Femur Fractures

Intracapsular Fractures of the Proximal Femur

Blood supply to the head of the femur

4 groups 1. Extracapsular arterial ring

2. Ascending cervical branches

3. Subsynovial intracapsular ring ( Chung)

4. Artery of the lig teres

Epidemiology

increased freq with

age
dementia
malignancy
chronic illness

decreased freq with

long term physical activity
supplemental Vit D3 and Cain elderly women
HRT

Classification

1. an incomplete or impacted fracture
   
2. a complete but undisplaced fracture
   
3. a complete partially displaced fracture
   
4. a completely displaced fracture

Treatment

Pt less than 65

and do not have a chronic illness, poor life expectancy ® ORIF

Pt bw 65 and 75

those with high functional demand ® ORIF
those with low demand , chronic illness® arthroplasty

Pt more than 75

arthroplasty

Internal fixation

Timing of treatment

reduction of a displaced fracture of the femoral neck improves blood supply to the femoral head reduction within 8 12 hrs minimises risk of AVN if reduce within 8 hrs risk of AVN in a displaced fracture is ~ 20%.
2448 hrs risk is ~ 40%
ref: Swiontkowski etal JBJS 66A: 837846, 1984

Closed Reduction

Leadbetter ( ref : JBJS 20:108113, 1938)
affected hip flexed to 90 deg in slight adduction, traction then applied, then the thigh is internally rotated , then while maintaining IR the thigh is abducted and brought down to level in extension

Open Reduction

indicated if CR fails
anterolat approach bw TFL + G medius, open capsule, disimpact and reduce

Method of fixation

3 cannulated screws
CHS not recommended as is too large an implant and if placed incorrectly can jeopardise blood supply
If CHS used use a derotation screw to control rotation

Arthroplasty

Complications

AVN

late segmental collapse occurs in

~ 10% undisplaced fracture
~ 30% displaced fracture

Failure of fixation

Nonunion

rare in undisplaced fracture
~ 30% in displaced fracture
treat with either a valgus osteotomy or an arthroplasty

DVT/PE

DVT ~ 40%
low dose warfarin in pts who justify risk of anticoagulation

Prognosis

At 2 yrs after primary ORIF

nonunion in 33%
AVN in 16%
reoperation rate 2036% ( ie 2.5 times that for hemiarthroplasty)

At 2 yrs from hemiarthroplasty

dislocation 2%
reoperation rate 618%

At 2 yrs from THR

dislocation 11%

Intertrochanteric Fractures

classification

AO

proximal femur type

A1 pertrochanteric simple
A2 pertrochanteric multifragmentary
A3 intertrochanteric

Kyle, Gustilo and Premer JBJS 61A: 216221, 1979

type 1: stable undisplaced , no comminution
type 2: stable displaced , min comminuted. Reduction ®stable construct
type 3: unstable , large posteromed comminuted area
type 4: also have a subtrochanteric component

Treatment

2nd generation nail if pyriformis fossa intact
no advantage to use osteotomies if using a sliding screw device
ref : Hopkins , Nugent and Dimon "Medial displacement Osteotomy for unstable intertrochanteric fractures" CORR 245: 169172, 1989

Complications/ Prognosis

Mortality

~ 30% at 1 yr , after this the expected normal curve is followed

Infection

~1%

Nonunion

rare

Mechanical / technical failures

nail cutting out
pin penetration
fracture below implant seen esp in gamma nail

Subtrochanteric fractures

Classification

Type 1

High: fracture line extends into the lesser trochanter

Type 2

Low: lesser trochanter remains intact

Treatment

Type 1

if pyriformis fossa intact 2nd gen nail
not intact CHS

Type 2

2nd gen nail

Complications

implant failure

malunion

Option osteotomy if severe or symptomatic

nonunion

Options valgus osteotomy
bone graft

Femoral Head and Neck Fractures in Children

Mechanism

Classification

1. a trans epiphyseal separation , with or without dislocation of the femoral head from the acetabulum AVN ~50% 100%
   
2. displaced or nondisplaced Transcervical fracture AVN ~ 40%
   
3. displaced or nondisplaced basal cervical fracture AVN ~25%
   
4. intertrochanteric fracture AVN rare

Treatment

1. gentle CR if unsuccessful immed open reduction
   if dislocated use post approach for post dislocation and ant approach for ant dislocation
   less than 2yo hip spica usually adequate
   more than 2yo fix with smooth pins in young childrencannulated screws in adolescents

2. +3: undisplaced spica, close FU
   displaced anatomical reduction and stable fixation if not reduced get increased rate of coxa vara and nonunion
   For all intracapsular fractures recommend decompression of the intracapsular haematoma as it has been reported that pressure intracapsularly can jeopardise the blood supply to the femoral head
   Undisplaced fracture or displaced fracture closed reduced aspirate haematoma
   displaced fracture requiring open reduction formally decompress by anterior capsulotomy (Watson Jones)

4. less than 8 yo traction or traction followed by spica, close FU
   more than 8 yo ORIF with paediatric hip screw

Complications

AVN
Coxa vara

~ 20% , less risk in ORIF than in nonop treatment
due to malunion, AVN, premature physeal closure
if neck shaft angle less than 110 deg osteotomy
more than 110 deg will remodel

Premature physeal closure

increased risk in AVN, when pins cross the physis
May need to epiphyseodese the other side if LLD projected to be more than 2.5 cm

Nonunion

7% due to failing to obtain or maintain adequate reduction
treat with subtrochanteric osteotomy

Femoral Shaft Fractures

Mechanism

Classification

AO

Type A simple

1. Spiral
   
2. Oblique ( angle more than 30 deg)
   
3. Transverse (angle less than 30 deg)

Type B multifragmentary: wedge

1. Spiral wedge
   
2. Bending wedge
   
3. Fragmented wedge

Type C Multifragmentary: complex

1. Spiral
   
2. Segmental
   
3. Irregular

1. minimal or no comminution more than 75% circumferential contact of major prox and distal fragments
   
2. 5075% circumferential contact of major prox and distal fragments
   
3. less than 50% of contact but contact still maintained
   
4. segmental comminution no contact bw major prox and dist frags
   
5. segmental bone loss

Related injuries

Ipsilateral

hip fractures 5%
tibial fracture 10%
knee lig injury 5%

Treatment

Prognosis/ Complications

delayed or nonunion

rare: less than 2%

infection

~1% in closed fracture
24% in open fracture

knee motion full in 90%

heterotopic ossification at tip of nail

mild 35%
mod 15%
severe 10%

rarely clinically significant

nerve palsy from excessive traction

pudendal n most common
sciatic n

most resolve

Supracondylar Femoral Fractures

Mechanism

Classification AO

1. Extra articular
   
2. partial intraarticular
   
3. complete intraarticular

Treatment

options Nonop

cast brace
AKPOP
appropriate for undisplaced fracture, extra articular fracture

operative

IM nailing
flexible IM rods eg Zickel device
ORIF condylar screw and plate/ blade plate
condylar buttress plate

Prognosis

Femoral Fractures Paediatric

Acceptable alignment:

less than 15^o angulation will remodel
Accept less than 10^o varus / valgus
Accept less than 15^o apex anterior bow
Accept less than 5^o apex posterior bow
Accept less than 10^o rotation malalignment