4. DEVELOPMENT OF PROXIMAL FEMUR
• Proximal femur consist of single physis at birth.
• At 4 yeas of age, physis separates into 2 centers of ossification
• Capital femoral epiphysis
• Trochantric apophysis
• Trochantric apophysis closes at 16 to 18 yrs
• Capital femoral physis closes at 18 yrs
• Capital femoral physis for 15% growth of lowerlimb.
5. TRABECULAR PATTERN
• Presence or absense of trabecular lines indicates the stages of
osteoporosis
• Ward’s triangle: formed by primary tensile, primary
compressive and secondary compressive group of trabeculae
10. • BLOOD SUPPLY OF FEMORAL HEAD
• 1. Extracapsular arterial ring
• 2. Ascending cervical branches
• 3. Artery of ligamentum teres
• The extracapsular arterial ring is formed posteriorly
by a large branch of medial femoral circumflex artery
and anteriorly by a branch of lateral femoral
circumflex artery
11. • Ascending cervical branch or retinacular vessels arise
from the extracapsular arterial ring
• Ascending cervical branch ascends over the femoral
neck in anterior, posterior, medial and lateral groups
• Lateral vessels provide more blood supply to head
and neck of femur.
• Ascending cervical arteries forms a subsynovial intra-
articular arterial ring • At the subsynovial intra-
articular ring, epiphyseal arterial branches arise that
enter the femoral head.
12. • Epiphyseal artery forms 2 groups of vessels 1.lateral
epiphyseal arteries 2.Inferior metaphyseal arteries
• Most important is, lateral epiphyseal arterial group
supplying the lateral weight bearing portion of the
femoral head
• The artery of the ligamentum teres is a branch of the
obturator artery
13. BLOOD SUPPLY BEFORE MATURITY
• AT BIRTH- BOTH MEDIAL& LATERAL CIRCUMFLEX
FEMORAL ARTERIES SUPPLY THE HEAD, THE FOVEAL
ARTERY SUPPLIES ONLY SMALL AREA OF MEDIAL HEAD
• BY AGE OF 3 YR • CONTRIBUTION OF LAT.
CIRCUMFLEX FOMORAL ARTERY DIMINISHES AND
ENTIRE BLOOD SUPPLY COMES FROM MED.
CIRCUMFLEX ARTERY.
• BY 8 YR • THE FOVEAL ARTERY PROVIDES 20% OF
BLOOD TO FEMUR HEAD AND MAINTAINS IT INTO
ADULTHOOD
14. • A 60 year old diabetic patient sustained injury to the left hip
after he slipped and fell in the toilet. The patient was unable to
walk after the fall. He was carried to the hospital. Clinical
examination revealed externally rotated, shortened left lower
limb. Hemodynamically patient was stable with no evidence of
any other serious injury. Discuss:
• Differential diagnosis
• Outline the management of the most probable diagnosis.
15. NECK OF FEMUR FRACTURE
• Intra capsular fracture
• Femoral neck fracture occurs mainly in the elderly
people with osteoporosis
• Fracture can occur in people with normal bone density
with high force (Road Traffic Accident)
• Stress fracture occasionally seen in athletic people
(increased cyclic loading)
16. RISK FACTORS
Non-modifiable
• Age
• Sex
• Ethnicity
• Reproductive factors
• Family history
Modifiable
• Weight
• Smoking
• Alcohol
• Level of physical activity
• Diet and nutritional status
17. MECHANISM OF INJURY
Old age:
• 1.fall with lateral rotation strain of lower limb
• 2. fall producing a direct blow over the greater
trochanter
Young individuals – high energy trauma
18. CLINICAL FEATURES
• History of trivial trauma
• Pain
• Swelling
• Tenderness
• In undisplaced/impacted fracture 1. Ambulatory 2.
Minimal pain
• In displaced fractures: 1. External rotation deformity
2. Shortening 3. Unable to ambulate 4. Echymosis 5.
Restricted movements. 6. unable to perform a straight
20. • PAUWEL classification
• Based on the angle of fracture from the horizontal
• Classifcation was proposed to be predictive of fixation failure
or nonunion with an increasing angle of fracture. • Has not
been shown to be reliable in predicting the outcome
21. GARDEN CLASSIFICATION
• Based on the degree of displacement, which is judged on the
AP radiograph by determining the relationship of the trabecular
lines in the femoral head to those in the acetabulum.
• Types I and II -undisplaced Types III and IV -displaced
22. • Garden I fracture is a valgus-impacted subcapital
fracture
• Garden II fracture, the fracture is complete but
undisplaced and the trabecular lines in the head are
colinear with those in the acetabulum and the femoral
neck distal to the fracture.
• Garden III subcapital fractures are incompletely
displaced fractures. The femoral head has not lost
contact with the femoral neck, but the head is varus
and extended, resulting in angulation of the
trabecular lines.
• Garden IV fracture is completely displaced and the
trabecular lines line up as the femoral head returns to
23. INVESTIGATIONS
• Xray Antero Posterior view of pelvis with hip joint
• Traction & internal rotation view of affected hip joint
• Cross table lateral view – to assess posterior
comminution
• CT scan
• MRI Scan
29. CLOSED REDUCTION WHITMAN TECHNIQUE
• The fractured extremity is tied to footplate in an externally rotated
position
• With the extremity externally rotated, it is abducted approximately
20*
• Traction is applied
• The extremity is internally rotated until the patella is internally
rotated 20 - 30*.
LEADBETTER TECHNIQUE
• Hip is flexed to 90*
• Traction along long axis of femur
• Thigh is internally rotated & abducted
• Reduction is evaluated by “heel palm” sign
30. CLOSED REDUCTION & CANNULATED SCREW FIXATION
• Screws are fixed in Inverted triangle configuration
• 1st screw: inferior aspect of head to prevent neck varus
• 2nd screw: placed posteriorly
• 3rd screw: placed anteriorly
33. CALCAR
FEMORALE
• Normal ridge of dense bone arise
from endosteal surface
posteromedial margin of proximal
femur shafr, near lesser trochanter
• Vertical oriented
• Project laterally to greater trochanter
• Purpose : reinforce femoral neck
posteriorly
34. BIPOLAR
PROSTHESIS
ADVANTAGES
• WIDE RANGE OF MOVEMENTS
• STABILITY WILL BE IMPROVED
• PREVENTS THE COMPLICATIONS
• INCREASED LIFE SPAN OF PROSTHESIS
• CAN DO A TOTAL HIP LATER
ADVANTAGES
INDICATIONS
1.Non union
2.Young patient(50-55yrs) acetabular
erosion is less, compared to unipolar
hemiarthroplasty
35. TOTAL HIP ARTHROPLASTY
INDICATIONS
1.Pre existing acetabular disease
2.Displaced fracture in old age - >60yrs
3.Avasular necrosis of femoral head
4.Neglected fracture
36.
37. COMPLICATIONS OF FRACTURE NOF
• Absence of cambium layer of periosteum.
• fracture heals through endosteal callus
• Diminished blood flow
• Synovial fluid washes away the hematoma formation
• Shearing and distraction forces
