Early management of fracture neck of femur

Abhishek Jain; Alok C Agrawal; Bikas K Sahoo; Sandeep K Yadav; Bikram Keshri Kar; Harshal S Sakale

doi:10.4103/jodp.JODP_8_18

SYMPOSIUM: FRACTURE NECK OF FEMUR

Year : 2018 | Volume : 1 | Issue : 1 | Page : 8-10

Early management of fracture neck of femur

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

Date of Web Publication

28-Dec-2018

Correspondence Address:
Dr. Alok C Agrawal
Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), Raipur, Chhattisgarh 492099
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jodp.JODP_8_18

Abstract

Femoral neck fracture is considered a medical emergency as an early fixation helps in getting an accurate reduction, preservation of blood supply, removal of tamponade within the capsule, and early mobilization. This article deals with the science of early management of femoral neck fractures.

Keywords: Early management, fracture neck of femur, problems

How to cite this article:
Jain A, Agrawal AC, Sahoo BK, Yadav SK, Kar BK, Sakale HS. Early management of fracture neck of femur. J Orthop Dis Traumatol 2018;1:8-10

How to cite this URL:
Jain A, Agrawal AC, Sahoo BK, Yadav SK, Kar BK, Sakale HS. Early management of fracture neck of femur. J Orthop Dis Traumatol [serial online] 2018 [cited 2023 Jun 4];1:8-10. Available from: https://jodt.org/text.asp?2018/1/1/8/248907

Introduction

Femoral neck fracture is highly common in elderly population and usually follows low-energy trauma.^[1],[2] It is estimated that the hip fracture risk is 23.3% in men and 11.2% in women over their lifetime.^[3] The femoral neck fractures are uncommon among young people, only 2% in patients younger than 50 years,^[4] and are usually follows high-energy trauma. The incidence increases with age; after the age of 50 years, the incidence is doubled for each subsequent decade and is two to three times higher in women than in men.^[5] Eighty percent of hip fractures occur in women and 90% in people older than 50 years.^[2]

The management of femoral neck fractures has constantly changed:

Hip spica in abduction and internal rotation (Whitman abduction cast)^[6]
Smith Peterson nail
Jewett nail

All these were abandoned because of high nonunion rates and morbidity due to bedsores.

Then came smooth pins, which are now used only in children. Thereafter cannulated cancellous (CC) screws were introduced, which are now the standard implant in young patients for joint preservation.

In the elderly patients, the emphasis on early mobilization led to joint replacement starting from partial hip replacement to total hip replacement (THR).

Anatomical Constraints

The vascular supply of the femoral head comes from three main arteries: the medial femoral circumflex artery (MFCA), the lateral femoral circumflex artery (LFCA), and the obturator artery.^{[7],[8],[9],[10]} In the adults, the obturator artery provides variable amount of blood supply to the femoral head via the ligamentous teres. The LFCA gives rise to the inferior metaphyseal artery by way of the ascending branch and provides vascularity to the the majority of the inferoanterior femoral head. The largest contributor to the femoral head, especially the superolateral aspect of the femoral head, is the MFCA.^[10] The lateral epiphyseal artery complex comes from the MFCA and courses along the posterosuperior aspect of the femoral neck before supplying the femoral head. It is important to know and understand that these terminal branches supplying the femoral head are intracapsular. Thus, disruption or distortion due to fracture displacement of terminal branches to the femoral head plays a significant role in the development of osteonecrosis.

Diagnosis

In the elderly patients, femoral neck fractures usually occur as a result of a fall from standing height. Poor bone density, multiple medical problems, and propensity to fall are major risk factors for femoral neck fracture. In young adults, the mechanism of injury is often high-energy trauma, such as motor vehicle accident or fall from height. In young adults, the mechanism of injury is often high-energy trauma, such as motor vehicle accident or fall from height which leads to substantial axial load on the limb with the hip in an abducted position.^[11],[12] The clinical presentation of patient with femoral neck fracture will show a shortened, flexed, and externally rotated leg. Radiographic evaluation should include anteroposterior (AP) pelvis, AP and lateral plain radiographs of the entire femur. Although uncommon, ipsilateral femoral neck and shaft fractures can occur in 2%–6% of all femoral shaft fractures.^[13]. The osteoporotic bone and fall from a standing height lead to a low-energy injury and result in a femoral neck or intertrochanteric hip fracture; the femoral neck fracture seen in the elderly patients will often be subcapital. It is usually transverse fracture pattern with impaction at the fracture site. The fracture pattern seen in young adults is due to the axially loaded mechanism on an abducted hip which results in a basicervical or more distal femoral neck fracture. The fracture pattern has a tendency to be more vertically oriented and thus more unstable.^[14]

Despite known limitations, femoral neck fractures in the elderly patients are frequently described using the Garden classification.^[15],[16] In this age group, treatment can be recommended based on describing the fracture as nondisplaced (Grade I, II) or displaced (Grade III, IV). The Garden classification is not as useful for describing femoral neck fractures in young adults. The Pauwels classification might be more descriptive and useful because it is based on fracture pattern and is concerned for achieving a stable fixation in femoral neck fracture in the young population. It is based on the angle of femoral neck fracture relative to the horizontal axis. They are as follows: Type I: <30° relatively horizontal; Type II: 30°–50°; and Type III: >50°. This biomechanical model implied that Type I femoral neck fractures will have more intrinsic stability because of the compressive forces that predominate. On the other end of the spectrum, Type III femoral neck fractures are more unstable and seen in young adults more frequently. The fracture pattern is more vertically oriented, resulting in increased shear force, varus moment, and instability. Type III fracture patterns have been shown to be more difficult to achieve fixation and have higher risk of failure of fixation, malunion, nonunion, and avascular necrosis (AVN).^[14]

Garden proposed an alignment index^[15],[16] based on post-op AP and lateral X-rays. On the AP view, the angle between medial bony trabeculae of femoral head and medial cortex of the femoral shaft is measured; it is about 160°. On the lateral view, the angle formed by central axis of head, neck, and the shaft of femur is measured; it is about 180°. Garden proposed that the angle should be between 155° and 180°, otherwise the incidence of nonunion and AVN increases.

Lowell S-curves: Lowell described an assessment method for post-op reduction adequacy. According to him, in an intact proximal femur, an S-curve or reverse S-curve can be seen regardless of the rotation. When an anatomic reduction is obtained, both the S-curves are seen in AP and lateral views. When nonanatomic reduction is obtained, a C-curve is seen; it is formed when concave outline of the femoral neck appears as a tangent to the femoral head.

Surgical Treatment for Young Patients

Reduction technique

Whitman technique: Traction is applied to the abducted, extended, externally rotated hip with subsequent internal rotations.^[15]

Leadbetter technique: Hip is flexed to 90° with slight adduction and traction is applied in line with femur followed by internal rotation to 45°; leg is then brought into abduction and full extension.

Flynn method: External rotation of femoral shaft followed by traction in long axis of femoral neck and internal rotation of femoral shaft.

Pauwels Grade 1 and 2: Inverted triangle configuration of three CC screws.^[17],[18]

Pauwels Grade 3: CC screws or dynamic hip screw (DHS).^{[19],[20],[21]} Basicervical femoral neck fractures with comminution is a fracture pattern where DHS will provide more stable fixation than three CC screws. DHS was preferred and recommended over CC screw in Pauwels Grade 3.

Surgical Treatment in the Elderly Patients

Displaced femoral neck fracture

Arthroplasty that is hemiarthroplasty or THR is preferred over internal fixation as there are increased chances of implant failure and varus collapse due to osteoporosis.

Total hip arthroplasty is preferred over hemiarthroplasty because the latter has the following disadvantages:

lower Harris hip score
early acetabular wear
need of secondary conversion to THR in active individuals

On the other hand, THR has only two disadvantages compared to hemiarthroplasty:

longer time of surgery
more blood loss

It is clear that these disadvantages did not affect patient outcomes; and therefore, THR is the preferred procedure.^[21]

Conclusion

Femoral neck fracture should be identified and treated as per age group and fracture classification. Reduction is of utmost importance while fixation, which should be assessed intraoperatively using the Garden’s alignment index and Lowell’s S-curves. Joint replacement is best reserved for the elderly patients depending on medical comorbidity and advantages such as less failure and early mobilization.

Financial support and Sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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