1. Femoral neck fractures
Re-written by: Daniel Habashi

2. Anatomy Physeal closure at the age of 16
Neck-shaft angle 130 ° +/- 7 ° .
Anteversion 10 degr +/- 7 degr
Calcar femorale
Posteromedial
Dense plate of bone

3. Blood Supply
Greater fracture displacement = greater risk of vascular disruption to femoral head
Revascularization of the head
Intact vessels
Vascular ingrowths across the fracture site

4. Epidemiology
250 thousand hip fractures annually

5. Classification Pauwels Type 1 = 30 ° Type 2 = 50 ° Type 3 = 70 °
Angle describes vertical shear vector
Type 1 = 30 °
Type 2 = 50 °
Type 3 = 70 °

6. Classification Garden (1961) I II III IV complete full displacement
Valgus impacted or incomplete II
Complete non displaced
III
Complete partial displacement
IV complete full displacement
** portends risk of AVN and nonunion

7. Classification Functional classification Stable Unstable
Impacted Garden I
Non-displaced Garden II
Unstable
Displaced Garden III and IV

8. Treatment Non-Operative Very limited role Activity modification
Skeletal traction
Operative
ORIF
Hemiarthroplasty
Total hip replacement

9. Decision making variables
Patient characteristics
Young (under 65)
High energy injuries
Often multi-trauma
High Pauwels angle (vertical shear pattern)
Elderly
Lower energy injury
Comorbidities
Pre-existing hip disease
Fracture characteristics
Stable
Unstable

10. Young patients Non-displaced fractures Displaced fractures
At risk for secondary displacement
Urgent ORIF recommended  OPEN REDUCTION INTERNAL FIXATION
Displaced fractures
Patients native femoral head best
AVN related to duration and degree of displacement
Irreversible cell death after 6-12 hours
Emergent ORIF recommended

11. Pre-operative considerations
Regional vs general anesthesia
Mortality / long term outcome
No difference

12. Pre-operative considerations
Surgical timing
Surgical delay for medical clearance in relatively healthy patients probably not warranted
Increased mortality, complications, length of stay
Surgical delay up to 72 hours for medical stabilization warranted in unhealthy patients

13. Non-displaced fractures
ORIF – standard of care
Predictable healing
Nonunion under 5%
Minimal complications
AVN under 8%
Infection under 5%
Relatively quick procedure
Minimal blood loss
Early mobilization
Unrestricted weight bearing with assistive device PRN

14. Approach for open reduction
SMITH-PETERSON
Anterior approach
Best for transcervical

15. Sliding compression screw fixation
Compression hip screws
Sacrifices large amount of bone
May injure blood supply
Biomechanically superior in cadavers
Anti-rotation screw often needed
Increased cost and operative time
No clinical advantage over parallel screws
May have role in high energy / vertical shear fractures

16. Hemiarthroplasty Unipolar vs. Bipolar
Bipolar theoretical advantages
Lower dislocation rate
Less acetabular wear / protrusio
Less pain
More motion

17. Hemiarthroplasty cemented vs. non-cemented
Cement (PMMA)
Improved mobility, function, walking aids
Most studies show no difference in morbidity / mortality
Sudden intra-op cardiac death risk slightly increased:

18. Cemented vs. non-cemented
Conclusion
Cement gives better results
Function
Mobility
Implant stability
Pain
Cost-effective
Low risk of sudden cardiac death
Use cement with caution

19. Pre-operative considerations
Surgical approach
Posterior approach to hip
60% higher short-term mortality vs. anterior
Dislocation rate
No significant difference

20. ORIF or Replacement
Prospective, randomized study ORIF vs. cemented bipolar hemi vs. THA
Ambulatory patients > 60 years of age

21. Stress Fractures
Patient population
Females 4-10 times more likely

22. Stress fractures Clinical presentation Activity weight bearing related
Anterior groin pain
Limited ROM at extremes
+/- antalgic gait
Must evaluate back, knee, contralateral hip

23. Stress fractures Imaging Plain radiographs are negative in up to 66%
Bone scan
Sensitivity %
Specificity 76-95%
MRI 100% sensitive / specific
Also differentiates synovitis, etc

24. Stress fractures - complications
Tension sided and compression sided fx’s over 50% treated non-operatively
Varus malunion

25. Femoral neck nonunion
Definition: not healed by one year
0-5%

26. And then he just finished it and that’s it….