Femur Fractures

 


Intracapsular Fractures of the Proximal Femur

Blood supply to the head of the femur

ref: Crock " An atlas of the arterial supply of the head and neck of the femur in man"
CORR 152: 1727, 1980
Chung JBJS 58A: 961970, 1976

4 groups 1. Extracapsular arterial ring

= trochanteric anastomosis
major contributions posteriorly from the horizontal br of the med circumflex femoral , and, anteriorly from ascending br of the lat femoral circumflex artery

2. Ascending cervical branches

( = retinacular br's) arise from 1.
pass up beneath the synovial and capsular reflections in their passage they give branches to the metaphysis of the femoral neck
there is a free intramedullary anastomosis bw branches of the superior nuttrient artery system,br's of the extracapsular ring, br's of the ascending cervical branches, and the subsynovial ring
4 groups sup, inf, med, lat the lateral supplies most of the blood to femoral head
at the margin of the artic cartilage these vessels form a second ring the

3. Subsynovial intracapsular ring ( Chung)

( = circulus articuli vasculosis Hunter, 1743). This ring may be complete or incomplete (complete more often in males). From this ring epiphyseal branches arise that enter the femoral head

4. Artery of the lig teres

from the lat br of the obturator artery supplies small area about the fovea in the vast majority

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

Garden R.S. " Reduction and Fixation of subcapital fracturesof the femur"
OCNA 5: 683712, 1984
Types
  1. an incomplete or impacted fracture
  2. a complete but undisplaced fracture
  3. a complete partially displaced fracture
  4. a completely displaced fracture
Eliasson etal "Displacement in femoral neck fractures"
Acta Orth Scand 59:359371, 1988
Displaced ( = Garden 1+2)
Undisplaced (= Garden 3+4)

Treatment

based on pt age and grade of fracture
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
pts of any age with less than 1 yr life expectancy® hemiarthroplasty
pts less than 75 with a limited life expectancy of more than 1yr®bipolar

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

AMP for pts more than 70
THR for pts less than 70

Complications

AVN

undisplaced fracture ~ 10%
displaced fracture up to ~ 80% either partial or complete (variable reporting)
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

ref: LuYao etal " Outcomes after displaced fractures of the femoral neck"
JBJS 76A: 1525, 1994
Metaanalysis of 116 papers
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%

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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

Type 1,2,3: ORIF with CHS
Type 4: CHS if pyriformis fossa not intact, supplemental BG

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

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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

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Femoral Head and Neck Fractures in Children

Mechanism

high energy trauma

Classification

Types
  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

Types
  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)
  1. 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
REF: Hughes and Beaty "Fractures of the head and neck of the femur in children"
JBJS 76A:283292, 1994

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Femoral Shaft Fractures

Mechanism

usually high energy

Classification

by location, fracture pattern, comminution, soft tissue injury, mechanism

AO

Type A simple

a single circumferential disruption of the diaphysis may be
  1. Spiral
  2. Oblique ( angle more than 30 deg)
  3. Transverse (angle less than 30 deg)

Type B multifragmentary: wedge

a fracture with one or more intermediate fragments in which after reduction, here is some contact between the main fragments may be
  1. Spiral wedge
  2. Bending wedge
  3. Fragmented wedge

Type C Multifragmentary: complex

a fracture with one or more intermediate fragments in which after reduction, there is no contact bw the main prox and distal fragments may be
  1. Spiral
  2. Segmental
  3. Irregular
Winquist and Hansen " Comminuted fractures of the femoral shaft treated by closed intramedullary nailing" OCNA 11:633647, 1980
Types
  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
type 1 +2 are stable to length and rotation, types 3,4,5 are not,thereffore statically lock

Related injuries

Ipsilateral
hip fractures 5%
tibial fracture 10%
knee lig injury 5%
compartment syndrome rare

Treatment


IM nailing primary nailing for both closed and open fractures
ref: Grosse etal "Open adult femoral shaft fracture treated by early intramedullary nailing" JBJS 75B: 562565, 1993
Winquist etal "Closed intramedullary nailing of femoral fractures: a report of 520 cases" JBJS 66A: 529539, 1984

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

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Supracondylar Femoral Fractures

Mechanism

High energy in young pt
Low energy in aged

Classification AO

Types
  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

Results superior in ORIF over closed means
ref: Healy and Brooker " Distal femoral fractures comparison of open and closed means of treatment" CORR 174:166171, 1982
36/47 fractures treated open good result; 18/51 good for fracture treated closed
Siliski etal "Supracondylar intercondylar fractures of the femur: treatment by internal fixation" JBJS 71A:95104, 1989
52 pts: type C1 fracture 92% good or excellent
type C2 or type C3 fractures 77% good or excellent
Leung etal " interlocking intramedullary nailing for supracondylat and intercondylar fractures of the distal femur" JBJS 73A: 332340, 1991
37fractures in 35 pts fixed with GK nail ater reduction of artic fragments
94% good or excellent results

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Femoral Fractures Paediatric

Immediate or early spica cast is the current standard for the infant to age of 10 years with optimal position 90o- 90o.
Acceptable alignment:
less than 15o angulation will remodel
Accept less than 10o varus / valgus
Accept less than 15o apex anterior bow
Accept less than 5o apex posterior bow
Accept less than 10o rotation malalignment

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