Prof. Dr. Sadeq Al-Mukhtar Consultant orthopaedic surgeon FRACTURE FEMUR Lec.- 1+2 Prof. Dr. Sadeq Al-Mukhtar Consultant orthopaedic surgeon

1- Fracture neck femur. 2- Intertrochanteric fracture 3-Diaphyseal fracture.

Prof. Sadeq Al-Mukhtar Consultant Orthopaedic Surgeon Fracture Neck Femur Prof. Sadeq Al-Mukhtar Consultant Orthopaedic Surgeon

Epidemiology 97% occurs in patients more than 50 years old. The incidence increases with age. 3% occurs in under 50 years age(20-40) due to high energy trauma, sports, industrial & motor vehicle accidents. In 20-40 years most hip fractures are subtrochanteric or basi- cervical. Fractures in elderly are serious injuries, about 250,000 fractures per year in USA & the number is projected to double by the year 2050 & the cost exceeds 6 billion $ per year

Anatomy The femoral side of the hip is made of the femoral head with its articular cartilage & the femoral neck which connects the head to the shaft in the region of intertrochanteric area. The synovial membrane incorporates the entire head &the anterior neck but only the middle part of the neck posterior .The neck shaft angle is 130(+_7) degree. The Ante version is 10(+_7).

The diameter of femoral head ranges from 40-60 mm The diameter of femoral head ranges from 40-60 mm. The thickness of the articular cartilage ranges from 4mm in the apex to 1mm in the periphery. Blood supply of the head from: 1- Artery of ligamentum teres that usually originates from anterior obturator artery but it supplies only small area of the head near the attachment of the ligament.

2- Lateral, medial, anterior & posterior Capital vessels. 3- Lateral, medial, anterior &posterior cervical vessels. All these 2&3 vessels groups comes from intertrochanteric ring. Accumulation of intracapsular hematoma interferes with the venous outflow &perhaps the vascular inflow. After 12 hours necrosis of the head starts.

Biomechanics Falling from standing position leads to direct blow on the greater trochanter. Osteoporosis is the precipitating factor. In young& middle aged high velocity trauma is needed to induce fracture. Postmenopausal& senile osteoporosis predisposes to fracture .By the age of 65 years, 50% of women show bone mineral content below the threshold for fracture. By the age of 85 year this will reaches 100% In elderly it can occur with minor trauma on an externally rotated thigh or the bone is so weak that powerful muscle contraction can lead to fracture.

Classifications 1- Anatomical classification: A- Intracapsular: Subcapital (high risk) Tran cervical (moderate risk) Basal (less risk) intracapsular anteriorly, extra capsular posteriorly. Sometimes, high energy fracture occur in young which involve the shaft of femur then to the base of the neck then to the sub capital area. Usually these are undisplaced.

B- Extra-capsular: Inter-trochanteric fractures Per-trochanteric Notes:Intracapsular fractures carry poor prognosis because of poor blood supply which lead to avascular necrosis & non-union while extracapsular fractures carry good prognosis due to the good blood supply

2- Gardens classification: They are classified according to the degree of displacement of the fracture fragment. 1- Incomplete fracture(abduction& impacted) making the neck in valgus. 2- Complete fracture without displacement; the neck alignment looks normal. 3- Complete fractures with partial displacement. 4- Complete fractures with complete displacement.

1&2 are considered as undisplaced fractures& have good prognosis while 3&4 are displaced fracture& have poor prognosis. Stage 1 can slowly progress to stage 4 if untreated.

Pauwels classification: They are classified according to the direction of the fracture: Pauwel s 1: The angle from the horizontal line is 30-49 degree. Pauwel s 2: The angle from the horizontal line is 50-69 degree . Pauwel s 3: The angle is 70& more.

All the available classifications can not determine the exact displacement that occurred at the time of accident, the degree of vascular damage & the condition of the posterior femoral neck.

Clinical features Patient is usually old with history of trauma. The patient is unable to stand or walk. On examination the limb is shorter, externally rotated & he is unable to move it. Movement of the hip is tender &limited.

Diagnosis It is achieved by history,Examination, & X-Ray of the hip, A.P& Lateral views are required. Differential diagnosis: Non-traumatic fractures of the neck of femur:- Pathological fractures: Multiple myeloma, Secondary bone tumors.

Post-irradiation fractures. Stress fractures: Hair-line fracture with no shortening or deformity.

Treatment According to the treatment required, the complications likely to occur & the prognosis; patient are divided into three age groups; Fractures in elderly; over 70 years. Fractures in young & middle aged. Fractures in children.

Each group has its own problems but there is one common factor to them ( the danger of injury to the retinacular vessels with end result of avascular necrosis). This can sometimes be the cause of non-union whatever the method used for immobilization &even in cases where union has occurred late avascular necrosis. Changes in the weight bearing segment of the head can result in a stiff& painful joint .IT IS NOT WITHOUT REASON THAT THE INJURY HAS BEEN LABELLEDE THE UNSOLVED FRACTURE. There must be rigid lines of demarcation, each fracture must be carefully& individually assessed.

The Aim of treatment Accurate reduction. Rigid fixation Early mobilization to avoid complications.

Causes of avascular necrosis Interference with blood supply of the head. No periosteum( some believe there is very thin one) so only endosteal healing will occur resulting in poor callus. Dissolution of the fracture hematoma by synovial fluid.

Treatment of patients above 70 years Because of high incidence of AVN &non-union& complications of prolonged immobilization, the treatment is Arthroplasty. Partial Arthroplasty: Using Austen Moore or Thompson's prosthesis. Total hip replacement (THR): Indications includes delayed union &secondary osteoarthritis involve acetabulum.

Treatment of young &middle aged patients Accurate reduction by:- Closed reduction under anesthesia.or Open reduction) Rigid fixation by screws( at least 3 screws), using DHS(dynamic hip screws), or Smith-Petersons nail…..ect.

Treatment in Children Some prefer conservative but the best method of fixation by multiple pins &immobilization by hip spica for 6 weeks &weight bearing after 8-12 weeks. Notes: Even undisplaced fractures are not immune from complications like AVN.

Complications General: 1- DVT& Pulmonary embolism: It is due to prolonged immoblication, treated by prophylactic early mobilization, if happens give Anticoagulants. 2- Bed sores: It is due to prolonged immobilization, bad nursing &pressure on the skin& bony prominence leading to necrosis that may be followed by infection. It is treated by prophylactic frequent turning of the patient, talk powder& pneumatic bedes. 3- Pneumonia, chronic UTI. 4- Psychological trauma..

Local complications Avascular necrosis AVN: Incidence is 10-30% ( 10% in undisplaced fractures, &30% in displaced fractures). It may be partial or complete with consequent collapse of the bone structure leading to fragmentation. It takes months or even 2-3 years to occur. If involved the fracture site it may lead to failure to union whereas collapse at the articular surface leads to O.A & the patient complains of hip pain & inability to walk X-Rays reveal increased bone density, collapse & later an O.A changes.

2- NON UNION Causes are:- 1- Interference with blood supply. 2- Inadequate immobilization& early mobilization. 3- Dissolution of the hematoma by synovial fluid. Pathology of non-union: When there is failure to unite, the fracture undergoes absorption& if it is associated with AVN the head will collapse.

Clinical features: Hip pain, lateral rotation of the limb& inability to walk with shortening. Treatment:- In young patient: If the head is viable to make the fracture line horizontal, the treatment is: Subtrochanteric valgus osteotomy. Rigid fixation &bone graft. In elderly, Arthroplasty. 3- Osteoarthritis.

Fractures of the Trochanteric region These fractures occur in the region between the greater &lesser trochanters. They are common in elderly especially in women, more than the fracture of neck femur. Compared to patients with fractured femoral neck, patients with intertrochanteric fractures are significantly older, more likely to be limited to home ambulation& more dependant in their activities of daily living: therefore they tend to have overall poorer prognosis .Because the region is a vascular area so we note blood supply is excessive & AVN is less than 1%.

Classification 1- Stable fracture:-The the postero-medial buttress remains intact or minimally comminuted& therefore collapse of the fracture fragment is unlikely. 2- Unstable fracture: The large segment of postero-medial wall is fractured free& comminuted& therefore tends to collapse in varus.

KYLE Classification 1- Non-displaced stable fracture: without comminution (stable) 21% 2- Minimal comminution but displaced fracture: once reduced become (stable) 36% 3- Large postero-medial comminuted area .This is a problem fracture (unstable) 28% 4- Intertrochanteric & subtrochanteric fracture: It is uncommon (unstable) 15%

Treatment Types; 1- Conservative; Traction for 6-8 weeks. 2- Surgical; Because patients are elderly& complications of such fractures are high so surgery is indicated. Principles:- Reduction either closed under screen or open reduction. Rigid fixation by pin& plate, DHS ,angled plate …etc.

Complications General; The same as complications of fracture neck femur . Local; 1- Malunion; Varus deformity or external rotation which is treated by corrective osteotomy& fixation. 2- Non-union; rare due to soft tissue interposition, treated by ORIF & bone graft.

Subtrochanteric fracture These are fractures in the area between lesser trochanter & the junction between proximal and middle 3rd of femur. It occur in all age groups but there are two peak ages of incidence; 1- Late adolescence & early adulthood; here high energy trauma is needed. 2-Geriatric; minor trauma to bone lesion like metastatic tumor lung, breast cancer) causing pathological subtrochanteric fracture.

The upper fragment is flexed due to spasm of the iliopsoas& abducted by gluteal muscle while the distal segment is adducted by adductor muscles

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Diaphyseal fractures are common in young adult and if occurred in elderly, think of pathological fracture,. Due to thick muscles in the thigh this makes the shaft fractured only by severe trauma and causing severe bleeding that may reach about two liters of blood.

Types:- 2- Spiral fractures. 1- Transverse fractures. 2- Spiral fractures. 3- Oblique fracture with or without butterfly. 4- Comminuted fractures.

Clinical findings - History of trauma. - On examination:- there is shock , deformity, externally rotated limb, swelling, tenderness with loss of function. - x-ray revels the fractures& its type.do AP and lateral view

Treatment : Urgent: this includes treatment of shock and dealing with other injuries of vital organs regarding the fracture immobilized by Thomas splint Conservative : Skeletal traction for 6 to 8 weeks followed by cast bracing for other 6 to 8 weeks then physiotherapy. Sometimes continueous traction without cast bracing. regarding quadriceps and hamstring during traction better to use lower femoral skeletal traction .

Surgical treatment Indications 1- failure of conservative treatment due to muscle(soft tissue)interposition or mal alignment . 2- transverse fracture. 3- multiple fractures. 4- pathological fractures. 5- presence of any contraindication to conservative treatment especially in elderly patients. 6- vascular injuries associated with the fracture.

Notes: in regions of the world where intramedullary technique are not available or where risks of surgery are unacceptable, non-operative treatment remain the treatment of choice.

Types of surgical treatment : 1-open intramedullary nailing used in patients in whom closed reduction and internal fixation are not possible as in arthrodesis or stiffness of hip joint.its also used in patients whom the guide pin cant pass in the canal as in presence of bony fragments in th canal ,also used in open fractures where the ends of the bones aare exposed. 2-flexible nail :antgrade or retrograde flexible nailing of Enders nail ;single or multiple under fluoroscopic control (unreamed) 3-closed antigrade interlocked reamed nailing ,it has good results especially if undreamed(less blood loss and decrease operation time). 4-closed retrograde nailing through lateral epicondyl area. 5- plate fixation;

Indications of plate fixation - Inadequate experience with above techniques or if fluoroscopy was not available or if instruments and implants are not available or if associated with vascular injury and plating can be done through the same approach. - In non-union and mal-union in which the canal is obstructed and sometimes osteotomy or bone graft is needed. - In the presence of arthrodesis of hip and here nailing is difficult or impossible.

Extenal fixation 1- Compound fractures ,temporary or definitive treatment. 2- Multiply injured patient for rapid mobilization' 3- Fractures associated with vascular injury need to be repaired

Complications Early:- shock, fat embolism ,DVT that causes pulmonary , vascular injury, infection. Late:- 1- Delayed union: If healing not occurs in within 3-4 months. It is treated by bone graft and IF. 2-Malunion: Up to 2 cm shortening and 10-15 degrees angulation is accepted but never rotation. Treatment is corrective osteotomy and IF. 3- Joint stiffness; prevented by early mobilization

Supracondylar fracture This is common in young adults usually caused by direct violence. Types; Simple and comminuted. It may be associated with intra-articular extension T or Y fracture.

Fracture femur in children This is usually caused by direct trauma. Treatment is almost always by conservative methods i.e skin traction then if the fracture becomes stable, apply pop for 4-6 weeks. Children less than 4 years; use Gallows traction. Two cm shorting and up to 20 degrees angulation is accepted in children but again no rotation. Complications - Malunion - Leg length discrepancy usually shortening but may be increase in length due to 1- Active healing process( hyperaemia and hypervascularity).2- Increased growth hormone secretion.

Treatment; 1- Young adults are usually treated conservatively by high tibial skeletal traction in 90 degree flexed knee to cancel the action of gastrocnemus muscle for 4-6 weeks. 2 –In elderly by IF; the types of fixation are ; - Blade plate - Dynamic condylar screws - Other plates.

Early; Vascular injury, skin damage. Late; Non-union,Knee stiffness. Complications; Early; Vascular injury, skin damage. Late; Non-union,Knee stiffness.

Condylar fractures These are the same as supracondylar fractures but always check distal neurovascular function. It is usually caused by direct injury to the knee. It takes T or Y shaped fracture. On examination; Swelling, tender knee , doughy consistency due to hemoarthrosis (rapid onset, to differentiate it from simple knee effusion). Check x-ray to prove it.

Treatment 1- Conservative by skeletal traction 4-6 weeks. 2- Surgical treatment by internal fixation; DCP, Compression screws with washers. With posterior above knee slab followed by full cast for 4-6 weeks followed by physiothrerapy and gradual weight bearing.

Displacement of femoral epiphysis This occurs in children. It is type-2 salter-Harris fracture. Caused by lateral or hyperextension force. Complications; Malunion leading to deformity and growth disturbance (like any epiphyseal injury).

Treatment succeed or unstable, reduction under screen and percutaneous k-wire followed by posterior above knee slab. Conservative by manipulation under anaesthesia and pop. If not succeed or unstable, reduction under screen and percutaneous k-wire followed by posterior above knee slab.

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