Neck of femur fracture, Intertrochanteric femur fracture classification, reduction, treatment, adverse outcome of treatment and management

1. Neck of Femur Fracture &
Pertrochanteric Femur
Fracture
Presenter : Dr Yash Oza (PG in Orthopaedics)
Moderator : Dr Vikas Illur

2. Anatomy

3. Neck Shaft Angle
Portion of neck that is intracapsular is
deficient in cambium layer

4. • Blood Supply

5. • Trabecular Pattern

6. Neck of femur Fracture

7. Assessment of Patient
• MOI
• Elderly female, Osteoporotic , Fall sideways
• Young patients – High energy trauma – Associated with
Shaft femur fracture
• Military person – Stress fracture due to repetitive cyclic
loading
• Sign & Symptoms
• Leg is shortened and externally rotated
• All motions are painful
• Neurovascular injury is extremely rare

8. Imaging studies
• Xray
• Diagnosis & treatment choice can be
based on AP view only.
• In equivocal cases lateral xray may be
helpful determining displacement
• AP xray with 10-15degree internal
rotation taken to eliminate
anteversion.

9. • Technetium bone scan
• It was done in past In suspected NOF #
cases with normal xray
• CT Scan
• More accurate in finding occult
fracture
• MRI is more accurate than CT
finding occult fracture
• PET-CT at 6 week could detect
recovery of vascularity and could
predict risk of ANV

10. • Pre Op Care
• Role of traction
• Reduces the perfusion of head by MCFA and also
negatively influence venous circulation
• No benefit in pain & Quality of reduction
• So Not used
• Medication
• Pain killers

11. Classification
• A number of classification system have been
devised for NOF# but in any event location of the
intracapsular fracture has not been shown to
influence management or outcome.
• Various classification are –
• Anatomical Classification
• Garden Classification
• Pauwels Classification
• AO/ATO Classification

12. Garden Classification
Type 1: Incomplete fracture. So
called abducted or impacted
fracture. The trabecular pattern of
inferior neck is not interrupted.
They appear bent.
Type 2: Complete fracture of
femoral neck without
displacement. Trabecular pattern
of weight bearing portion of neck is
interrupted but their alignment is
undisturbed.

13. Garden’s classification
• Type3: Complete fracture with partial
displacement. The trabecular pattern
of femoral head does not line up with
trabecular pattern of acetabulum.
• Type4: Complete fracture with
complete displacement. Trabecular
pattern of femoral head lines up with
trabecular pattern of acetabulum.

14. Pauwels Classsification
An increasing angle leads to a more unstable fracture and an increase in
the shear stress at the fracture site. This shear leads to higher rates of
nonunion.

15. AO/OTA Classification

16. Outcome measures for NOF#
• Most commonly reported outcome is mortality
• Studies on fixation provide outcome data on AVN,
Fixation failure and nonunion
• Arthroplasty complication include – dislocation,
infection
• There are many hip-specific outcome score –
• Harris Hip Score
• Oxford Hip Score
• Johanson Hip Score
• Charnley Score
• Activities of Daily living (ADLs) Score
• Functional Indenpendance Measure (FIM)

17. Treatment Options
• Non-surgical
• Surgical
• Internal Fixation
• Arthroplasty
• Depends on
• Age of the patient
• Amount of displacement
• Amount of comminution
• Vascular impairment
• Interval between injury and reduction

18. Non - surgical
• It is an option for undisplaced NOF# in young and
patient unfit for the surgery
• Methods
• skin traction
• Derotation casts
• Outcome
• Displacement
• Non Union
• AVN

19. Methods to evaluate accuracy of reduction
• Garden’s Alignment index
• In AP view, the angle formed by central axis of medial
trabecular system in capital fragment and the medical
cortex of shaft
• In Lateral view, the central axis of head and neck lie in
straight line.

20. • Lowell Method
• Femoral Head with the neck forms “S” or “inverted S”
shaped curve in any projection
• If fracture is not reduced it produces broken “C” curve

21. Surgical Treatment
• CRIF
• Multiple Pin (Knowles, Moore)
• Cannulated Hip Screw ( ANIS)
• AO Cannulated screw
• Cannulated hip bolt
• Sliding or telescopic screw (DHS)
• SP Nailing
• ORIF
• Mayer’s muscle pedicle graft and internal fixation
• Arthroplasty
• Hemiarthroplasty
• Austin Moore prosthesis
• Thompson’s prosthesis
• Bipolar
• THR

22. Closed reduction and Internal fixation
• For Garden I & II fractures
• Garden I
• Incomplete or impacted fractures
• Least risk of displacement and AVN
• Multiple Pin/CC Screw/Moore pins can be used
• Garden II
• Sliding hip screw or Knowles pin may be required due to
bony instability

23. Open Reduction & Internal fixation
• Indications are –
• Failed CRIF after 2 attempts
• Age >60yrs
• Very young adults & children where absolute reduction
is important
• Advantages
• Spinning of head can be controlled
• Bone grafting can be done
• Arthrotomy or joint aspiration can be done which may
benefit reduction

24. • Disadvantages
• Interference with blood supply
• Higher rate of non union
• Infection

25. Multiple pins
• Cheap
• Easy fixation
• Chance of penetrating hip less
• Rotation forces prevented
• Chances of AVN less

26. Compression Hip screw and plates
• Advantages
• No rotation takes place at # site
• Cheaper
• Early weight bearing
• Incidence of proximal migration and cut-out is less
• Implant failure is less
• Disadvantages
• The screw has potential to rotate the femoral head
during incursion ( placing an accessory pin above the
screw prior to screw insertion prevents rotation)

27. AO CC Screw
• Newer method
• Widely used in children and young adults
• Early mobilization possible

28. Mayer’s muscle pedicle graft and internal fixation
• Indication :
• Displaced NOF# after closure of
epiphyseal plate
• Impacted # with AVN
• Late diagnosed #
• Non Union cases
• Impending AVN
• Alternate procedure to
arthroplasty in early age group
Graft : 3 cm from the tip of
GT ,which includes insertion
of Quadratus femoris

29. • Advantages
• In posterior comminution , fracture stability enhanced as
graft is posterior
• Additional source of blood supply to head
• Direct visualization of neck
• Permits accurate reduction since the capsule is opened
• Disadvantages
• Possible damage to remaining posterior blood supply of
head
• Risk of infection
• Extensive soft tissue dissection
• Contraindication
• Short Life expectancy
• Pathological fracture
• Ispilateral arthritis hip

30. Hemi-Arthroplasty
• Absolute indication
• Age>65yrs , displaced #
• NOF # that can’t be reduced
• Fixation failure
• Pathological NOF#
• Old undiagnosed NOF#, >3week
• NOF# with complete dislocation of head
• Mentally retarded patient
• Uncontrolled seizures

31. • Relative Indication
• Advanced physiological age with life expectancy not
more than 10-15 yrs
• Parkinson’s Ds, Hemiplegia, other neurological Ds
• Osteoporosis
• Pauwel type 3
• # involving superior weight bearing surface of head
• Contraindication
• Active young adult
• Severe osteoporosis
• Acetabular involvement
• Pre-Existing sepsis

32. • Advantages
• Immediate mobilization with weight bearing
• Eliminates AVN, Non union, Fixation failure
• In failure cases revision arthroplasty can be done
• Lesser reoperation rates
• Disadvantages
• More extensive procedure than internal fixation
• Risk of infection
• In case of mechanical failure, salvage procedure
becomes complicated

33. • Types of Prosthesis
• Austin Moore Prosthesis
• Thompson’s Prosthesis
• Bipolar Prosthesis ( Low friction Arthroplasty)
AMP Thompson’s

34. THR
• Performed to salvage complication of NOF#
• Other indication –
• Severe RA and OA
• Active patient with age > 70yrs who suffers a stress #
• NOF# Metastasis in acetabulum

35. Adverse Outcomes
• Fixation failure
• It increases risk of non-union
• Diagnosis : Increasing pain, shortening of leg, xray
• THR is best treatment option

36. • Non Union
• Occurs in 10-20%
• Diagnosis :
• Pain at # site even after 6 month post-op
• Xray
• Causes
• Vascular insufficiency
• Shearing forces at # site
• Increased intraarticular pressure
• Inaccurate Reduction
• Fixation failure
• Arthroplasty is ideal treatment option in old patient
• If patients is <40yrs age then
• Revision fixation
• Muscle pedicle graft
• Vascularized fibula graft
• Valgus osteotomy

37. • AVN
• It leads to joint incongruity, pain, degenerative joint
disease
• Diagnosis :
• Groin Pain on walking
• Xray
• Technitium-99m bone scan
• MRI is sensitive in detecting aseptic necrosis ( Though not used
as metallic implants are in situ)
• Treatment
• Analgesic & physiotherapy
• Vascularized fibular grafting
• Osteotomies of proximal femur
• THR

38. • Prosthesis Dislocation
• Choice of surgical approach and implant size influence
the dislocation rates
• Small Femur Head – More dislocation
• Posterior Approach - More dislocation
• Treatment :
• Closed Reduction possible with Unipolar & THR implants
• In bipolar prosthesis closed reduction is associated with risk of
implant disassociation
• In Bipolar prosthesis Open reduction may be required after
failed closed reduction
• Prosthesis Loosening
• A late complication and not seen routinely because of
limited life expectancy of patients

39. • Osteotomies
• McMarray’s – Displacement osteotomy
• Valgus Osteotomy
Aim – Change the Femoral
Neck angle to 150 degree

40. Intertrochanteric Femur Fracture
• Most common fracture of the proximal femur
• It is extracapsular fracture

41. • Mechanism of injury
• Elderly patient – fall sideways
• Young Patients – High velocity trauma
• Clinical features
• Limb is shortened and externally rotated
• Swelling over hip region
• Ecchymosis over GT may be seen later
• Hip movements painful

42. • Xray
• AP(with traction) & Lateral view
• AP Views – usefull knowing # obliquity, quality of bone and
allows comparison with normal side
• Lateral View – help to assess size, location and comminution
of posterior fragment and help determine fracture stability
• Technetium bone scan
• To diagnose occult #, it requires 2-3 days to become positive
• MRI
• To diagnose occult #, It reveals # within 24 hours of injury

43. Classification
• Boyd & Griffin Classification
• It includes all 3 from extracapsular NOF# to subtrochanteric #

44. • Evan’s Classification
• Based on direction of fracture

45. • AO/OTA Classification

46. Treatment
• Non operative
• Operative

47. Non operative Method
• Indication
• Unfit for surgery
• Non-ambulatory patients
• Protocol
• Early mobilization – bed chair mobilization – but
ambulation is delayed
• Maintain traction until fracture union occurs , usually
10-12 weeks

48. • Methods
• Buck’s Traction
• Russell Skeletal traction
• Balanced traction in Thomas splint
• Plaster spica
• Derotation boot
• Complication
• Pressure sores
• UTI
• Joint contractures
• Pneumonia
• Thromoembolism

49. Buck’s Traction
Russell Skeletal traction
Derotation boot

50. Operative Treatment
• Goal of surgery is strong & Stable fixation
• Factors determining strength of fracture fragment
are –
• Bone Quality
• Fracture Geometry
• Reduction
• Implant Design
• Implant placement

51. Reduction methods
• Closed reduction
• Fracture table is essential
• Ideally slight valgus position on AP to be achived
• In Lateral Femoral head neck and trochanteric area to be
in straight line
• Patella is always facing upwards

52. • Open reduction
• Indication –
• Failed closed reduction
• Large posterior spike
• Reverse oblique #
• If gap exist medially or posteriorly
Types : -
• Anatomical reduction
• With help of clamps & forceps anatomically stable
reduction is achieved
• Non-Anatomical reduction
• In severely comminuted # where anatomical reduction
even with open methods is difficult or impossible
• Osteotomy is done to convert it into stable reduction
1. Medial Displacement Osteotomy ( Dimon-Hughston)
2. Valgus Osteotomy (Sarmiento)
3. Lateral Displacement osteotomy (Wayne county)

53. Implants
• Nail Plate devices
• S-P nail & Plates
• Jewette Nail
• Thornton Nail
• Holt Nail
• AO blade plate

54. Smith Peterson nail & plate
Jewette Nail
AO Blade plate

56. • Sliding Compression Screw plate devices
• Richards
• Calandruccio plate
• Medoff sliding plate
• DHS
• Dynamic Condylar screw
• Percutaneous compression plate

57. Medoff Slinding plate
DHS
Percutaneous
Compression plate

58. • Intramedullary devices
• Condylo cephalic
• Ender’s nail
• Single rigid condylocephalic rods of Harris
• Cephalomedullary Nail
• Gamma nail
• Russell taylor reconstruction nail
• The uniflex nail
• Proximal femoral nail
• Recon nail

59. Ender’s nail
Single rigid
condylocephalic rods
of Harris
Gamma nail

60. Russell
taylor
reconstructi
on nail
TFN

61. Positioning of the Lag Screw
• Correct fracture reduction is prerequisite for being
able to correctly position the lag screw
• An angle of 130 or 135 degree appears to be
optimal
• The lag screw position is low to the central in AP
and central in lateral views.
• Screw tip to apex distance should be twice the
diameter of lag screw (8*2=16mm) . This prevents
screw cutout

62. Trochanteric fracture with loss of
lateral support
• Loss of lateral support in IT fracture allows femur to
displace medially.
• Each degree of medialization increases risk of
fixation failure by 1%
• Mean degree of lateralization with slinding screw
(10%) is more than intramedullary nail (2%)
• So, IT fracture with loss of lateral support should be
treated with intramedullary nailing

63. Arthroplasty
• Indication
• Pathological #
• Severe osteoporotic bone
• Renal Dialysis Patient
• Pre-existing arthritis
• Patient unsuitable for internal fixation
• Hemiarthroplasty & THR both can be done

64. Post Op Care
• Pain Control
• Early mobilization
• DVT prophylaxis ( Mechanical & Chemical)
• Nutrition

65. Complication
• Loss of fixation – mostly due to eccentric
placement of the screw – Screw cutout
• Medialization ( More with sliding hip screw)
• Malrotation deformity ( more with intramedullary
nail)

66. • Refracture around the implant
• IM nail has more risk of # around implant
• Common causes are
• A large diameter nail
• Large diameter distal screw
• Distal screw lose to the tip
• Overtightening of distal screw
• Too short nail for subtrochanteric type fracture
• Treatment – Exchange nail,Plate fixation
• For refracture at proximal end Arthroplasty should be
considered

67. • Non Union
• Very rare
• Head AVN
• 1-2% risk
• Limb shortening
• Varus malunion may lead to limb shortening

68. Summary

70. Thank you