FRACTURES OF THE FEMUR

DR. CODRIN HUSZAR University Hospital Bucharest

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FEMORAL NECK FRACTURES

Fractures of the femur

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Epidemiology

250,000 Hip fractures annually (U.S.A.)

• Expected to double by 2050
medications, malnutrition

At risk populations • Elderly: poor balance&vision, osteoporosis, inactivity,

• • •

• incidence doubles with each decade beyond age 50

higher in white population Other factors: smokers, small body size, excessive caffeine Young: high energy trauma

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APPLIED ANATOMY

  

Physeal closure age 16 Neck-shaft angle ~ 135° Anteversion ~15°

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APPLIED ANATOMY

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APPLIED ANATOMY

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CLASSIFICATION – Garden (1961) Type I
Valgus impacted or incomplete

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CLASSIFICATION – Garden (1961) Type II
Complete Non-displaced

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CLASSIFICATION – Garden (1961) Type III
Complete Partial displacement

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CLASSIFICATION – Garden (1961) Type IV
Complete Full displacement

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CLASSIFICATION – Pauwels (1931)

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Functional Classification

• Stable •Impacted (Garden I) •Non-displaced (Garden II) • Unstable •Displaced (Garden III and IV)
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DISPLACEMENT

Shortening Adduction External rotation Fractures of the femur
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COMPLICATIONS

IMMEDIATE

EARLY

LATE

GENERAL shock

LOCAL
DVT infection

GENERAL
Pressure sores Urinary / respiratory infections

LOCAL
AVN NonU

Fixation failure
Artritis Joint stiff.

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Treatment

Goals

• Improve outcome over natural history • Minimize risks and avoid complications • Return to pre-injury level of function • Provide cost-effective treatment

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Treatment

OPTIONS : • Operative •IF •Hemiarthroplasty •Total Hip Replacement • Non-operative •very limited role
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Treatment Decision Making Variables

Patient Characteristics

• •

Young (arbitrary physiologic age < 65)

• High energy injuries

• High Pauwels Angle (vertical shear pattern)
Elderly

Often multi-trauma

• Lower energy injury • Comorbidities • Pre-existing hip disease

Fracture Characteristics

• •

Stable Unstable
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Treatment Young Patients
(Arbitrary physiologic age < 65)

• Non-displaced fractures

• Displaced fractures

• At risk for secondary displacement • Urgent IF recommended • Patients native femoral head best • AVN related to duration and degree of displacement • Irreversible cell death after 6-12 hours • Emergent CRIF recommended
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Treatment Elderly Patients

Operative vs. Non-operative

Displaced fractures

• Unacceptable rates of mortality, morbidity, and poor
outcome with non-operative treatment [Koval 1994]

Non-displaced fractures

• Standard of care is operative for all
femoral neck fractures

• Unpredictable risk of secondary displacement

• Non-operative tx may have developing role in select
patients with impacted/ non-displaced fractures [Raaymakers 2001]

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Treatment Pre-operative Considerations

Surgical Timing

• Surgical delay for medical clearance in
relatively healthy patients probably not warranted

• Surgical delay up to 72 hours for medical

• Increased mortality, complications, length of stay

stabilization warranted in unhealthy patients

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Non-displaced Fractures

INTERNAL FIXATION - standard of care • Predictable healing

• Minimal complications • Relatively quick procedure • Early mobilization
• Minimal blood loss
• Partial / unrestricted weight bearing
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• Nonunion < 5% • AVN < 8% • Infection < 5%

Displaced Fractures Hemiarthroplasty vs. IF

IF :  Complications

• Nonunion 10 -33% • AVN 15 – 33% • Loss of reduction / fixation failure 16%

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Displaced Fractures Hemiarthroplasty vs. IF

Hemi associated with

• Lower reoperation rate (6-18% vs. 20-36%) • Improved functional scores • Less pain • More cost-effective • Slightly increased short term mortality

Literature supports hemiarthroplasty for displaced fractures [Lu-yao JBJS 1994]

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Arhroplasty

Hemiarthroplasty unipolar / bipolar cemented / uncemented
Total arthroplasty (degenerative changes affecting the acetabulum)
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Thompson

Moore

Hemiarthroplasty (unipolar)
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Total arthroplasty

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Total arthroplasty

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TROCHANTERIC FRACTURES

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Incidence

250,000 Hip Fractures a Year (U.S.A.)

Double by 2040 to 500,000
50% are Intertrochanteric Fractures

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Demographics

90% >65y/o F>M

Peak @ 80y/o

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Etiology

Osteoporosis
Low energy fall

• Common
• Rare

High Energy

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Femoral trochanteric area :

• •

Extra-capsular femoral neck 2.5 cm below the inferior border of the lesser trochanter

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Classification – Stability

Posteromedial cortex Cominution

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Pertrohanteric fracture

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Extracapsular femoral neck base fracture

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Comminuted pertrochanteric fracture

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Intertrochanteric fracture (reverse obliquity fracture)

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Trochantero – diaphyseal fractures

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Subtrochanteric fracture

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EVANS Classification

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COMPLICATIONS

IMMEDIAT E GENERAL shock

EARLY
LOCAL DVT infection GENERAL
Pressure sores Urinary / respiratory infections

LATE
LOCAL Malunion NonUnion Fixation failure
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Fractures of the femur

Goals of Treatment

Obtain Reduction
Good position Internal Fixation Mechanically Adequate Permit Immediate Transfers & Early Ambulation
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ORIF : Sliding Hip Screw + Side Plate (DHS)

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CRIF : Intramedullary Sliding Hip Screw

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Introduction du clou et forage du col

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Fractures of the femur

Photos J. Chouteau

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Fractures of the femur

Photos J. Chouteau

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ENDER elastic nails

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DIAPHYSEAL FRACTURES
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Demographics. Etiology

Common injury due to major violent trauma

(elderly : simple falls)
  

1 femur fracture/ 10,000 people (U.S.A.) More common in young people Motor vehicle, motorcycle, auto-pedestrian, aircraft, and gunshot wound accidents are most

frequent causes
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Complications

! High energy trauma :
Haemoragic shock (1 – 1.5L) Associated fractures Politrauma

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COMPLICATIONS

IMMEDIATE
GENERAL
SHOCK FAT EMBOLISM

EARLY
LOCAL
DVT INFECTION U / R TRACT INFECTIONS

LATE
LOCAL
DELAYED / NONUNION MALUNION FIXATION FAILURE JOINT STIFFNES OSTEITIS

LOCAL
OPEN
FRACTURE

GENERAL
PRESSURE SORES

NEURO-VASC
INJURIES

MUSC.
INTERPOSITION

PE

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Femur Fracture Management

 

Initial traction with portable traction splint or transosseous pin and balanced suspension Shock treatment / Politrauma care Timing of surgery is dependent on:

• Resuscitation of patient • Other injuries - abdomen, chest, brain • Isolated femur fracture
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Femur Fracture Management

Antegrade nailing is still the gold standard

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La mise en place d’un clou nécessite un alésage de la cavité médullaire toujours rétrécie au tiers moyen Fractures of the femur

Reaming

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Locking

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Blood Supply

Reaming / nail insertion destroys intramedullary endosteal blood supply Periosteal blood flow increases Medullary blood supply is re-established over 8-12 weeks if spaces left in canal by implant Unreamed intramedullary nailing decreases blood flow less; restoration of endosteal blood flow earlier but equal to reamed canal at 12 weeks
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 

Femur Fracture Reaming

Reaming of the femoral shaft fracture

• Multiple studies demonstrate that the thoracic
injury is the major determinant of pulmonary complications, NOT the use of a reamed IM nail

• Charash J Trauma 1994 • Van Os J Trauma 1994 • Ziran J Trauma 1997 • Bone Clin Orthop 1998 • Bosse JBJS 79A 1997

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External fixation

Open fractures Vascular injuries

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