1. Neck of Femur Fractures
Wayne Hoskins

2. 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

3. Anatomy

4. Fracture location

5. 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

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

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

9. Shenton’s Line

10. 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 #

11. 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

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

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

14. 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

15. 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

16. 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

17. 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

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

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

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

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

22. 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

23. 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

24. 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

25. X-rays

26. 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)

27. 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

28. 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

29. 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

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

31. 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