Neck of Femur Fractures

Wayne Hoskins

Background

• NOF #’s common with advancing age

• High morbidity & mortality

• Only 1/3 return to living environment

• Death: 20-35% at 1 year in patients aged 82 +/-7

Anatomy

Fracture location

Head blood supply

• Profunda femoris gives off medial & lateral circumflex femoral arteries– Extracapsular anastomosis at base of neck– Ascending cervical branches– Intracapsular branches

• Majority via MCFA, ↓ via ligamentum teres

Garden classification

1. Incomplete impacted #

2. Complete # undisplaced

3. Displaced capsule intact

4. Displaced

Fracture classification

• Garden classification: poor inter-observer reliability:– displaced = 1 & 2– undisplaced = 3 & 4

Shenton’s Line

Mechanism of #

• Direct or indirect:

1. Direct blow to GT

2. ER: impinging posterior cortex on rim

3. Bending torque – major trauma

4. Violent muscle contraction

5. Cyclical loading / insufficiency #

NOF # complications

• AVN– Undisplaced 5-10%– Displaced 10-20%– RFs: displacement, velocity of injury, delay in

reduction, non-anatomical reduction• Non-union

– Undisplaced 5-10%– Displaced 20-30%– RFs - initial displacement, non anatomical

reduction, instability, no compression across #, vascularity

Presentation

• Typically elderly female

• Low energy fall

• Hip pain

• Short & ER leg

• Unable to weight bear

NOF # risk factors

• Osteoporosis

• Co-morbidities

• Dementia

• Poor mobility / vision

Work up – not just a #

• History– Mechanism of injury– Cause of fall - exclude medical cause: TIA, UTI,

MI, arrythmia, electrolyte imbalance etc– Other injuries from fall– Risk factors for osteoporosis– Co-morbidities/medications: ?anaesthetic review

pre-op, ?choice of operation

• ? Gen Med vs. Ortho admission– Ortho Geri’s consult

Work up

• Examination: pain, unable to weight bear, short ER leg, ?delirium

• Investigations:– ECG, FWT, urine MCS– Bloods: FBE, UEC, CMP, albumin, ESR,

Vit D, Coags, G&H– DEXA bone scan

Imaging

• Pelvis & hip XR

• ?undisplaced # - gold standard = MRI

• CT if MRI unavailable

• Bone scan less useful, changes take up to 1week in elderly

• Pre-op CXR

Medical management

• Treat co-morbidities whilst await OT:- electrolyte imbalances- anemia- pneumonia / UTI / infection- arrythmia / MI etc

• Post-op manage co-morbidities, RFs falls & osteoporosis: consider Vit D, Ca, bisphosphonates

Surgical management

• Surgical option based on:1. Displaced vs. undisplaced

2. Age of patient

3. Mobility/independence

4. Bone stock

• Aim perfect anatomical reduction and rigid fixation

Anti-coagulants

• Operate if on clopidogrel / aspirin

• If on warfarin: Vit K / FFP to reduce INR <1.5

Time to surgery

• Aim: surgery < 24 hours

• Jain JBJS Am 2002: significant reduction in AVN if fixed <12 hours

Surgical results

• Best results with healed # in anatomical position without AVN

• Quality of reduction is best predictor

Undisplaced subcapital #

• Cannulated screws used in young– 1 x inferior screw, 2x superior screws,

ensure threads cross # site, 5mm from surface, inferior screw above LT

• DHS + derotation screw used in old, independent walker

Displaced subcapital #

• Expected life > prosthesis survival (<65): aim to preserve the joint

• DHS + derotation screw– Closed or open anatomical reduction

• Union rates ↑ with anatomical reduction: accept no varus, <15 valgus, <10 AP plane

DHS technique

• Set up on traction table• Lateral incision: divide fascia lata• Ensure 2 guide wires centrally in femoral

heard1. Allows reaming for DHS2. Derotation screw

• Screws to attach plate• DHS Blade noe being used with osteoporotic

bone ↑ rotational stability

X-rays

Post-operative Mx

• DHS/Screws/Nail – admit to med ward– Surg ward: Hemi/THR/High energy trauma

• Young patients – PWB

• Elderly – WBAT to prevent complications

• Watch for AVN in subcapital #’s (usually 8-12 weeks, but up to 2 years)

Displaced subcapital #

• Expected life < prosthesis survival (>65)• Hemiarthroplasty < 5 year survival

– Bipolar no better than unipolar, difficult to reduce if Ds– No difference cemented vs uncemented outcome measures– Cemented hemi: ↑ operative time, blood loss, cement

pressurization complications, difficult revision• Moore’s if severe comorbidities/non walker – 30%

revision at 2 years• Gjertsen JBSB 2010 cf ORIF: both 25% mortality, 3

vs. 22% reoperation, more pain, lower QoL with ORIF

Displaced subcapital #

• Expected life < prosthesis survival (>65)

• THR 5-15 year survival young, active, mobile, associated joint disease (RA, OA, etc)– better ROM & pain relief vs hemi– Higher early Ds rate & early loosening– Long term Ds rate equal to hemi

Hemi/THR approach

• Posterior approach

- preserves gluteus medius

- observe sciatic n. ? ↓/↑damage

- ? ↓ Ds rate with bone anchors• Hardinge/anterolateral approach

- Trendelenburg gate

- Previous data ↓ Ds rate• Surgeon preference

Complications

• Infection

• Dislocation

• GT or Femoral shaft #

• Leg length discrepancy

• Loosening / pain

• Revision

Summary

• Full medical history and work up think medical admission with ortho consult

• Time to theatre

• Surgical choice based on age, # type, mobility, comorbidities

• High morbidity and mortality