Frienchzel Joy A. Asis

Group 3 BSN 3-A

Femoral Fractures

Fractures of the femur are common and may affect the femoral neck, the femoral shaft or distal (supracondylar) femur, which often also involve the knee joint. Fractures of the femoral neck are far more common in the elderly but fractures of the femoral shaft and supracondylar fractures are usually caused by violent trauma and most often occur in adolescents and young adults.

Intracapsular fractures of the neck of femur

These can follow relatively minor trauma in the elderly. Fractures in younger patients are usually caused by a high-energy impact.1

Intertrochanteric fractures affect the base of the femoral neck. Initial management is the same as for an intracapsular fracture of the neck of femur (see below under Management section).2

May disrupt the blood supply to the femoral head, leading to avascular necrosis.

Risk factors

Increased risk in the elderly because of osteoporosis, osteomalacia and falls.

Presentation

Pain may radiate to the knee. The patient may present with knee pain and no pain on movement of the hip.

Presentation may be a sudden inability to weight bear. There may be no history of injury, especially in an elderly patient with confusion or dementia.

The affected leg may be shortened, adducted and externally rotated. Pain over the hip may be particularly aggravated by rotation of the leg.

X-rays

AP pelvis and lateral hip X-rays: may show disruption of trabeculae, inferior or superior cortices and abnormality of pelvic contours.

Shenton's line is a radiographic, curved line formed by the top of the obturator foramen and the inner side of the neck of the femur. It is used to determine the relationship of the head of the femur to the acetabulum. This line is broken in fractures.

The vast majority of fractures are clearly seen on plain X-rays. MRI is the investigation of choice if there is any doubt (radioisotope scan or repeat X-rays after 24-48 hours if MRI is not available).

Intracapsular neck of femur fractures are graded by various classifications, including the Garden classification:

o Garden I: trabeculae angulated, inferior cortex intact. No significant displacement.o Garden II: trabeculae in line but a fracture line is visible from superior to inferior

cortex. No significant displacement.o Garden III: obvious complete fracture line with slight displacement and/or rotation

of the femoral head.o Garden IV: gross, often complete, displacement of the femoral head.

Management

Investigations: full blood count and cross-match. Initial assessment should also include renal function, glucose, ECG and perhaps a chest X-ray. Other investigations may be required, depending on history and general examination.

Intravenous access and commence intravenous infusion if indicated. Intravenous analgesia (plus an antiemetic if required, but studies have shown that routine

use of a prophylactic antiemetic in combination with opiate analgesia is unnecessary). Internal fixation with screws if undisplaced (arthroplasty should be considered for those

patients who are less fit); displaced intracapsular fractures may be treated by either reduction or internal fixation in younger fit patients, or by replacement of the femoral head with an arthroplasty in older less fit patients.3 Internal fixation is associated with less initial operative trauma but has an increased risk of reoperation on the hip.6

Patients with pre-existing joint disease, medium or high activity levels and a reasonable life expectancy should have a total hip replacement rather than hemiarthroplasty as primary treatment.

Complications include nonunion, malunion and avascular necrosis. There is a high risk of postoperative complications in the elderly, including pneumonia,

myocardial infarction, stroke, deep vein thrombosis and pulmonary embolus.

Extracapsular fractures of the neck of femur

Approximately half of all hip fractures are outside the hip joint capsule (extracapsular proximal femoral fractures).

Extracapsular hip fractures should all be treated surgically unless there are medical contra-indications.

These fractures are usually treated by internal fixation but hip arthroplasty may be used (internal fixation may fail, especially for unstable fractures).

The limited available evidence does not suggest significant differences in outcome between conservative and operative management programmes for extracapsular femoral fractures, but operative treatment is associated with a reduced length of hospital stay and improved rehabilitation. Isolated trochanteric avulsion fracture

Sudden violent force may avulse the insertion of gluteus medius from the greater trochanter, or iliopsoas from the lesser trochanter.

Initial management: adequate analgesia. Further management: gradual mobilisation and symptomatic treatment.

Subtrochanteric fractures

Involve the proximal femoral shaft, at or just distal to the trochanters. Usually caused by high-energy trauma in younger patients and are often associated with

other serious injuries. May follow relatively minor trauma in the elderly and patients with osteoporosis or metastatic disease.

Both intramedullary and extramedullary internal fixation has been advocated for the treatment of subtrochanteric femur fractures. There is some evidence that operation time and fixation failure are reduced with the use of intramedullary implants.

Shaft of femur fractures

Caused by a high-energy injury, such as road traffic accidents, unless pathological fracture in a patient with osteoporosis or metastatic disease.

There are often associated injuries to the hip, pelvis, knee and other parts of the body.

Diagnosis

Deformity, shortening, external rotation and abduction at the hip on the affected side.

Management

Initial managemento Assess vital functions and any associated chest, head, abdominal or spinal injuries.

Resuscitate and treat life-threatening injuries as necessary.o Splint fractures (Thomas' splint or equivalent traction splint).o X-rays of the femur.o Blood tests, including blood for cross-matching.o Obtain intravenous access and start fluid replacement.o Peripheral sensation and pulses should be closely monitored.o Analgesia: adequate intravenous analgesia. Femoral nerve block is usually effective.

Further managemento Intramedullary nailing is used for treating fractures of the femoral shaft.10

o Early immobilisation and treatment reduces the risk of complications.

Complications

Closed fractures may be associated with a large volume of blood loss before becoming obvious with swelling of the thigh.

Later complications include fat embolism, deep vein thrombosis, pulmonary embolism, infection, shortening, angulation and nonunion.

Supracondylar fractures

Fractures of the distal third of the femur usually occur as a result of violent direct injury. They are often comminuted and often intra-articular with associated damage to the knee

joint. The distal fragment of the femur tends to pulled backwards and the popliteal artery may be damaged.

Treatment: initially the same as for fractures of the femoral shaft but a femoral nerve block is not as effective and so additional analgesia is required.

Treatment for undisplaced fractures: often conservative with skeletal traction with the knee in 30° of flexion.

Displaced intra-articular fractures require internal fixation.

Femoral fracture

A femoral fracture is a bone fracture that involves the femur.

Classification

A femoral fracture that involves the femoral head, femoral neck or the shaft of the femur immediately below the lesser trochanter may be classified as a hip fracture, especially when associated with osteoporosis.

Femoral shaft fractures can be classified with the Winquist classification, which is based on the amount of comminution:

Type I or 1: transverse or short oblique fractures with no comminution or a small butterfly fragment of less than 25% of width of the bone

Type II or 2: a comminuted with a butterfly fragment of 50% or less of the width of the bone Type III or 3: comminuted with a large butterfly fragment of greater than 50% of the width

of bone Type IV or 4: Segmental comminution

What is a femur fracture?The femur is one of the largest and strongest bones in the body. The femur is the thigh bone--it extends from the hip joint down to the knee joint. Because the femur is such a strong bone, it can take tremendous force to cause a femur fracture.

What causes a femur fracture?As stated previously, the femur is a tremendously strong bone--in order for a femur fracture to occur, either a large force must be applied or something is wrong with the bone. In patients with normal bone strength, the most common causes of femur fractures include:

o Car accidents

o Falls from a height

Patients may also have bone that is weakened by osteoporosis, tumor, or infection. These conditions can lead to a so-called pathologic femur fracture.

Femur fractures are generally separated into three broad categories:

Proximal Femur FracturesProximal femur fractures, or hip fractures, involve the upper-most portion of the thigh bone, just adjacent to the hip joint. These fractures are further subdivided into different types of hip fractures that are discussed elsewhere. You can find more information about these fractures by going to one of the following pages:

o Hip Fractures

o Femoral Neck Fractures

o Intertrochanteric Femur Fractures

Femoral Shaft FracturesA femoral shaft fracture is a severe injury that generally occurs in high-speed motor vehicle collisions and significant falls. These injuries are often one of several major injuries experienced by a patient.

The treatment of a femoral shaft facture is almost always with surgery. The most common procedure is to insert a metal rod down the center of the thigh bone called an intramedullary rod. This procedure reconnects the two ends of the bone, and the rod is secured in place with screws both above and below the fracture. The intrameduallary rod generally remains in the bone for the life of the patient, but can be removed if it causes pain or other problems.

Other less commonly used treatments of a femur fracture include a plate and screws or an external fixator. These treatment options may have to be used if an intrameduallary rod cannot be used for

some reason. In certain patients, depending on the fracture type and associated injuries, an intramedullary rod may not be an option; in these cases one of the other treatments (plate and screws, external fixator, etc.) will be selected.

Supracondylar Femur FracturesA supracondylar femur fracture is an unusual injury to the femur just above the knee joint. These fractures often involve the cartilage surface of the knee joint, and must be treated with this cartilage injury in mind. Patients who sustain a supracondylar femur fracture are often at high risk of developing knee arthritis later in life.

Supracondylar femur fractures are more common in patients with severe osteoporosis and in patients who have previously undergone total knee replacement surgery. In these groups of patients the bone just above the knee joint may be weaker than in normal patients, and therefore more prone to fracture. However, patients may also sustain a supracondylar femur fracture after high-energy injuries as described above.

The treatment of a supracondylar femur fracture is highly variable, and may utilize a cast or brace, external fixator, plate, screws, or an intramedullary rod. There are many variations to these fractures that affect the best choice for fixation of the fracture.

A hip fracture is a femoral fracture that occurs in the proximal end of the femur (the long bone running through the thigh), near the hip joint.

The term "hip fracture" is commonly used to refer to four different fracture patterns and is often due to osteoporosis; in the vast majority of cases, a hip fracture is a fragility fracture due to a fall or minor trauma in someone with weakened osteoporotic bone. Most hip fractures in people with normal bone are the result of high-energy trauma such as car accidents.

Femoral head fracture denotes a fracture involving the femoral head. This is usually the result of high energy trauma and a dislocation of the hip joint often accompanies this fracture.

Femoral neck fracture (sometimes Neck of Femur (NOF), subcapital, or intracapsular fracture)

Subtrochanteric fracture actually involves the shaft of the femur immediately below the lesser trochanter and may extend down the shaft of the femur.

Signs and symptoms

The classic clinical presentation of a hip fracture is an elderly patient who sustained a low-energy fall and now has pain and is unable to bear weight. On examination, the affected extremity is often shortened and unnaturally, externally rotated compared to the unaffected leg.

Risk factors

Hip fracture following a fall is likely to be a pathological fracture. The most common causes of weakness in bone are:

Osteoporosis . Homocysteine , a toxic 'natural' amino acid linked to the cause of heart disease, Other metabolic bone diseases such as Paget's disease, osteomalacia, osteopetrosis and

osteogenesis imperfecta. Stress fractures may occur in the hip region with metabolic bone disease.

Benign or malignant primary bone tumours are rare causes of hip fractures. Metastatic cancer deposits in the proximal femur may weaken the bone and cause a

pathological hip fracture. Infection in the bone is a rare cause of hip fracture.

In a study of 135,000 people 50 or older, those taking high doses of a proton pump inhibitor (PPI) more likely to break a hip.

Diagnosis

X-rays of the affected hip usually make the diagnosis obvious; AP and lateral views should be obtained.

In situations where a hip fracture is suspected but is not obvious on x-ray, a CT scan with 3D reconstruction may be helpful. MRI has gained importance in the diagnosis of occult fractures of the femoral neck. Within 24 hours changes can be seen on MRI. Bone scan is less useful because it may take up to 1 week to demonstrate changes especially in the elderly.

As the patients most often require an operation, full pre-operative general investigation is required. This would normally include blood tests, ECG and chest x-ray.

Femoral neck

Garden Type 1 Fractured Neck of FemurFemoral neck fracture three months after surgery.

Femoral neck fractures involve the narrow neck between the round head of the femur and the shaft. This fracture often disrupts the blood supply to the head of the femur.

Garden classified this fracture into four types:

Type 1 is a stable fracture with impaction in valgus. Type 2 is complete but non-displaced. Type 3 is displaced (often rotated and angulated) with varus displacement but still has some

contact between the two fragments. Type 4 is completely displaced and there is no contact between the fracture fragments.

The blood supply of the femoral head is much more likely to be disrupted in Garden types 3 or 4 fractures.

Surgeons may treat these types of fracture by replacing the fractured bone with a prosthesis arthroplasty. Alternatively the treatment is to reduce the fracture (manipulate the fragments back into a good position) and fix them in place with three metal screws.

A serious but common complication of a fractured femoral neck is avascular necrosis. The vasculature to the femoral head is easily disturbed during fractures or from swelling inside the joint

capsule. This can lead to strangulation of the blood supply to the femoral head and death of the bone and cartilage.

Intertrochanteric

Intertrochanteric fractures occur between the greater and lesser trochanters. They are usually fixed with a sliding hip screw and plate. Healing is usually good when the patient is healthy.

Hip fractures are treated in one of two ways: Traction or orthopedic surgery.

Management

Most hip fractures are treated by orthopedic surgery, which involves implanting an orthosis. The surgery is a major stress on the patient, particularly in older people. Pain is significant, forcing the patient to remain immobilized. Since prolonged immobilization can be more of a health risk than the surgery itself, post-op patients are encouraged to become mobile as soon as possible, often with the assistance of physical therapy (physiotherapy).

If operative treatment is refused or the risks of surgery are considered to be too high the main emphasis of treatment is on pain relief. Skeletal traction may be considered for long term treatment. Aggressive chest physiotherapy is needed to reduce the risk of pneumonia and skilled nursing to try to avoid pressure sores and DVT/pulmonary embolism Most patients will be bedbound for several months. Non-operative treatment is no longer an alternative in developed countries with modern health care.

Fractured neck of femur

Medial fracture in a 92-year-old woman

Fracture treated with cannulated screws

For low-grade fractures (Garden types 1 and 2), standard treatment is fixation of the fracture in situ with screws or a sliding screw/plate device. This treatment can also be offered for displaced fractures after the fracture has been reduced.

In elderly patients with displaced fractures many surgeons prefer to undertake a Hemiarthroplasty, replacing the broken part of the bone with a metal implant. The advantage is that the patient can mobilize without having to wait for healing.

Intertrochanteric fracture

Intertrochanteric hip fracture in a 17-year-old male

Fracture supported by dynamic hip screw

An intertrochanteric fracture, below the neck of the femur, has a good chance of healing. Treatment involves stabilizing the fracture with a lag screw and plate device to hold the two fragments in position. A large screw is inserted into the femoral head, crossing through the fracture; the plate runs down the shaft of the femur, with smaller screws securing it in place.

The fracture typically takes 3–6 months to heal. As it is only common in elderly, removal of the dynamic hip screw is usually not recommended to avoid unnecessary risk of second operation and the increased risk of re-fracture after implant removal. The most common cause for hip fractures in the elderly is osteoporosis; if this is the case, treatment of the osteoporosis can well reduce the risk of further fracture. Only young patients tend to consider having it removed; the implant may function as a stress riser, increasing the risk of a break if another accident occurs.

Hip replacement

In some hip fractures, the doctor completely removes the head and neck of the femur, and replaces it with a prosthetic implant.

Complications

Nonunion, failure of the fracture to heal, is common (20%) in fractures of the neck of the femur, but much more rare with other types of hip fracture. The rate of nonunion is increased if the fracture is not treated surgically to immobilize the bone fragments.

Malunion, healing of the fracture in a distorted position, is very common. The thigh muscles tend to pull on the bone fragments, causing them to overlap and reunite incorrectly. Shortening, varus deformity, valgus deformity, and rotational malunion all occur often because the fracture may be unstable and collapse before it heals. This may not be as much of a concern in patients with limited independence and mobility.

Avascular necrosis of the femoral head occurs frequently (20%) in fractures of the neck of femur, because the blood supply is interrupted. It is rare after intertrochanteric fractures.

Hip fractures rarely result in neurological or vascular injury.

Surgical

Deep or superficial wound infection has an approximate incidence of 2%. It is a serious problem as superficial infection may lead to deep infection. This may cause infection of the healing bone and contamination of the implants. It is difficult to eliminate infection in the presence of metal foreign bodies such as implants. Bacteria inside the implants are inaccessible to the body's defence system and to antibiotics. The management is to attempt to suppress the infection with drainage and antibiotics until the bone is healed. Then the implant should be removed, following which the infection may clear up.

Implant failure may occur; the metal screws and plate can break, back out, or cut out superiorly and enter the joint. This occurs either through inaccurate implant placement or if the fixation does not hold in weak and brittle bone. In the event of failure, the surgery may be redone, or changed to a total hip replacement.

Mal-positioning: The fracture can be fixed and subsequently heal in an incorrect position; especially rotation. This may not be a severe problem or may require subsequent osteotomy surgery for correction.

Medical

Many of patients are unwell before breaking a hip; it is not uncommon for the break to have been caused by a fall due to some illness, especially in the elderly. Nevertheless, the stress of the injury,

and a likely surgery, does increase the risk of medical illness including heart attack, stroke, and chest infection.

Blood clots may result. Deep venous thrombosis (DVT) is when the blood in the leg veins clots and causes pain and swelling. This is very common after hip fracture as the circulation is stagnant and the blood is hypercoagulable as a response to injury. DVT can occur without causing symptoms. A pulmonary embolism (PE) occurs when clotted blood from a DVT comes loose from the leg veins and passes up to the lungs. Circulation to parts of the lungs are cut off which can be very dangerous. Fatal PE may have an incidence of 2% after hip fracture and may contribute to illness and mortality in other cases.

Mental confusion is extremely common following a hip fracture. It usually clears completely, but the disorienting experience of pain, immobility, loss of independence, moving to a strange place, surgery, and drugs combine to cause delirium or accentuate pre-existing dementia.

Urinary tract infection (UTI) can occur. Patients are immobilized and in bed for many days; they are frequently catheterised, commonly causing infection.

Prolonged immobilization and difficulty moving make it hard to avoid pressure sores on the sacrum and heels of patients with hip fractures. Whenever possible, early mobilization is advocated; otherwise, alternating pressure mattresses should be used.

Prognosis

Hip fractures are very dangerous episodes especially for elderly and frail patients. The risk of dying from the stress of the surgery and the injury in the first few days is about 10%. If the condition is untreated the pain and immobility imposed on the patient increase that risk. Problems such as pressure sores and chest infections are all increased by immobility. The prognosis of untreated hip fractures is very poor.

Post operation

Among those affected over the age of 65, 40% are transferred directly to long-term care facilities, long-term rehabilition facilities, or nursing homes; most of those affected require some sort of living assistance from family or home-care providers. 50% permanently require walkers, canes, or some other such device for mobility; all require some sort of mobility assistance throughout the healing process.

Among those affected over the age of 50, approximately 25% die within the next year due to complications such as blood clots (deep venous thrombosis, pulmonary embolism), infections, and pneumonia.

Patients with hip fractures are at high risk for future fractures including hip, wrist, shoulder, and spine. After treatment of the acute fracture, the risk of future fractures should be addressed. Currently, only 1 in 4 patients after a hip fracture receives treatment and work up for osteoporosis

the underlying cause of most of the fractures. Current treatment standards include the starting of a bisphosphonate to prevent future fracture risk by up to 50%.