Classification and management of fractur

Classification and management of fracture neck of femur : 

Classification and management of fracture neck of femur J. Preethi

Skeletal anatomy : 

Skeletal anatomy Has an internal trabecular system oriented along the lines of stress area of weakness ( WARD’S ) Osteoporosis – thinned out weak trabeculae

Singh‘s grading of osteopenia : 

Singh‘s grading of osteopenia

Vascular anatomy : 

Vascular anatomy Extra capsular arterial ring Retinacula of weitbrecht Sub synovial intraarticular ring artery of ligamentum teres - branch of obturator or medial circumflex A.

Vascular anatomy : 

Vascular anatomy Femoral A profunda femoris Medial circumflex lateral circumflex EXTRACAPSULAR ARTERIAL RING few branches major branches medullary branches small metaphysial vessels ascending cervical branches form 4 groups Neck of femur SUBSYNOVIAL INTRA ARTICULAR RING HEAD OF FEMUR

Healing of a fracture neck of femur : 

Healing of a fracture neck of femur cambium layer of periosteum is absent, so has to heal only through endosteal callus blood remains inside the joint capsule, increasing intracapsular pressure and further damaging the femoral head; synovial fluid hinders clotting Displaced fracture leads to avascularity

Mechanism of injury : 

Mechanism of injury OLD AGE A trivial injury Predisposing osteoporosis Direct blow on greater trochanter External rotation of the extremity YOUNG AGE rare High energy trauma Cyclical loading stress fractures

Classification : 

Classification Intra capsular, Extra capsular Impacted, undisplaced, displaced Stress fractures, pathological fractures, post irradiation fractures

Classification : 

Classification ANATOMICAL Bank’s sub classification Difficulty in describing the fracture by radiography. Different types could be artifactual secondary to x ray parallax Relative infrequency of true cervical

Classification : 

PAUWEL’S Classification as the femoral neck is spiral, its only the x ray projection of the fracture line that varies in obliquity with rotation of distal fragment It may indicate prognosis post reduction and the quality of reduction

Classification : 

GARDEN’S {on AP view} Stage I incomplete fracture of the neck (so-called abducted or impacted) Classification

Classification : 

GARDEN’S Stage II complete without displacement Classification

Classification : 

GARDEN’S Stage III complete with partial displacement: fragments are still connected by posterior retinacular attachment; there is malalignment of the femoral trabeculae Classification

Classification : 

GARDEN’S Stage IV this is a complete femoral neck fracture with full displacement: the proximal fragment is free and lies correctly in the acetabulum so that the trabeculae appear normally aligned Classification

Classification : 

Undisplaced garden I & II Displaced Garden III & IV Classification

Classification : 

ORTHOPEDIC TRAUMA ASSOCIATION B 1 : subcapital with slight displacement B 2 :transcervical B 3: displaced subcapital Classification

Classification : 

Classification Delbet classification for pediatric age group 1. Type I transepiphyseal IA without dislocation IB with dislocation 2. Type 2 transcervical 3. Type III cervicotrochanteric 4. Type IV intertrochanteric

Classification : 

Classification Perlington’s : angle the fracture line forms with respect to the vertical I – 70 II - 50 III - 30

Clinical features and diagnosis : 

Clinical features and diagnosis UNDISPLACED, IMPACTED FRACTURES CLINICAL: Slight pain over groin, referred pain in the knee May be able to walk with a limp Tenderness over greater trochanter Only minor discomfort during active and passive range of movements

Radiological features : 

Radiological features X ray may not show fracture In that case an MRI or BONE SCAN can be done MRI can be done in first 24 fracture line can be visualized as linear low-signal-intensity areas surrounded by bone marrow edema, which is hypointense relative to normal marrow on T1-weighted images or hyperintense on T2-weighted images. Bone scan can be done only after 72 hrs in osteopenic adults

Clinical features and diagnosis : 

DISPLACED FRACTURES Leg lies in external rotation abduction and slight shortening Pain in entire hip Don’t perform range of movements Clinical features and diagnosis Immobilization of the limb is done using a splint

Radiological features : 

Radiological features AP and Lateral Fracture line Fracture angle Break in shenton line Posterior wall communition Prominent lesser trochanter Degree of osteoporosis

Orthopedic emergency : 

Orthopedic emergency Femoral neck fractures should be treated as an orthopedic emergency Surgery performed within 6 to 12 hrs in displaced fractures and within 24 hrs in non displaced

Aims of treatment : 

Aims of treatment Early anatomical reduction impaction of fracture fragments Rigid internal fixation Will permit early mobilization and prevents late complications

Management of garden stage I & II : 

Management of garden stage I & II Operative : fracture reduction and stabilization Less risk of avascular necrosis Increased risk subtrochanteric fractures No compression at fracture site more risk of avascular necrosis decreased risk subtrochanteric fractures provides compression at fracture site

Cancellous lag screws : 

Cancellous lag screws Inverted triangle configuration under radiographic guidance Within 5 mm of subchondral bone Start above lesser trochanter A fourth screw can be placed in gross posterior communition

Sliding hip screws : 

Sliding hip screws Anti rotation screw superiorly Transfers bending movements to the lateral cotex Used for basicervical type where it is the treatment of choice

Conservative methods : 

Conservative methods Only indications are: Elderly with poor medical condition Non ambulatory patients with minimal discomfort

Management of garden stage III & IV : 

Management of garden stage III & IV

Reduction techniques : 

Reduction techniques closed open With hip in extension Whitman’s method Massie Mc Elevenny Deyerle With hip in flexion Lead better Smith patterson Flynn Under two plane x ray control and image intensification

Assesment of reduction : 

Assesment of reduction Alignment index Lowell’s S or reverse S

Slide 32: 

Stability of reduction: intactness of the posterior cortex no displacements with rotation in combination with anteversion and retroversion no varus calcar cortex aligned supporting the femoral head

Management of garden stage III & IV : 

Management of garden stage III & IV

Mc Murray’s osteotomy : 

Mc Murray’s osteotomy Osteotomy proximal to lesser trochanter Distal fragment pushed medially and fixed internally Converts shearing forces into compressive forces Head is supported by the distal fragment : arm chair effect

Total hip replacement : 

Total hip replacement Indications: Associated symptomatic hip disease Highly active patient Extremly cooperative patient with excellent mental status who are likely to survive more than 10 years Metastatic fracture involving acetabulum as a salvage foll. Failed internal fixation or hemiarthroplasty

Hemiarthroplasty : 

Hemiarthroplasty

Hemiarthroplasty : 

Hemiarthroplasty Advantages of modular prosthesis: Neck length component can be adjusted to tension of abductors Offset of femoral neck can be adjusted without increasing leg length Can easily be converted into a THR if necessary Unipolar bipolar

Hemiarthroplasty : 

Hemiarthroplasty Austin Moore prosthesis in adequate calcar femori Thompson prosthesis In inadequate calcar femori

Slide 40: 

Stress fractures : Fullerton and snowdy classification Type A : tension fractures Type B: compression fractures Type C : displaced fractures primary prosthesis Old fractures > 3 wks Pathological fractures Psychosis Neurological disorders

Complications : 

Complications

Early complications : 

Early complications INFECTION Periop infection prevented by a cephalosporin 1 g iv before surgery and 1 g iv 8 hrly for 3 doses Early or late Superficial or deep Can produce bone erosion , dislocation , septic arthritis and osteomyelitis DEEP VEIN THROMBOSIS 50% incidence in absence of prophylaxis Fatal PE 0.5 – 2% Low molecular weight heparin s.c. once a day can be given as prophylaxis

Early complications : 

Early complications DISLOCATION OF PROSTHESIS Cause: mechanical or infective Reduction is done under GA closed or open Traction for few days and bracing in 15 deg abd and limit of 70 deg flex for 6 wks until soft tissues heal.

Late complications : 

Late complications

Nonunion : 

Nonunion 20 to30% displaced fractures, rare in non displaced Leighton's classification of femoral neck nonunion

Nonunion : 

Nonunion Shearing stress in fractures with vertical inclination X ray shows radiolucent zone Bone scan can be done to distinguish from avascular necrosis CT could be done to evaluate the fracture MRI diff with steel implants

Nonunion : 

Nonunion

Slide 49: 

Meyer’s bone graft Useful in post. communition using a vascularised quadratus femoris muscle pedicle Pauwel’s osteotomy Intertrochanteric osteotomy

Avascular necrosis : 

Avascular necrosis 66 to 84% can be partial or total –microscopic event –early phenomenon Late segmental collapse 7 to 27% usually within 2 yrs Factors affecting femoral head survival -- remaining vascular supply -- revascularisation Prevention : early anatomic reduction and stable internal fixation

Avascular necrosis : 

Avascular necrosis Investigations: x ray –increased density of femoral head bone scan– 100%sens MRI & CT Treatment : acetabular cartilage : viable- hemiarthroplasty nonviableTHR

Late complications : 

Late complications Heterotopic ossification Pain : due to prosthesis loosening , migration, sepsis

Intertrochanteric fractures : 

Intertrochanteric fractures Extra Capsular Fracture neck of femur the blood supply to the proximal fragment is not interfered with and there is a greater area of contact between the two fragments; hence the fractures unite easily.  Stable Type: There is a single fracture line and it is a two piece fracture. Unstable Type: This is a comminuated fracture with multiple fractures at the trochanteric level

Comparison : 

Comparison

Slide 55: 

Management The principle of the treatment is reduction of the fracture and maintenance of the fragments in good position till union occurs. Conservative Treatment application of continuous skeletal traction.  For cases with marked coxa vara, continuous skeletal traction through the upper tibia is applied and the leg is immobilised in the Bohler Braun splint and the foot end of the bed is raised.  When the coxa vara is not marked, skin traction in Thomas' splint will be sufficient.

Slide 56: 

Operative Treatment manipulative reduction and internal fixation McLauglin two piece nail plate single piece angled nail plate (Jewett) has been found to be mechanically superior and gives good results compression hip screw and plate system has enabled earlier mobilisation of the hip and weight bearing. Complications malunion with coxa vara and shortening.  If gross, it can be corrected by osteotomy.

Slide 57: 

Thank you!