Fracture neck of femur

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Information about Fracture neck of femur

Published on January 3, 2016

Author: drsram

Source: slideshare.net

1. Fracture neck of femur Dr. Shatrughna Ram F.R.C.S., M.Ch. (Ortho), F.I.C.S. Advanced Orthopaedic Centre Patna 800016, INDIA www.drshatrughnaram.com

2. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com Introduction • Relatively common fracture • Increasing incidence due to • High speed of travel • Ageing population and osteoporsis • High Morbidity and mortality • 10% Hospital mortality in elderly • 30% of the elderly die within one year of operation • After one year resume their normal mortality rate 03/01/2016 Fracture neck of femur 2

3. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com Introduction Contd... • 10% surgical non-union, 20% avascular necrosis in fresh displaced fracture fixation • Much higher in old displaced fractures 03/01/2016 Fracture neck of femur 3

4. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com History • Lagenbeck (1850) • First internal fixation • Whitman (1904) • Closed reduction and hip spica • Smith - Peterson (1931) • SP Nail fixation • Richard’s Hip screw (DHS) • Physical pressure causes bone absorption 03/01/2016 Fracture neck of femur 4

5. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com History Contd… • Asnis and other cannulated screws • Osteogenic potency remains poor • Fibular graft alone or with 1Asnis screw (1998) • needs cumbersome of Hip Spica or flaper and prolonged bed rest • Ram & Roshan (2006) • Fibular graft with 2 Asnis screw 03/01/2016 Fracture neck of femur 5

6. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com Type of Fracture of Neck of Femur • Sub capital • Trans cervical • Basal 03/01/2016 Fracture neck of femur 6

7. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com Basal Fracture Neck of Femur • Vascularity • plenty • Non-union • not a problem • Treat like I.T. fracture 03/01/2016 Fracture neck of femur 7

8. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com Displaced Sub-capital & Transcervical Fracture (Gardens III & IV) • Great challenges to Orthopaedic surgeons • Prosthetic replacement • For the elderly • McMurray’s or abduction osteotomy • For the younger • Fibular graft alone • Cumbersome of hip spica or flaper and prolonged bed rest • Fibular graft with 2 cannulated screws • Early return to function 03/01/2016 Fracture neck of femur 8

9. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com Discussion • Great challenges to Orthopaedic surgeons • Unsolved fracture – treatment and results • Results depend upon • Extent of injury – displacement and comminution • Adequacy of the reduction and fixation • Time interval between injury and fixation: < 1day, < 3 days , < 1week, > 1 week 03/01/2016 Fracture neck of femur 9

10. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com Garden’s classification 03/01/2016 Fracture neck of femur 10

11. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com Results of Early Treatment Garden’s classification Non-surgical Surgical (ORIF) Non-union Non-union AVN Grade I 10% 0% 0% Grade II 50% 5% 10% Grade III 100% 10% 20%Grade IV 03/01/2016 Fracture neck of femur 11

12. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com Causes of Non-union • Poor circulation • Synovial fluid bathing the fracture • Absence of Periosteum • all healing is endosteal • Temponad 03/01/2016 Fracture neck of femur 12

13. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com Blood Circulation  Extra capsular arterial ring  Ascending cervical branches  Arteries of the Ligamentum teres  The poor blood supply further deteriorates with trauma and temponad 03/01/2016 Fracture neck of femur 13

14. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com Blood Circulation Contd…  03/01/2016 Fracture neck of femur 14

15. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com Treatment for Fresh Fracture Neck of Femur Garden’s type 1 & 2 03/01/2016 Fracture neck of femur 15

16. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com Treatment for Fresh Fracture Neck of Femur Contd… Garden’s type 3 & 4 03/01/2016 Fracture neck of femur 16

17. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com Encouraged with better results of late treatment in neglected femoral neck fracture in young adults • Baksi • ORIF + muscle pedicli graft - 100% union • Nagi et al • ORIF + Fibular graft - 100% union • Ram et al • ORIF + 2 Cannulated Screws & Fibular Graft - 91% union • Clinical orthopedics 2006, No. 447 03/01/2016 Fracture neck of femur 17

18. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com 03/01/2016 Fracture neck of femur 18

19. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com Treatment for Fresh Fracture Neck of Femur Contd… • Strut free fibular graft with 2 cannulated screws Garden’s type 3 & 4 03/01/2016 Fracture neck of femur 19

20. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com Method • Fracture reduced accurately on a traction table – closed or open • 3 guide wires placed and reamed • Whole fibular graft fixed in the centre • 2 Asnis screws: 1 above and 1 below • Radiological control: Image intensifier • No plaster • Walking in 3-5 days with crutches • Partial weight to full weight bearing in 8 -20 wk 03/01/2016 Fracture neck of femur 20

21. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com Advantages of Free Fibular Graft • Easy to take and apply • Practically no morbidity at donor site • No cumbersome of hip spica or flaper • Early mobilization • Better fracture union rate (? 95%) 03/01/2016 Fracture neck of femur 21

22. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com Treatment for Old Fracture Neck of Femur Contd... 03/01/2016 Fracture neck of femur 22

23. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com Treatment for Old Fracture Neck of Femur Contd... 03/01/2016 Fracture neck of femur 23

24. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com Treatment for Old Fracture Neck of Femur Contd... 03/01/2016 Fracture neck of femur 24

25. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com Treatment for Old Fracture Neck of Femur Contd... 03/01/2016 Fracture neck of femur 25

26. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com Treatment for Old Fracture Neck of Femur Contd... 03/01/2016 Fracture neck of femur 26

27. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com Treatment for Old Fracture Neck of Femur Contd... 03/01/2016 Fracture neck of femur 27

28. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com Treatment for Old Fracture Neck of Femur Contd... 03/01/2016 Fracture neck of femur 28

29. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com Treatment for Old Fracture Neck of Femur Contd... 03/01/2016 Fracture neck of femur 29

30. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com Treatment for Old Fracture Neck of Femur Contd... 03/01/2016 Fracture neck of femur 30

31. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com Treatment for Old Fracture Neck of Femur Contd... 03/01/2016 Fracture neck of femur 31

32. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com Treatment for Old Fracture Neck of Femur Contd... 03/01/2016 Fracture neck of femur 32

33. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com Conclusion • Adequate reduction and fixation of displaced femoral neck fracture with free fibular graft and 2 cannulated screws gives a high union rate ( ? 95%). • It eliminates the burden of hip spica, flaper or bed rest and prolonged physiotherapy. 03/01/2016 Fracture neck of femur 33

34. Dr Shatrughna Ram - FRCS, Mch (Ortho), FICS - Orthopedic Surgeon in Patna, Bihar, India – www.drshatrughnaram.com Thank you!

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