Neck of Femur Fractures Wayne Hoskins

Background NOF #’s common with advancing age High morbidity & mortality Only 1/3 return to living environment Death: 20-35% at 1 year in patients aged 82 +/-7

Anatomy

Fracture location

Head blood supply Profunda femoris gives off medial & lateral circumflex femoral arteries Extracapsular anastomosis at base of neck Ascending cervical branches Intracapsular branches Majority via MCFA, ↓ via ligamentum teres

Garden classification 1. Incomplete impacted # 2. Complete # undisplaced 3. Displaced capsule intact 4. Displaced

Fracture classification Garden classification: poor inter-observer reliability: displaced = 1 & 2 undisplaced = 3 & 4

Shenton’s Line

Mechanism of # Direct or indirect: 1. Direct blow to GT 2. ER: impinging posterior cortex on rim 3. Bending torque – major trauma 4. Violent muscle contraction 5. Cyclical loading / insufficiency #

NOF # complications AVN Non-union Undisplaced 5-10% Displaced 10-20% RFs: displacement, velocity of injury, delay in reduction, non-anatomical reduction Non-union Displaced 20-30% RFs - initial displacement, non anatomical reduction, instability, no compression across #, vascularity

Presentation Typically elderly female Low energy fall Hip pain Short & ER leg Unable to weight bear

NOF # risk factors Osteoporosis Co-morbidities Dementia Poor mobility / vision

Work up – not just a # History ? Gen Med vs. Ortho admission Mechanism of injury Cause of fall - exclude medical cause: TIA, UTI, MI, arrythmia, electrolyte imbalance etc Other injuries from fall Risk factors for osteoporosis Co-morbidities/medications: ?anaesthetic review pre-op, ?choice of operation ? Gen Med vs. Ortho admission Ortho Geri’s consult

Work up Examination: pain, unable to weight bear, short ER leg, ?delirium Investigations: ECG, FWT, urine MCS Bloods: FBE, UEC, CMP, albumin, ESR, Vit D, Coags, G&H DEXA bone scan

Imaging Pelvis & hip XR ?undisplaced # - gold standard = MRI CT if MRI unavailable Bone scan less useful, changes take up to 1week in elderly Pre-op CXR

Medical management Treat co-morbidities whilst await OT: - electrolyte imbalances - anemia - pneumonia / UTI / infection - arrythmia / MI etc Post-op manage co-morbidities, RFs falls & osteoporosis: consider Vit D, Ca, bisphosphonates

Surgical management Surgical option based on: Displaced vs. undisplaced Age of patient Mobility/independence Bone stock Aim perfect anatomical reduction and rigid fixation

Anti-coagulants Operate if on clopidogrel / aspirin If on warfarin: Vit K / FFP to reduce INR <1.5

Time to surgery Aim: surgery < 24 hours Jain JBJS Am 2002: significant reduction in AVN if fixed <12 hours

Surgical results Best results with healed # in anatomical position without AVN Quality of reduction is best predictor

Undisplaced subcapital # Cannulated screws  used in young 1 x inferior screw, 2x superior screws, ensure threads cross # site, 5mm from surface, inferior screw above LT DHS + derotation screw  used in old, independent walker

Displaced subcapital # Expected life > prosthesis survival (<65): aim to preserve the joint DHS + derotation screw Closed or open anatomical reduction Union rates ↑ with anatomical reduction: accept no varus, <15 valgus, <10 AP plane

DHS technique Set up on traction table Lateral incision: divide fascia lata Ensure 2 guide wires centrally in femoral heard 1. Allows reaming for DHS 2. Derotation screw Screws to attach plate DHS Blade noe being used with osteoporotic bone  ↑ rotational stability

X-rays

Post-operative Mx DHS/Screws/Nail – admit to med ward Surg ward: Hemi/THR/High energy trauma Young patients – PWB Elderly – WBAT to prevent complications Watch for AVN in subcapital #’s (usually 8-12 weeks, but up to 2 years)

Displaced subcapital # Expected life < prosthesis survival (>65) Hemiarthroplasty < 5 year survival Bipolar no better than unipolar, difficult to reduce if Ds No difference cemented vs uncemented outcome measures Cemented hemi: ↑ operative time, blood loss, cement pressurization complications, difficult revision Moore’s if severe comorbidities/non walker – 30% revision at 2 years Gjertsen JBSB 2010 cf ORIF: both 25% mortality, 3 vs. 22% reoperation, more pain, lower QoL with ORIF

Displaced subcapital # Expected life < prosthesis survival (>65) THR 5-15 year survival  young, active, mobile, associated joint disease (RA, OA, etc) better ROM & pain relief vs hemi Higher early Ds rate & early loosening Long term Ds rate equal to hemi

Hemi/THR approach Posterior approach - preserves gluteus medius - observe sciatic n. ? ↓/↑damage - ? ↓ Ds rate with bone anchors Hardinge/anterolateral approach - Trendelenburg gate - Previous data ↓ Ds rate Surgeon preference

Complications Infection Dislocation GT or Femoral shaft # Leg length discrepancy Loosening / pain Revision

Summary Full medical history and work up  think medical admission with ortho consult Time to theatre Surgical choice based on age, # type, mobility, comorbidities High morbidity and mortality