More than 30% of all femoral neck fractures fail to unite specially in severely displaced cases. The patient complains of pain, shortening of the limb and difficulty with walking. |
| Prognosis | |
| Types | |
| Classification | Classification: ‘Garden classification’ in the most useful classification of femoral neck fracture, which is mainly a radiographic (x-ray) presentation based on the amount of displacement. Garden stage I- an incomplete impacted fracture in which the femoral head is tilted into valgus in relation to the neck. Garden stage II- a complete but undisplaced fracture. Garden stage III- a complete fracture with moderate displacement (<50%). Garden stage IV- a severely displaced fracture. |
| Observation | |
| Pathology |
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