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Slide 1
Re-written by: Daniel Habashi Femoral neck fractures
Slide 2
Anatomy Physeal closure at the age of 16 Neck-shaft angle 130
+/- 7 . Anteversion 10 degr +/- 7 degr Calcar femorale
Posteromedial Dense plate of bone
Slide 3
Blood Supply Greater fracture displacement = greater risk of
vascular disruption to femoral head Revascularization of the head
Intact vessels Vascular ingrowths across the fracture site
Slide 4
Epidemiology 250 thousand hip fractures annually
Slide 5
Classification Pauwels Angle describes vertical shear vector
Type 1 = 30 Type 2 = 50 Type 3 = 70
Slide 6
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
Slide 7
Classification Functional classification Stable Impacted Garden
I Non-displaced Garden II Unstable Displaced Garden III and IV
Slide 8
Treatment Non-Operative Very limited role Activity modification
Skeletal traction Operative ORIF Hemiarthroplasty Total hip
replacement
Slide 9
Decision making variables Patient characteristics Young (under
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
Slide 10
Young patients Non-displaced fractures At risk for secondary
displacement Urgent ORIF recommended OPEN REDUCTION INTERNAL
FIXATION 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
Slide 11
Pre-operative considerations Regional vs general anesthesia
Mortality / long term outcome No difference
Slide 12
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
Slide 13
Non-displaced fractures ORIF standard of care Predictable
healing Nonunion under 5% Minimal complications AVN under 8%
Infection under 5% Relatively quick procedure Minimal blood loss
Early mobilization Unrestricted weight bearing with assistive
device PRN
Slide 14
Approach for open reduction SMITH-PETERSON Anterior approach
Best for transcervical
Slide 15
Sliding compression screw fixation Compression hip screws
Sacrifices large amount of bone May injure blood supply
Biomechanically superior in cadavers Anti-rotation screw often
needed Increased cost and operative time No clinical advantage over
parallel screws May have role in high energy / vertical shear
fractures
Slide 16
Hemiarthroplasty Unipolar vs. Bipolar Bipolar theoretical
advantages Lower dislocation rate Less acetabular wear / protrusio
Less pain More motion
Slide 17
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:
Slide 18
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
Slide 19
Pre-operative considerations Surgical approach Posterior
approach to hip 60% higher short-term mortality vs. anterior
Dislocation rate No significant difference
Slide 20
ORIF or Replacement Prospective, randomized study ORIF vs.
cemented bipolar hemi vs. THA Ambulatory patients > 60 years of
age
Slide 21
Stress Fractures Patient population Females 4-10 times more
likely
Slide 22
Stress fractures Clinical presentation Activity weight bearing
related Anterior groin pain Limited ROM at extremes +/- antalgic
gait Must evaluate back, knee, contralateral hip
Slide 23
Stress fractures Imaging Plain radiographs are negative in up
to 66% Bone scan Sensitivity 93-100% Specificity 76-95% MRI 100%
sensitive / specific Also differentiates synovitis, etc
Slide 24
Stress fractures - complications Tension sided and compression
sided fxs over 50% treated non-operatively Varus malunion
Slide 25
Femoral neck nonunion Definition: not healed by one year
0-5%