Delayed diagnosed femoral neck fractures

Bikram K Kar; Alok C Agrawal; Sandeep K Yadav; Harshal Sakale; Bikas Sahoo

doi:10.4103/jodp.JODP_6_18

SYMPOSIUM: FRACTURE NECK OF FEMUR

Year : 2018 | Volume : 1 | Issue : 1 | Page : 15-20

Delayed diagnosed femoral neck fractures

Bikram K Kar, Alok C Agrawal, Sandeep K Yadav, Harshal Sakale, Bikas Sahoo
Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), Raipur, Chhattisgarh, India

Date of Web Publication

28-Dec-2018

Correspondence Address:
Dr. Sandeep K Yadav
Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), Raipur, Chhattisgarh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jodp.JODP_6_18

Abstract

Treatment of displaced femoral neck fractures includes internal fixation with/without graft supplementation or internal fixation plus osteotomy or arthroplasty. The literature contains conflicting evidence regarding rates of mortality, revision surgery, major postoperative complications, and function in patients with displaced femoral neck fractures who present delayed, treated either by internal fixation or arthroplasty. The purpose of our study was to summarize the management protocol of fracture of neck of femur when they present at different duration and at different stage.

Keywords: Complications, delayed diagnosis, etiology, fracture neck of fracture

How to cite this article:
Kar BK, Agrawal AC, Yadav SK, Sakale H, Sahoo B. Delayed diagnosed femoral neck fractures. J Orthop Dis Traumatol 2018;1:15-20

How to cite this URL:
Kar BK, Agrawal AC, Yadav SK, Sakale H, Sahoo B. Delayed diagnosed femoral neck fractures. J Orthop Dis Traumatol [serial online] 2018 [cited 2023 Jun 4];1:15-20. Available from: https://jodt.org/text.asp?2018/1/1/15/248905

Introduction

Intracapsular fractured neck of femur is treated as an emergency in adults (younger than 60 years), and quick efforts are made to restore blood supply of the femoral head.^[1] Some advocate that such cases should be regarded as “vascular emergencies” and operative interventions should be rendered within 6–8h.^[1],[2]Two major complications threatening the patients with this fracture include nonunion and avascular necrosis (AVN) of the femoral head.^[3],[4]Incidence of nonunion and aseptic necrosis of the femoral neck following osteosynthesis is estimated at 10%–30% and 15%–30%, respectively.^[3],[4]However, most studies suggest that early fixation with proper reduction is necessary for good results. In some cases, the problem remains hidden and patients with delayed fractures are referred to orthopedic centers.^[4] In adults and adolescents, femoral neck fractures usually occur because of high-energy traumas and are accompanied by several multisystem injuries. Therefore, so much time is spent on examining other organs that the golden time is lost for early surgical treatment of femoral neck fractures.^[5],[6]Although femoral neck fractures usually occur because of high-energy trauma, they may also result from low-energy trauma.^[5],[7]

Also many a times, patients present with fracture neck of femur 2 weeks after the occurrence because of initial management by local bone setters. Just because of negligence or unassessment of severity, they present delay when the golden hour is already lost.

Differences exist between young adults and older patients on the treatment of femoral neck fractures. According to the literature, closed reduction with internal fixation (CRIF) is the best treatment method as it is effective, less invasive, and requires less operation time.^[5] Treatment and fear of complications in patients with delayed femoral fractures are important concerns of orthopedic surgeons.

Radiographs
- Recommended views
  - Obtain anterio-posterior (AP) pelvis and cross-table lateral, and full length femur film of ipsilateral side
  - Consider obtaining dedicated imaging of uninjured hip to use as template intraoperatively
  - Traction-internal rotation AP hip is best for defining fracture type
  - Garden classification is based on AP pelvis [Table 1] and [Table 2]
    Table 1: Garden classification
    
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    ,
    Table 2: Pauwels classification
    
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Computed tomography (CT)
- Helpful in determining displacement and degree of comminution in some patients
Magnetic resonance imaging (MRI)
- Helpful to rule out occult fracture
- Helpful in assessing viability of femoral head after fracture
Bone scan
- Helpful to rule out occult fracture
- Not helpful in reliably assessing viability of femoral head after fracture
Duplex scanning
- Rules out deep venous thrombosis if delayed presentation to hospital after hip fracture

Sandhu et al.^[13] have proposed a radiological classification for this injury based on the following variables: (1) fracture site (irregular or smooth), (2) size of proximal fragment (>2.5 or <2.5cm), (3) gap between fragments (<1cm, 1–2.5cm, or >2.5cm), and (4) signs of AVN. This classification involves an MRI for determination. It has not been validated and does not alter management.

Scintigraphy may have a role in early postoperative evaluation of AVN before plain radiographic features are identified. Bone scans performed within 2 weeks of operation following 306 non-neglected hip fractures have been shown to determine the healing course with an accuracy of 91% (into categories of uneventful healing, hardware failure, nonunion, and AVN). Broeng et al.^[24] showed that decreased uptake noted on a bone scan 1–3 weeks postoperatively and 2 months postoperatively was indicative of eventual loss of reduction or segmental collapse in 50% of patients, whereas normal or increased uptake at those times correlated with uncomplicated healing in 90% of patients.

Factors contributing to nonunion of femoral neck

Inaccurate reduction
Unsound or loss of fixation
Vascular insufficiency
Posterior comminution
No treatment
Osteoporosis
Smoking

Viberg et al.^[25] conducted a study and published that low bone bone mineral density (BMD) may be a factor in internal fixation failure. Although not statistically significant, the subgroup analysis for undisplaced fractures showed a hazard ratio of 6 for low BMD as compared to 0.8 for the whole group.

Leighton’s classification of femoral neck nonunion

Type I: Inadequate fixation or nonanatomic reduction^[26]
Type II: Loss of fixation with fracture displacement
Type III: Fibrous nonunion with no displacement and intact fixation

Treatment

We searched in MEDLINE database about the management of delayed presentation of fracture neck of femur and reviewed many articles. No single clear-cut schematic, diagrammatic guideline for this unsolved fracture is available.

“The neglected femoral neck fracture in young adults: review of a challenging problem” by Roshan and Ram^[12] and another review by Jain et al.^[27] were useful [Table 3] and [Table 4], [Figure 1], [Figure 2], [Figure 3].

Table 3: Neglected femoral neck fracture in young adults: a comparison of the literature

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Table 4: : Data on miscellaneous procedures

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Figure 1: Flow chart for management of neglected neck femur fracture

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Figure 2: Fixation with fibular strut grafting

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Figure 3: Transtrochantric osteotomy with fixation

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Conclusion

Fracture neck of femur remains an unsolved fracture from the beginning of orthopedics, even today with advanced tools and infrastructures because of its peculiar anatomy. Not a single definite method of treatment is available. It varies from person to person, age to age, status of head and neck, and depends on patient’s requirement. Sometimes Mcmurray^[15] osteotomy also helps the patient to live a life with full weight-bearing with his ability to sit cross-legged on floor, though it produces a bit shortening. Therefore, each case is to be dealt as a different case considering its history, geography, status, and requirement of the patient.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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