Femoral neck fracture in adult

1. Femoral Neck Fractures
Dr. Mohammad Mahdi Shater
Orthopedic Surgery Resident
Baqiyatallah University of Medical Sciences
‫الرحیم‬ ‫الرحمن‬ ‫اهلل‬ ‫بسم‬
Rockwood and Green's Fractures in Adults

2. - Hip fractures are common and comprise 20% of the
operative workload of an orthopedic trauma unit.
- Intracapsular femoral neck fractures account for 50% of all
hip fractures.
- Only 15% of these fractures are undisplaced
- They are uncommon in patients younger than 60 years.
- The risk of a second hip fracture within 2 years approaches
10% in women and 5% in men.

4. Mechanisms of Injury:
- Simple fall
-External rotation of the leg, with increasing
tension in the anterior capsule and iliofemoral
ligaments

5. The usual site of the fracture is in the weakest part of the
femoral neck, located just below the articular surface.
More rarely, the fracture is a result of higher energy trauma
and these injuries are more common in younger patients
They are associated with distal radial fractures and proximal
humeral fractures in elderly patients.

6. Signs and Symptoms :
- Most patients will have a history of a simple, low-energy fall
as the cause of injury.
- In 2% to 3% of cases, there is no history of trauma and the
injury may be pathologic or a stress fracture.
- Stress fractures can occur in younger patients and are
typically associated with heavy repetitive physical activity in
males or the triad of anorexia nervosa, osteoporosis, and
amenhorrea in female patients.

7. Physical findings may be limited in an undisplaced fracture.
There may be no obvious deformity with the only finding a
painful range of motion of the hip.
In displaced femoral neck fractures, the affected leg is
typically shortened and externally rotated.

8. Imaging :
- AP and lat. Radiographs
- MRI
- technetium bone scan
*In 2% of cases, the fracture may be difficult or impossible to
visualize on plain radiographs*

9. Technetium bone scan:
false-negative in osteopenic bone if the
investigation is carried out within 48 to 72 hours
of the fall.
*It is also sensitive but not specific*

11. Classification of Femoral Neck Fractures:
- Garden Classification
-Pauwels Classification
-AO/OTA Classification

12. Garden Classification

13. Pauwels Classification

15. Singh‘s Index

16. -The femoral neck-shaft angle : 130-135 degrees.
-Femoral neck anteversion : 15-25 degrees.

18. Blood Supply:
There are three sources:
- Capsular vessels
- Intramedullary vessels
- ligamentum teres.

21. Common Surgical Approaches:
- Anterior (Smith Petersen)
- Anterolateral (Watson-Jones)
- Direct Lateral (Hardinge)
- Posterior(Moore or Southern)

22. Nonoperative Treatment of Undisplaced Femoral Neck
Fractures:
- Patients can be mobilized touch weight bearing with
crutches, and the fracture can be expected to heal in 4
to 6 weeks.
- The advantage of this methodis that it avoids surgery,
but most studies show that there is a significant risk of
displacement during nonoperative treatment.

23. Operative Treatment of Undisplaced:
- Choice for the undisplaced intracapsular hip fracture
- Cannulated screw :three screws/two screws

24. Operative Treatment of Displaced Femoral Neck Fractures:
There was much more variation in patients between the age
of 60 and 80 years, with surgeons using reduction and
fixation, unipolar hemiarthroplasty, bipolar hemiarthroplasty,
and THR to differing extents.
-In patients younger than 60 years: Reduction and Fixation
-In patients older than 80 years: Arthroplasty

25. - The usual method of reduction is to apply gentle traction
and internal rotation to the leg.
-The junction of the convex femoral head and neck should
produce an S-shaped curve in all planes.
- On the AP view, a valgus reduction is preferable to a varus
reduction.
- A valgus reduction is inherently more stable, whereas a
varus reduction is associated with a much higher risk of
fixation failure.

26. - 20-degree varus reduction is associated with a 55% risk of
failure.
- less than 20 degrees of posterior angulation to minimize the
same complication.
- The risk of AVN has been shown to be lowest with anatomic
reduction. Either varus or valgus reductions increase the risk
-Failure to achieve a stable reduction is most commonly due
to posterior comminution of the femoral neck.

27. - On the AP view, the angle subtended by the central axis of
the medial trabecular system in the head and the medial
cortex should normally be 160 degrees.
On the lateral view, the central trabecular axis in the head is
in line with the femoral neck, an angle of 180 degrees.
Garden reported good results when the angle was between
155 and 180 degrees on either view.

29. - Patients can be mobilized using touch eight-bearing for 6
weeks.
- Femoral neck fracture union is often slow and usually takes
longer than 6 months in the majority of cases.
- Patients require regular radiographs until this time to ensure
the fracture is uniting uneventfully.

30. -AVN tends to manifest itself after fracture union and is most
common in the second year after injury.
-Younger patients should be followed up for 2 years, with
radiographs on a 6-monthly basis, to detect this complication.

31. Hemiarthroplasty:
-The procedure is usually carried out with the patient in the
lateral position.
-Lateral exposures may result in some abductor weakness,
but there is a lower risk of dislocation.
- Due to the large head diameter, the risk of dislocation is low
(2% to 3%) and wound infection rates should be of the order
of 1% to 2%.

32. Uncemented implants have been associated with an
increased risk in proximal femoral fractures at the time of
insertion.
Cemented stems have also been associated with better
functional outcomes, with less thigh pain.

33. -The results of bipolar hemiarthroplasty for femoral neck
fractures have generally been good.
-The complication rates are higher than those reported for hip
arthroplasty in osteoarthritis but still acceptably low.
-Dislocation and infection rates are usually 3% or lower.

34. Outcome of unipolar vs. bipolar hemiarthroplasty:
There was no difference in the reported rates of
dislocation, deep infection,reoperation rates, or other
general complications such as DVT.
Levels of mobility also showed no significant differences.

35. THA Indications:
- Independently mobile patients with no cognitive
impairment
- Some medical conditions: CRF, RA
- Displaced subcapital fractures in OA
- Patients younger than 60 years
- Steroid treatment, alcoholism,and other conditions
associated with osteoporosis
*Age less than 65 years and obesity were associated with
an increased risk of loosening

36. - Hip fractures are uncommon in patients younger than 60
years and account for only 3% of all hip fractures.
In younger adults.
-These injuries are often the result of high-energy trauma.
- These factors include chronic diseases associated with
osteoporosis, steroid treatment, and alcohol abuse.
- A recent study identified smoking as a significant risk for hip
fractures in women younger than 65 years.

37. If the fracture is undisplaced, it may be treated by reduction and
fixation as a scheduled urgent procedure.
A displaced intracapsular hip fracture in a young patient requires
more urgent treatment.
In most patients a satisfactory reduction can be achieved closed.
If the reduction is not adequate, then open reduction can be
considered.
Rate of nonunion : open reductionhas > closed reduction in younger
patients.

38. Ipsilateral Femoral Neck and Shaft Fractures:
- In young adults with high-energy
- iatrogenic injury : antegrade femoral nailing

39. • Antegrade femoral nailing with a second-generation nail
allowing simultaneous fixation of the femoral neck
• Fixation of the femoral neck fracture with cannulated
screws and retrograde intramedullary nailing of the femoral
shaft fracture
• Fixation of the femoral neck fracture with cannulated
screws and plating of the femoral shaft fracture
• Fixation of both fractures with a sliding hip screw with a
long plate to allow femoral fixation

41. * If the femoral neck fracture is undisplaced, an antegrade
secondor third-generation femoral nail is recommended.
* If the femoralneck fracture is displaced and any difficulty is
anticipated in achieving a closed reduction, screw fixation and
retrograde nailing of the femoral shaft fracture is probably
best.
* Plating of the femoral shaft fracture is usually reserved for
cases where the shaft fracture is in the distal third of the
bone.

42. Femoral Neck Fractures in Rheumatoid Arthritis:
Displaced intracapsular hip fractures Arthroplasty

43. Stress Fractures:
- Most proximal femoral stress fractures are intracapsular
in location
- The fracture is often incomplete and is located either on
the superior or inferior surface of the femoral neck.
- Fractures on the superior surface of the neck are tension
fractures and are more liable to become complete and
displaced.They should be treated with internal fixation.

44. - Compression fractures are more common in younger
patients.
- They are inherently more stable and may initially be
treated nonoperatively with 6 to 8 weeks of protected
weight-bearing.
-If the fracture fails to heal, internal fixation is indicated.

46. Femoral Neck Fractures in Paget’s Disease:
-Fractures of the femoral neck are considered to be less
frequent than intertrochanteric or subtrochanteric fractures in
Paget’s disease.
- The disease can produce a coxa vara deformity, and this is
associated with an increased risk of failure with reduction and
fixation.
- Displaced intracapsular fracture  Hemiarthroplasty
- If the acetabulum is involved  THA

47. Metastatic Femoral Neck Fractures:
*Intracapsular pathologic fractures of the femoral neck
are less common than those in the pertrochanteric
region
*They should be suspected in patients with:
- History of carcinoma with a predilection for bony spread
(lung, breast, prostate, kidney, thyroid)
-Those who present with minimal or no history of trauma
- Patients with evidence of a lytic lesion in the femoral neck.

48. *For patients with limited functional demands or life
expectancy, a bipolar hemiarthroplasty is a reasonable choice.
*Patients with a more favorable prognosis and better function
should be considered for THA.