Femoral Neck Fracture - Orthopaedic Trauma - Lecture Slides, Slides of Orthopedics

Download Femoral Neck Fracture - Orthopaedic Trauma - Lecture Slides and more Slides Orthopedics in PDF only on Docsity! Femoral Neck Fracture Docsity.com Anatomy • Physeal closure age 16 • Neck-shaft angle 130° ± 7° • Anteversion 10° ± 7° • Calcar Femorale Posteromedial dense plate of bone Docsity.com Epidemiology • 250,000 Hip fractures annually – Expected to double by 2050 • At risk populations – Elderly: poor balance & vision, osteoporosis, inactivity, medications, malnutrition • incidence doubles with each decade beyond age 50 – higher in white population – Other factors: smokers, small body size, excessive caffeine & ETOH – Young: high energy trauma Docsity.com Classification • Pauwels [1935] – Angle describes vertical shear vector Docsity.com Classification • Garden [1961] I Valgus impacted or incomplete II Complete Non-displaced III Complete Partial displacement IV Complete Full displacement ** Portends risk of AVN and Nonunion Docsity.com Treatment • Options – Non-operative • very limited role • Activity modification • Skeletal traction – Operative • ORIF • Hemiarthroplasty • Total Hip Replacement Docsity.com Treatment Decision Making Variables • Patient Characteristics – Young (arbitrary physiologic age < 65) • High energy injuries – Often multi-trauma • High Pauwels Angle (vertical shear pattern) – Elderly • Lower energy injury • Comorbidities • Pre-existing hip disease • Fracture Characteristics – Stable – Unstable Docsity.com Treatment Young Patients (Arbitrary physiologic age < 65) – Non-displaced fractures • At risk for secondary displacement • Urgent ORIF recommended – Displaced fractures • Patients native femoral head best • AVN related to duration and degree of displacement • Irreversible cell death after 6-12 hours • Emergent ORIF recommended Docsity.com Treatment Pre-operative Considerations • Regional vs. General Anesthesia – Mortality / long term outcome • No Difference – Regional • Lower DVT, PE, pneumonia, resp depression, and transfusion rates – Further investigation required for definitive answer Docsity.com Treatment Pre-operative Considerations • Surgical Timing – Surgical delay for medical clearance in relatively healthy patients probably not warranted • Increased mortality, complications, length of stay – Surgical delay up to 72 hours for medical stabilization warranted in unhealthy patients Docsity.com Non-displaced Fractures • ORIF standard of care • Predictable healing – Nonunion < 5% • Minimal complications – AVN < 8% – Infection < 5% • Relatively quick procedure – Minimal blood loss • Early mobilization – Unrestricted weight bearing with assistive device PRN Docsity.com Approach For Open Reduction Watson-Jones • Anteriolateral exposure • Best for basalar neck and IT patterns • Allows placement of sliding hip screw through same incision Docsity.com What Reduction Is Acceptable? • Ideal reduction is Anatomic – Acceptable: < 15º valgus < 10º AP angulation • Any varus is unacceptable • Fixation: Multiple screws in parallel – No advantage to > 3 screws – Uniform compression across fracture – In-situ pin impacted fractures * ↑ AVN with disimpaction [Crawford 1960] – Fixation most dependent on bone density Docsity.com Screw Fixation • Screw location – Avoid posterior/ superior quadrant » Blood supply » Cut-out – Biomechanical advantage to inferior/ calcar screw [Booth 1998] Docsity.com Displaced Fractures Hemiarthroplasty vs. ORIF • ORIF is an option in elderly ** Surgical emergency in young patients ** • Complications • Nonunion 10 -33% • AVN 15 – 33% • AVN related to displacement • Early ORIF no benefit • Loss of reduction / fixation failure 16% Docsity.com Displaced Fractures Hemiarthroplasty vs. ORIF • Hemi associated with • Lower reoperation rate (6-18% vs. 20-36%) • Improved functional scores • Less pain • More cost-effective • Slightly increased short term mortality • Literature supports hemiarthroplasty for displaced fractures [Lu-yao JBJS 1994] [Iorio CORR 2001] Docsity.com Hemiarthroplasty Unipolar vs. Bipolar • Bipolar theoretical advantages • Lower dislocation rate • Less acetabular wear/ protrusio • Less Pain • More motion Docsity.com Hemiarthroplasty Cemented vs. Non-cemented • Cement (PMMA) – Improved mobility, function, walking aids – Most studies show no difference in morbidity / mortality • Sudden Intra-op cardiac death risk slightly increased: – 1% cemented hemi for fx vs. 0.015% for elective arthroplasty • Non-cemented (Press-fit) – Pain / Loosening higher – Intra-op fracture (theoretical) Docsity.com Hemiarthroplasty Cemented vs. Non-cemented • Conclusion: – Cement gives better results • Function • Mobility • Implant Stability • Pain • Cost-effective – Low risk of sudden cardiac death • Use cement with caution Docsity.com Treatment Pre-operative Considerations • Surgical Approach – Posterior approach to hip • 60% higher short-term mortality vs. anterior – Dislocation rate • No significant difference [Lu-Yao JBJS 1994] Docsity.com Stress Fractures • Patient population: – Females 4–10 times more common • Amenorrhea / eating disorders common • Femoral BMD average 10% less than control subjects – Hormone deficiency – Recent increase in athletic activity • Frequency, intensity, or duration • Distance runners most common Docsity.com Stress Fractures • Clinical Presentation – Activity / weight bearing related – Anterior groin pain – Limited ROM at extremes – ± Antalgic gait – Must evaluate back, knee, contralateral hip Docsity.com Stress Fractures • Imaging – Plain Radiographs • Negative in up to 66% – Bone Scan • Sensitivity 93-100% • Specificity 76-95% – MRI • 100% sensitivity / specificity • Also Differentiates: synovitis, tendon/ muscle injuries, neoplasm, AVN, transient osteoporosis of hip Docsity.com Stress Fractures Complications • Tension sided and Compression sided fx’s (>50%) treated non-operatively • Varus malunion • Displacement – 30-60% complication rate • AVN 42% • Delayed union 9% • Nonunion 9% Docsity.com Femoral Neck Nonunion • Definition: not healed by one year • 0-5% in Non-displaced fractures • 9-35% in Displaced fractures • Increased incidence with – Posterior comminution – Initial displacement – Inadequate reduction – Non-compressive fixation Docsity.com Femoral Neck Nonunion • Clinical presentation – Groin or buttock pain – Activity / weight bearing related – Symptoms • more severe / occur earlier than AVN • Imaging – Radiographs: lucent zones – CT: lack of healing – Bone Scan: high uptake – MRI: assess femoral head viability Docsity.com Osteonecrosis (AVN) Femoral Neck Fractures • 5-8% Non-displaced fractures • 20-45% Displaced fractures • Increased incidence with – INADEQUATE REDUCTION – Delayed reduction – Initial displacement – associated hip dislocation – ?Sliding hip screw / plate devices Docsity.com Osteonecrosis (AVN) Femoral Neck Fractures • Clinical presentation – Groin / buttock / proximal thigh pain – May not limit function – Onset usually later than nonunion • Imaging – Plain radiographs: segmental collapse / arthritis – Bone Scan: “cold” spots – MRI: diagnostic Docsity.com Osteonecrosis (AVN) Femoral Neck Fractures • Treatment – Elderly patients » Only 30-37% patients require reoperation • Arthroplasty – Results not as good as primary elective arthroplasty • Girdlestone Resection Arthroplasty – Limited indications Docsity.com