Questions and Answers
What is the epidemiology of femoral neck fractures?
Why are femoral neck fractures so important to reduce correctly?
The neck is intracapsular and bathed in synovial fluid and lacks a periosteal layer, so callus formation is limited.
If a femoral neck fracture is found, what else must be evaluated?
Femoral shaft fracture.
What X-Rays are ordered for femoral neck fractures?
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What is the prognosis of femoral neck fractures?
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What is the normal neck shaft-angle?
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What is normal femoral anteversion?
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What is the major blood supply to the femoral head?
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What is the Garden Classification of femoral neck fractures?
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What is the Pauwels Classification?
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What are the symptoms and physical exam findings of hip fractures?
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MRI, bone scan, and duplex are useful in femoral neck fractures.
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What is the main osteology about the femoral neck responsible for its stability?
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Where is the capsule of the femur attached?
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Match the ligaments with their attachments:
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What are three goals of treatment for hip neck fractures?
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Nonoperative treatment is considered when for hip fractures?
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Following a hip fracture, what is essential?
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What increases the risk of osteonecrosis in femoral neck fractures?
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What is the treatment of osteonecrosis?
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What is the second highest complication of femoral neck fractures?
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What most closely correlates with failure of fixation after reduction?
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What are the four treatment options for nonunion in femoral neck fractures?
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Why does a valgus osteotomy work in nonunion?
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What did 2-year follow-up show in patients with >70 years and displaced femoral neck fractures?
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How does DHS compare to cannulated screws?
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Co-managing these trauma patients results in?
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Where are tension sided stress fractures seen?
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Where are compression sided stress fractures seen?
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How many 'impacted' fractures displace?
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How many of impacted neck fractures develop osteonecrosis?
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What are contraindications to three screw fixation in impacted neck fractures?
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Describe the technique for fracture reduction of femoral necks.
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What are the guidelines for acceptable hip reduction?
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What is the diagnosis for a 78-year-old patient with pain after previous hip fracture treatment?
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What is the treatment for a 78-year-old patient with a diagnosis of osteonecrosis?
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Study Notes
Epidemiology of Femoral Neck Fractures
- Most prevalent in the aging population, with a higher incidence in women compared to men.
- Higher occurrence in whites compared to blacks.
- Considered the most expensive fracture type in the US.
Importance of Proper Reduction
- The femoral neck is intracapsular, surrounded by synovial fluid, which complicates callus formation due to the absence of a periosteal layer.
Associated Injuries
- A femoral shaft fracture is found in 6-9% of cases associated with neck fractures.
- The neck fracture must be repaired first to ensure anatomic reduction and prevent complications such as avascular necrosis (AVN) and nonunion.
Imaging Techniques
- Required X-rays include:
- AP pelvis
- AP hip and cross-table lateral with internal rotation to best define the fracture
- AP femur
Prognosis
- One-year post-operative survival rates are around 25-30%.
- Pre-injury mobility is a critical predictor of survival after surgery.
- Chronic kidney disease patients have a 2-year mortality rate of 45%.
Anatomical Angles
- Normal neck-shaft angle is approximately 130 degrees with a variability of ±7 degrees.
- Normal femoral anteversion measures approximately 10 degrees with a variability of ±7 degrees.
Blood Supply to Femoral Head
- The medial femoral circumflex artery is the primary blood supply, with contributions from:
- Anterior and inferior head from the lateral femoral circumflex artery
- Inferior gluteal artery
- Small contribution from the ligamentum teres
Garden Classification
- Used to classify femoral neck fractures but specific details are required for complete understanding.
Pauwels Classification
- Another classification system for femoral neck fractures needing further elaboration.
Symptoms and Physical Exam Findings
- Impacted and stress fractures typically present with groin pain or referred pain to the medial knee/thigh; displaced fractures cause complete hip pain.
- Physical exam may reveal no visible deformity for impacted fractures, but with external rotation and abduction noted in displaced fractures.
Use of Advanced Imaging
- MRI and bone scans can identify occult fractures but have limited efficacy in evaluating the viability of the femoral head post-fracture.
- Duplex ultrasound is useful for ruling out deep vein thrombosis (DVT) after hip fractures.
Osteology Contributing to Stability
- The calcar femorale, a vertically oriented plate radiating from the posterior medial shaft to the greater trochanter, plays a crucial role in stability.
Capsule of the Femur
- Attached anteriorly to the intertrochanteric line and posteriorly 1-1.5 cm proximal to the intertrochanteric line.
Ligaments Associated with Femoral Neck
- Iliofemoral ligament (Y ligament of Bigelow) located anteriorly.
- Pubofemoral ligament also located anteriorly.
- Ischiofemoral ligament found posteriorly.
Hip Joint Forces
- Hip joint forces vary with different postures:
- Straight leg: 1.5 times body weight (BW)
- One-legged stance: 2.5 times BW
- Two-legged stance: 0.5 times BW
Trabecular Anatomy of Femoral Head
- Trabecular architecture aligns parallel to compressive forces, with vertical trabeculae from weight-bearing and horizontal trabeculae from abductor muscle forces.
Low-Energy Hip Fracture Subcategories
- Direct fractures occur from falls onto the greater trochanter or forced external rotation of the lower extremity.
- Indirect fractures happen when muscle forces exceed the strength of the neck.
Treatment Goals for Hip Neck Fractures
- Focus on allowing rapid mobilization, restoring hip function, and reducing discomfort.
Nonoperative Treatment Indications
- Considered only for patients with extreme medical risks or those who are demented nonambulators without pain.
Importance of Early Mobilization
- Essential to decrease the risks and complications associated with immobility, including atelectasis and venous stasis.
Treatment Options
- Differ for displaced versus nondisplaced femoral neck fractures; specific guidance needed for each situation.
Indications for ORIF
- Open reduction and internal fixation indicated for displaced fractures, particularly in younger or physiologically young patients.
Complications of Femoral Neck Fractures
- Osteonecrosis presents as the most significant complication, occurring in 10-45% of cases.
- Nonunion rates range from 5-30%, particularly higher in displaced fractures, unrelated to age or gender.
Risk Factors for Complications
- Initial displacement and nonanatomical reductions increase the risk of osteonecrosis.
- Varus malreduction closely correlates with failure of fixation after reductions.
Treatment Options for Nonunion
- Include valgus intertrochanteric osteotomy, free vascularized fibula grafts, arthroplasty for older patients, and revision ORIF.
Effectiveness of Valgus Osteotomy
- This technique transforms a vertical fracture line into a horizontal one, mitigating shear forces.
Long-term Follow-Up Outcomes
- High mortality rates in patients over 70 years with displaced femoral neck fractures initially; follow-up reveals fixation techniques yield 46% success, whereas arthroplasty is 8%.
Comparison of Fixtures
- Dynamic Hip Screw (DHS) shows lower reoperation rates compared to cannulated screws for certain types of fractures.
Co-management Benefits
- Results in reduced mortality, fewer post-operative complications, quicker surgery times, and improved mobility at four months.
Tension-Sided Stress Fractures
- Identify at the superior lateral neck on internally rotated views; have significant displacement risk necessitating in situ fixation.
Compression-Sided Stress Fractures
- Identified by a haze of callus at the inferior neck, involve minimal risk of displacement without additional trauma; managed conservatively unless symptoms arise.
Impaction and Osteonecrosis Statistics
- Approximately 40% of impacted or nondisplaced fractures may displace without internal fixation.
- 5-15% of impacted neck fractures may lead to osteonecrosis.
Contraindications for Screw Fixation
- Pathologic fractures, severe osteoarthritis/rheumatoid arthritis, Paget's disease, or metabolic conditions; prosthetic replacement recommended instead.
Fracture Reduction Technique
- Involves hip flexion with traction and external rotation to disengage fragments, followed by gradual extension and internal rotation.
Guidelines for Acceptable Hip Reduction
- Ensure AP view shows valgus or anatomic alignment; lateral view should maintain anteversion without posterior translation.
Common Postoperative Diagnoses
- Nonunion, indicated by groin and butt pain, managed with arthroplasty for older patients or osteotomy for younger patients.
- Osteonecrosis diagnosed by persistent pain, treated with weight-bearing adjustments, core decompression for early cases, and arthroplasty for late changes.
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Description
This quiz explores the critical aspects of femoral neck fractures, focusing on their prevalence in the aging population and the significance of proper reduction. It also covers associated injuries, necessary imaging techniques, and prognosis factors that affect post-operative survival rates.
