Fracture of neck of femur
Incidence and Mechanism:
The fracture of the neck of femur is common in the elderly. It does occur occasionally in young adults and even in children. It occurs more frequently in women. In India, the incidence of fracture neck of femur in children is higher than in the Western countries.
The fracture may result either from rotation violence at the hip due to tripping over something on the floor and falling or a direct violence over the lateral aspect of the hip by a fall on the side.
Two broad groups of fractures are recognized in the neck of femur
(1) Intracapsular fractures(2) Extra capsular fractures.
INTRACAPSULAR FRACTURE NECK OF FEMUR
This is also called a high fracture neck of femur. In this group, the proximal fragment often loses part of its blood supply and hence, the union of this fracture is difficult. This is a serious injury in the elderly patient. In the very old and debilitated person, it can precipitate a crisis in the precarious metabolic balance. It can become a terminal illness due to uremia, lung infection, bed sores etc, and be fatal.
This classification relies only upon the appearance of the hip on the AP radiograph. It is used to determine the appropriate treatment.
Subcapital fractures are classified along two continuums: the Pauwels and Linton classifications.
Type I: has an obliquity ranging from 0 to 30 degrees
Type II: has an obliquity ranging from 30 to 50 degrees
Type III: has an obliquity of 70 or more degrees
The greater the obliquity in the fracture, the higher the chances of either delayed or nonunion. This woman’s fracture is Pauwels Type II and therefore has an intermediate chance of delayed or nonunion.
Stage I: Incomplete fracture
Stage II: Complete but undisplaced fracture
Stage III: Complete, partially displaced fracture
Stage IV: Displaced and totally free fracture
Type I: Pauwel’s angle is less than 30 degrees, the fracture line is nearer the horizontal.
Type II: The angle is between 30 and 70 degrees.
Type III: The angle is more than 70 degrees and the fracture line is nearer the vertical.
In the more vertical fractures, the action of the gluteal and adductor museles produces a shearing force on the fracture line and hence nonunion is commoner. Thus, prognosis is worse in Type III and good in Type I.
Radiography is the preferred initial imaging modality in evaluating femoral neck fractures because of its near universal availability, ease of acquisition, and documented correlation with surgical results over many years of use.
However, radiography has some limitations. Spiral fractures are difficult to assess on a single view. Comminution is also not as easily demonstrated as it is with CT. Some stress fractures are simply not visible on plain images at all. However, radiography will likely remain the mainstay in the evaluation of these injuries in the near future, and cross-sectional imaging will play an increasing but supplementary role.
False Positives/Negatives: Some femoral neck fractures are not visible on radiographs obtained during the initial evaluation. If the clinical suspicion is strong, these cases can be further evaluated with MRI, which shows bone marrow edema, or nuclear medicine bone scanning, which shows increased tracer uptake. The latter is much less expensive than MRI and nearly as sensitive. The major drawback of bone scanning is in the first 48-72 hours after trauma, when its sensitivity is lower than that of MRI.
CT plays an increasingly important role in evaluating the hip after a fracture. CT is exquisite useful for imaging abnormalities of the bone itself. Because of its superior resolution, cross-sectional capabilities, and amenability to image reconstruction in the coronal and sagittal planes, CT is useful for assessing fracture comminution preoperatively and in determining the extent of union (or lack thereof) postoperatively.
Degree of Confidence: CT is the most useful test for evaluating bony injury. However, axial fractures in the plane of the images can on occasion be missed with CT. This potential is decreased with the use of images reconstructed in orthogonal planes and newer multidetector CT scanners.
MRI is both sensitive and specific in the detection of femoral neck fractures, because it can show both the actual fracture line and the resulting bone marrow edema. The superior contrast of MRI when appropriate pulse sequences are used, the intrinsic spatial resolution, and the ability to image in multiple planes (coronal, axial, and less commonly, sagittal) makes MRI the premiere imaging modality, especially in the setting of stress fractures, which can appear normal on initial plain images
Fractures at this level have a poor capacity for union due to the following factors.
a) Interference with the blood supply to the proximal fragment.
b) Difficulty in controlling the small proximal fragment.
c) The lack of organization of the fracture haematoma due to the presence of the synovial
Two essential principles to be followed in the surgical management of this fracture are
(a) perfect anatomical reduction.(b) rigid internal fixation.
The earlier method of stabilising the fracture was by internal fixation with Smith Petersen Trifin nail. The fracture is reduced by manipulation with the patient in a special orthopaedic table. The fracture is internally fixed with an S.P. Nail under radiological control.
The more recent method of internal fixation of the fracture is the use of multiple compression screws
Fracture neck of femur in Children
The fracture is reduced by manipulation and the leg immobilised in full plaster spica in abduction for 8-10 weeks. When indicated internal fixation could be done with multiple thin Austin Moore’s Pins.
Complications of Fracture Neck of Femur
The important complications are: a) Non-union b) Avascular necrosis of head of femur.
Failure of union of this fracture still occurs due to improper reduction of imperfect internal fixation. When this occurs, the patient complains of pain and develops instability on walking. The condition is treated by intertrochanteric osteotomy (McMurray) in the younger age group and replacement arthroplasty in the elderly.
In the very old patient with poor general condition, the only treatment possibly may be to keep the leg between sand bags and attend to the general care of the patient. As soon as the general condition is restored and the local pain relieved, physiotherapy is started. Movements of the hip are encouraged and the patient is got up on crutches about three weeks after the injury. Gradual weight bearing will lead to painless nonunion. This end result is practicable and is still useful in our country, in places where good surgical and hospital facilities are not available.
Avascular necrosis of the head of the femur is an unpredictable complication met with after any type of internal fixation. The patient presents with pain in the hip and limping. There is limitation of all movements of the hip with muscle spasm. Radiography shows patchy areas of increased density in the head of the femur. Treatment in the early stages is by rest, traction and weight relieving caliper. When indicated, osteotomy or replacement arthroplasty is done.
TROCHANTERIC FRACTURE OF FEMUR
(Extra Capsular Fracture neck of femur)
These are also called low fractures and are again classified as (i) Stable, (ii) Unstable fractures. In this group, the blood supply to the proximal fragment is not interfered with and there is a greater area of contact between the two fragments; hence the fractures unite easily. While union is the rule, it is common to see these fractures malunited with a coxa vara deformity.
The normal neck shaft angle is about 115 degrees. When the angle is reduced to nearer
90 degrees, the deformity is called Coxa Vara.
These fractures occur in the elderly and the nature of the violence is the same as in the intracapsular fracture.
On examination, the injured leg lies externally rotated and is obviously shorter. The degree of external rotation is greater than in the intra capsular fracture. There is marked local swelling and echymoses over the trochanteric area. All movements of the hip are extremely painful and limited. This has to be differentiated from intracapsular fracture.
Stable Type: There is a single fracture line and it is a two piece fracture.
Unstable Type: This is a comminuated fracture with multiple fractures at the trochanteric level
The principle of the treatment is reduction of the fracture and maintenance of the fragments in good position till union occurs.
This consists of the application of continuous skeletal traction. For cases with marked coxa vara, continuous skeletal traction through the upper tibia is applied and the leg is immobilised in the Bohler Braun splint and the foot end of the bed is raised. Traction with 12 to 15 Ibs is sufficient. The coxa vara gets corrected and the fracture unites in about 12 weeks. When the coxa vara is not marked, skin traction in Thomas’ splint will be sufficient. Excepting the fact that the patient occupies a hospital bed for about 3 months, there is no other serious defect in this conservative method and the results are highly satisfactory.
This consists of manipulative reduction and internal fixation. The internal fixation is done by a nail plate as shown in the figure. The McLauglin two piece nail plate has been commonly used. The use of a single piece angled nail plate (Jewett) has been found to be mechanically superior and gives good results. More recently the use of compression hip screw and plate system has enabled earlier mobilisation of the hip and weight bearing.
The main complication is malunion with coxa vara and shortening. If the coxa vara is gross, it can be corrected by osteotomy.
Fracture shaft femur:
Trauma-induced fractures of the femur occur with contact and during high-speed sports. A significant amount of energy is transferred to the limb in a femur fracture, such as might be generated in skiing, football, hockey, rodeo, and motor sports.
Femoral shaft fractures are the result of high-energy injuries. These fractures are often accompanied by other injuries. The first priority in treatment is to rule out other life-threatening injuries and stabilize the patient. Advanced Trauma Life Support guidelines should be followed.
Treatment for acute trauma-related femoral fractures is performed by an orthopaedic surgeon and usually involves surgical stabilization (see Surgical Intervention).
For stress fractures of the medial compression side, protected crutch-assisted touch-down weight bearing is implemented for 1-4 weeks, based on the resolution of symptoms and the appearance of callus. Progression to full weight bearing can gradually commence once pain has resolved. Patients must avoid running for 8-16 weeks while the low-impact training program/phase is completed. The progression can include (1) cycling, (2) swimming, and (3) running in chest-deep water prior to resuming more intensive weight-bearing training. Patients must maintain upper extremity and cardiovascular fitness and avoid lower extremity exercise early in the healing process. Prophylactic rod placement is not indicated.
The emergent management of femur injuries in the sports setting is intended to restore alignment. If limb deformity is present, inline longitudinal traction is applied, realigning the extremity and maintaining limb perfusion. A splint is applied to maintain the alignment as the patient is transported to the hospital for definitive treatment.
Intramedullary nailing is the treatment of choice for the majority of femoral shaft fractures occurring in adults. Reamed locked antegrade femoral nailing remains the criterion standard and can be performed with the patient in the supine or lateral position with or without the use of a fracture table. Recent clinical studies suggest results of retrograde femoral nailing approach success rates found with antegrade techniques. Retrograde nailing may be preferred when the fracture involves the distal femur or is associated with an ipsilateral femoral neck fracture. A floating knee (ie, an ipsilateral femoral shaft and tibia shaft fracture) is also a relative indication for a retrograde technique. The retrograde technique has also been found to be beneficial in obese patients, pregnant patients, and patients with total hip or total knee prostheses.
Physical therapy is recommended post surgical intervention inorder to achieve functional independence.
A Patella fracture or broken knee cap is usually caused by a forceful direct blow to the knee, such as the knee contacting the dashboard of a car in an accident or direct trauma from an opponent during sport. The Patella fracture may consist of a single crack across the kneecap or the kneecap may be broken into several pieces, in what is known as a ‘stellate’ fracture. In some instances a forceful contraction of the Quadriceps muscles can be enough to cause a fracture of the patella. This causes a horizontal crack across the knee cap, which makes it impossible for the patient to straighten their knee.
Mechanism and Types
Fractures of the tibia
Fractures of the tibia can involve the
Fractures of the tibia are the most common long bone fractures. Isolated midshaft or proximal fibula fractures are uncommon.
Toddler fracture (distal spiral fracture of the tibia) is most common in children aged 9 months to 3 years.
A fractured ankle can range from a simple break in one bone, which may not stop you from walking, to several fractures, which forces your ankle out of place and may require that you not put weight on it for three months.
Since there is such a wide range of injuries, there is also a wide range of how people heal after their injury.
Broken ankles affect all ages. Ankle fractures occur in 184 per 100,000 persons per year. During the past 30 to 40 years, doctors have noted an increase in the number and severity of broken ankles, due in part to an active, older population of “baby boomers.” In 2003, nearly 1.2 million people visited emergency rooms because of ankle problems.
Because a severe ankle sprain can feel the same as a broken ankle, every ankle injury should be evaluated by a physician.
Common complaints for a broken ankle include:
Besides a physical exam, X-rays are the most common way to evaluate an injured ankle. X-rays may be taken of the leg, ankle, and foot to make sure nothing else is injured.
Depending on the type of ankle fracture, the doctor may put pressure on the ankle and take a special X-ray, called a “stress test.” This X-ray is done to see if certain ankle fractures require surgery.
Sometimes, a computed tomography (CT, or CAT) scan is done to further evaluate ankle injuries.
For some ankle fractures, magnetic resonance imaging (MRI) may be done to evaluate the ankle ligaments.
Lateral Malleolus Fracture
The lateral malleolus fracture is a fracture of the fibula.
There are different levels at which that the fibula can be fractured. The level of the fracture may direct the treatment.
If the fracture is not out of place or just barely out of place and the ankle is stable, you may not need surgery. Some physicians let patients put weight on their leg right away, while others have them wait for 6 weeks.
Several different methods are used for protecting the fracture, ranging from a high-top tennis shoe to a short leg cast. Treatment may also be based on where the bone is broken.
A “stress” X-ray may be done to see if the ankle is stable. You will have to see your physician regularly to repeat your ankle X-rays to make sure the fragments of your fracture have not moved out of alignment during the healing process.
If the fracture is out of place or your ankle is unstable, your fracture may be treated with surgery. To make your ankle stable, a plate and screws on the side of the bone or a screw or rod inside the bone may be used to re-align the bone fragments and keep them together as they heal.
Medial Malleolus Fracture
Fractures can occur at different levels of the medial malleolus.
Medial malleolar fractures are sometimes isolated but often occur with a fracture of the fibula, posterior malleolus, or an injury to the ankle ligaments, as well.
If the fracture is not out of place or is a very low fracture with very small pieces, it can be treated without surgery.
A stress X-ray may be done to see if the fracture and ankle are stable.
The fracture may be treated with a short leg cast or a removable brace. Usually, you need to avoid putting weight on your leg for approximately 6 weeks.
You will need to see your physician regularly for repeat X-rays to make sure the fracture does not change in position.
X-ray of medial malleolus fracture/Surgical repair of a medial malleolus fracture. If the fracture is out of place or the ankle is “unstable,” surgery may be offered.
Occasionally, surgery may be considered even if the fracture is not out of place. This is done to decrease the risk of the fracture not healing (nonunion), and to allow you to start moving the ankle earlier.
Sometimes, the fracture can include “impaction,” or indenting of the ankle joint. This can require bone grafting to repair it, in order to lower any later risk of developing arthritis.
Different techniques for surgery can be used. Screws, a plate and screws, or different wiring techniques can all be used, depending on the fracture.
Posterior Malleolus Fracture
A posterior malleolus fracture is a fracture of the back of the “shin bone” at the level of the ankle joint.
This is usually not an isolated injury. Often, the lateral malleolus is also fractured because it shares ligament attachments with the posterior malleolus. There can also be a fracture of the medial malleolus.
Depending on how large the broken piece is, the back of the ankle may be unstable. Some studies have shown that if the piece is bigger than 25% of the ankle joint, the ankle becomes unstable and should be treated with surgery.
A fracture of the posterior malleolus is important to diagnose because the piece is covered by cartilage. Cartilage is the smooth surface that lines the joint. If the broken piece is larger than about 25% of your ankle and is out of place more than a couple of millimeters, the cartilage surface will not heal properly and the surface of the joint will not be smooth. This uneven surface typically leads to increased and uneven pressure on the joint surface, which leads to cartilage damage and the development of arthritis.
If the fracture is not out place and the ankle is stable, it can be treated without surgery.
Treatment may be with a short leg cast or a removable brace. Patients are typically advised not to put any weight on the ankle for 6 weeks.
If the fracture is out of place or if the ankle is unstable, surgery may be offered.
Different surgical options are available for treating posterior malleolar fractures. One option is to have screws placed from the front of the ankle to the back, or vice versa. Another option is to have a plate and screws placed along the back of the shin bone.
Bimalleolar Fractures or Bimalleolar Equivalent Fractures
“Bi” means two. “Bimalleolar” means that two of the three parts or “malleoli” of the ankle are broken.
A bimalleolar fracture most commonly means that the lateral malleolus and the medial malleolus are broken and the ankle is not stable.
A bimalleolar equivalent fracture means that the ligaments on the inside, or “medial,” side of the ankle are injured along with one of the other “malleoli.” Malleoli is pleural for malleolus. Usually, this means that the fibula is broken along with injury to the medial ligaments, making the ankle unstable.
A “stress test” X-ray may be done to see whether the medial ligaments are injured.
Bimalleolar fractures or bimalleolar equivalent fractures are unstable fractures and can be associated with a dislocation.
X-ray of bimalleolar ankle fracture/Surgical repair bimalleolar ankle fracture
These injuries are considered unstable and surgery is usually recommended.
Nonsurgical treatment might be considered if you have significant health problems, where the risk of surgery may be too great, or if you usually do not walk.
A splint is usually used until the swelling goes down. A short leg cast is then typically used. Casts may be changed frequently as the swelling subsides in the ankle.
You will need to see your physician regularly to repeat your X-rays to make sure your ankle remains stable.
Typically, weight bearing will not be allowed on your ankle for 6 weeks. After 6 weeks, the ankle may be protected by a removable brace as it continues to heal.
Usually, surgical treatment is recommended because these fractures make the ankle unstable.
Lateral and medial malleolus fractures are treated with the same surgical techniques as written above for each fracture listed.
“Tri” means three. Trimalleolar fractures means that all three malleoli of the ankle are broken. These are unstable injuries and they can be associated with a dislocation.
X-ray of Trimalleolar ankle fracture and surgical repair
These injuries are considered unstable and surgery is usually recommended.
As with bimalleolar ankle fractures, Nonsurgical treatment might be considered if you have significant health problems, where the risk of surgery may be too great, or if you usually do not walk.
Nonsurgical treatment is similar to bimalleolar fractures, as listed above.
Each fracture can be treated with the same surgical techniques as written above for each individual fracture.
X-ray of syndesmotic injury and repair
Treatment: Syndesmotic Injury
These are also known as “high” ankle sprains when there is no fracture. Depending on how unstable the ankle is without a fracture, these injuries can be treated without surgery. However, these sprains take longer to heal than the normal ankle sprain.
When there are fractures of other bones in the ankle, these are unstable injuries. They do very poorly without surgical treatment.
Certain types of bimalleolar ankle fractures have an associated syndesmotic injury. Your physician may do a “stress test” X-ray to see whether the syndesmosis is injured.
Rehabilitation is very important regardless of how an ankle fracture is treated.
When your physician allows you to start moving your ankle, physical therapy and home exercise programs are very important. Doing your exercises regularly is key.
Eventually, you will also start doing strengthening exercises. It may take several months for the muscles around your ankle to get strong enough for you to walk without a limp and to return to your regular activities.
Again, exercises only make a difference if you actually do them.
Your specific fracture determines when you can start putting weight on your ankle. Your physician will allow you to start putting weight on your ankle when he or she feels your injury is stable enough to do so.
It is very important to not put weight on your ankle until your physician says you can. If you put weight on the injured ankle too early, the fracture fragments may move or your surgery may fail and you may have to start over.
It is very common to have several different kinds of things to wear on the injured ankle, depending on the injury.
Initially, most ankle fractures are placed in a splint to protect your ankle and allow for the swelling to go down. After that, you may be put into a cast or removable brace.
Even after the fracture has healed, your physician may recommend wearing an ankle brace for several months while you are doing sporting activities.
People who smoke, have diabetes, or are elderly are at a higher risk for complications after surgery, including problems with wound healing. This is because it may take longer for their bones to heal.
Without surgery, there is a risk that the fracture will move out of place before it heals. This is why it is important to follow up with your physician as scheduled.
If the fracture fragments do move out of place and the bones heal in that position, it is called a “malunion.” Treatment for this is determined by how far out of place the bones are and how the stability of the ankle joint is affected.
If a malunion does occur or if your ankle becomes unstable after it heals, this can eventually lead to arthritis in your ankle.
General surgical risks include:
Risks from the surgical treatment of ankle fractures include
LISFRANC (Tarsal-Metatarsal) FRACTURE DISLOCATION
The Lisfranc injury to the forefoot is thought to have originated with Napoleon’s surgeon. During that time, if a rider was thrown from his horse and the foot was caught in the stirrups, the rider often suffered a severe fracture of multiple bones in the midfoot region with dislocation of the fragments. The resulting trauma often resulted in an amputation of the forefoot at a specific level called the Lisfranc joint, after the French surgeon who first noticed the pattern of this injury. Fortunately, although the injury is still called a Lisfranc injury, amputations are rarely done for this injury.
The most common injury to the Lisfranc joint occurs at the joint involving the 1st and 2nd metatarsals and the medial cuneiform. If the ligaments between the medial and mid cuneiforms are disrupted ssor between the 1st, 2nd metartarsal and the medial cuneiform, then the bones separate and the normal alignment of the joints is lost.
When recognized, this injury may be treated surgically and has a much better prognosis then when it is not diagnosed.
Obviously, with multiple fractures, injury to the Lisfranc joint is obvious. However, the difficulty develops with the subtle injuries that may result in a small chip fracture, or simply a torn ligament. Unfortunately, these injuries are difficult to diagnosis. If not treated, chronic pain often results.
Accurate diagnosis requires a physical exam to determine the amount of swelling, the location of the bruising, and the areas of tenderness. When the injury is suspected, x-rays are often taken of the foot. However, due to the subtle nature of the changes associated with this injury, multiple films are often necessary. In addition, even if the first set of x-rays is normal, as the swelling decrease with time, this may allow for the bones to move from their normal position, especially if the stabilizing ligaments have been torn and the joints have been made unstable. For that reason, it is often necessary to take x-rays during the healing process to evaluate for the possible delayed development of instability. In some patients, it is necessary to proceed to more sophisticated scanning techniques including CT scans or MRI. Unfortunately, it is possible to have a scan that is interpreted as normal, even when the joints are unstable and partially dislocated. (This is referred to as a false negative finding).
Once instability at the midfoot joints has been established the treatment is usually surgical if a significant separation of the bones exists. Surgical treatment usually requires that pins and/or screws be inserted to stabilize the bones and joints. This procedure is called an open reduction and internal fixation. This allows the normal anatomy to be re-established.
After surgery, it is critical that the patient remain non-weight bearing until full healing occurs. During this time, a short leg cast is usually applied. Once healing has occurred, several months after the surgery, it is necessary to remove the screws/ pins (internal fixation devices) prior to full weight bearing and resumption of activities.
A Jones fracture is an injury to the fifth metatarsal bone of the foot. The fifth metatarsal bone is at the base of the small toe, and the Jones fracture occurs in the midfoot area
This injury was first described in 1902 by Sir Robert Jones in an article titled “Fractures of the Base of the First Metatarsal Bone by Indirect Violence.” He included descriptions of six patients (one being himself) who sustained fractures in this area without a direct impact (his injury occurred while dancing).
Patients who sustain a Jones fracture have pain over this middle/outside area of their foot, swelling, and difficulty walking. Most often a Jones fracture is caused without significant injury or impact.
Treatment of an acute Jones fracture consists of immoblization with a cast. Patients should not place weight on the foot until instructed by their doctor. Crutches will be used for the initial healing phase.
Jones fractures can become chronic conditions if the fracture fails to unite, or heal. If this is the case, surgery will likely be recommended to secure the fracture in place with a screw, and bone graft may be used to stimuate a healing response.
Foot – Stress Fracture or March fracture
A stress fracture can occur as a result of prolonged repeated loads on the legs. Long distance runners are susceptible to this type of injury.
A stress fracture in athletes occurs mainly in the lower leg and foot (in the calcaneus, navicular and metatarsal bones). A stress fracture of the 2nd or 3rd metatarsal bone is sometimes called a ‘march fracture’ because soldiers running in boots often get it.
Often an X-ray of the injured bone will not show any sign of fracture until the fracture has actually started to heal (2-3 weeks later). If a stress fracture is suspected then you should rest completely for 6-8 weeks. Crutches can be helpful.
Apply a plaster cast for 2 – 6 weeks if pain is severe, followed by physiotherapy.