Femoral Neck Fracture

Case report
Case report
• Chief complaint: pain on the right leg
Patients come by family to Royal Prima Hospital with complaints of
right leg pain. When previously the patient fell due to slipping in the
bathroom on Wednesday 11/07/18. Besides that, the patient also
complains that she can't move her right foot. When the incident occurs
the patient does not experience nausea and vomiting (-), convulsions
(-), fainting (-), urinary and bowel function are in normal limit There are
no previous disease history nor drug usage history
Physical Examination
• VITAL SIGN
• General Conditions: Looks like
being sick
• Sensorium / GCS: CM / 15
• Blood pressure: 120/70 mmHg
• Pulse: 90 x / i
• Respiration: 20 x / i
• Temperature: 37 c
• GENERAL STATUS
• Head: Normocephali
• Eyes: Pupils: Isokor (+ / +) Sclera:
Ikterik (- / -) Conjunctiva: Anemis
(- / -) Light reflex: (+ / +)
• Ears: Normal form, edema (-)
• Nose: Normal form, edema (-),
hyperemia (-), septum deviation (-)
• Mouth: Normal form, cyanosis (-)
• Neck: limfadenopathy (-)
Physical Examination
Thorax (Lungs): Abdomen
• Inspection: symmetrical, lesion (-) • Inspection: symmetrical
• Palpation: fremitus left = right • Auscultation: normal peristalsis
• Percussion: relative & absolute lung border in • Palpation: tenderness (-)
normal impression • Percussion: deaf
• Auscultation: vesicular
Genitalia: no examination
Heart
• Inspection: ictus cordis is not visible
Extremities
• Palpation: ictus cordis palpable • Superior: warm acral, edema (-)
• Percussion: normal heart limit • Inferior: Pitting edema (-)
• Auscultation: Gallop (-)
• Murmur (-)
Physical Examination
• Local Status: Regio femur dextra

• Look
The facial expression is painful, there is no abnormal protrusion, deformity (-), slight
edema (+),

• Feel
Tenderness (+), crepitus (-), warm palpitations (+)

• Move
Active and passive movement of hip joint can’tbe evaluated due to pain
Active and passive movement of knee joint are in normal limit
Laboratory examination
No. Subject Result unit Normal

1 Hemoglobin 12.8 Mg/dl 13.5-15.5

2 Leukosit 7820 /mm3 5.000-11.000

3 Laju Endap Darah - Mm/jam 0-20

4 Trombosit 262000 /mm3 150.000-450.000

5 Hematocrit 36.1 % 30.5-45.0

6 Eritrosit 3.88 106/mm3 4.50-6.50

7 MCV 93.1 Fl 75.0-95.0

8 MCH 33 Pg 27.0-31.0

9 MCHC 35.5 g/dl 33.0-37.0

10 RDW 12.5 % 11.50-14.50

11 PDW 43.1 fL 12.0-53.0

 Normal value
no Subject Result Unit

13 PCT 0.23 % 0.100-0.500

14 Eosinofil 2.6 % 1-3

15 Basofil 0.2 % 0-1

16 Monosit 8.6 % 2-8

17 Neutrofil 67.4 % 50-70

18 Limfosit 19.1 % 20-40

19 LUC 2.1 % 0-4

20 Glukosa et random 123 Mg/dl <200

21 Bleeding time 3’ Minutes 1-5

22 Clothing time 8’ Minutes 5-15

radiologyxamination
Diagnose
Closed fracture neck of femur
Treatment
• Open reduction and internal fixation
Discussion
Femoral region anatomy
Ventral Femoral Muscles
• M. Illiopsoas
• M. Quadriceps Femoris
• M. Sartorius
• M. Pectineus
• M. Adductor Longus
• M. Adductor Brevis
• M. Adductor Magnus
• M. Gracilis
• M. Obturator Externus
Femoral
Triangle
• Triangular space at the superomedial 1/3 of
ventral femoral region

• Bordered by: inguinal ligament, adductor

longus m. and sartorius m.

• Contain:

• Femoral artery

• Femoral vein

• Femoral nerve

• Cut. Fem. Lateralis nerve

Dorsal Femoral Muscles
• M. Biceps Femoris

• M. Semitendinosus

• M. Semimembranosus
Femoral Artery
• - Superficial epigastric a.

• - Superficial iliac circumflex a.

• - External pudendal a.

• - Profunda femoris a.

• :: Medial circumflex femoral

• :: Lateral circumflex femoral

• :: Perforators

• - Descending genicular a.
Hip joint arteries
Hip joint anatomy
Definition
Proximal femur fracture is classified as fracture 31-
• 31-A inter trochanteric fracture
• 31-B femoral neck fracture
• 31-C femoral head fracture
Risk Factor
• Anatomical Factors
• The structure of the head and neck of femur os developed for the
transmission of body weight efficiently, with minimum bone mass, by
appropriate distribution of the bone trabeculae in the neck.
• The tension trabeculae and compression trabeculae along with the strong
calcar demorale on the medial cortex of the neck of femur form an efficient
system to withstand load bearing and torsion under normal stresses of weight
bearing.
• Women > Men
• Post menopausal
Etiology
• Elder 7th/8th decade
• RTA
• Direct trauma onto greater trochanter
• Fall from height
• Trauma directly
• Osteomalacia
• Diabetes
• Stroke
• Alcoholism
• Chronic debilitating disease
Mechanism of Injury
• Low Energy Trauma (most common in older patients)
• Direct : Fall onto greater trochanter or forced external rotation of the lower
extremity impinges an osteoporotic neck onto the posterior lip of the
acetabulum (resulting in posterior comminution)
• Indirect: Muscle forces overwhelm the strength of the femoral neck
• High-energy trauma
• Accounts for femoral neck fractures in both younger and older patients, such
as motor vehicle accident or fall from a significant height.
• Cyclial loading-stress fractures
• These are seen in athelets, military recruits, ballet dancers.
Classification
Sign & symptom
Presentation
• Symptoms
 impacted and stress fractures
slight pain in the groin or pain referred along the medial
side of the thigh and knee
 displaced fractures
pain in the entire hip region
Physical examination
• Physical exam
 impacted and stress fractures
-no obvious clinical deformity
-minor discomfort with active or passive hip range of motion,
muscle spasms at extremes of motion
- pain with percussion over greater trochanter

 displaced fractures
-eg in external rotation and abduction, with shortening
Imaging
Radiographs
recommended views
-obtain AP pelvis and cross-table lateral, and full length femur film of
ipsilateral side
- consider obtaining dedicated imaging of uninjured hip to use as
template intraop
- traction-internal rotation AP hip is best for defining fracture type
- Garden classification is based on AP pelvis
• CT-Scan
helpful in determining displacement and degree of comminution in
some patients
Imaging
• MRI
- helpful to rule out occult fracture
- not helpful in reliably assessing viability of femoral head after fracture
• Bone scan
- helpful to rule out occult fracture
- not helpful in reliably assessing viability of femoral head after fracture
• Duplex Scanning
- indication : rule out DVT if delayed presentation to hospital after hip
fracture
Treatment
- Nonoperative
observation alone. Indications : may be considered in some patients who are non
ambulators, have minimal pain and who are at risk for surgical intervention.

- operative
• ORIF
Indications : displaced fractures in young or physiologically young patients,
and ORIF indicated for most patients < 65 years old.
• Cannulated screw fixation
Indications : nondispalaced transcervical fracture, and Garden I and II
fracture patterns in the physiologically elderly.
• Sliding hip screw
Indications : basicervical fracture, vertical fracture
pattern in young patient.
• Hemiarthroplasty
Indications : Controversial, debilitated elderly
patients, and metabolic bone disease.
• Total Hip Arthroplasty
Indications : Controversial, older active patients,
arthroplasty for garden III and IV in patient < 85 years
old, and patients with preexisting hip osteoarthritis (
more predictable pain relief and better fuctional
outcome than hemiarthroplasty).