Makindo Medical Notes

Related Subjects: |Fractured Neck of Femur |Fractured Shaft Femur |Supracondylar Femur Fractures |Femoral fractures and Injuries

Intracapsular fractures have a higher incidence of AVN (Avascular Necrosis) and non-union due to the femoral head blood supply. If displacement is minimal, internal fixation gives the best outcome. In displaced fractures, there is a high risk of AVN, so the head is excised, and a prosthesis is inserted.

About

• Intracapsular fractures are at risk of AVN (Avascular Necrosis).
• 30% of patients will die within 1 year.
• Fractures are most commonly seen in the elderly.
• Most fractures are due to instability and osteoporotic bone.
• Patients often have multiple co-morbidities.

Epidemiology

• 80,000 hip fractures per year in the UK.
• Increasing number as the population ages.

Anatomy

Aetiology

• Falls and Osteoporosis.
• The medial femoral circumflex artery is at high risk of compromise in neck of femur fractures (NOF#).
• A femoral neck fracture can compromise the flow in this artery due to its close proximity to the femoral neck, leading to ischaemia and subsequent avascular necrosis (AVN).

Risk Factors for Bone Fragility

• Osteoporosis: Age, inactivity, smoking, excessive alcohol intake, low BMI (<18.5), heredity.
• Previous osteoporotic fractures double the risk of future fractures.
• Other Conditions: Metastases, Paget's disease, osteomalacia, hyperparathyroidism, myeloma.

Risk Factors for Falls

• Muscle weakness, abnormalities of gait or balance.
• Neurological diseases (e.g., Parkinson's disease, stroke).
• Poor visual acuity.
• Drug therapy: sedatives, hypnotics, diuretics, antihypertensives, alcohol, sedation.

Clinical Features

• Pain and external rotation, adduction, and shortening of the affected leg.
• Check history—simple explained fall or medical causes.
• Exclude presyncope/syncope by assessing for postural hypotension or cardiac arrhythmia.
• Identify co-morbidities that may influence patient management.

Types of Fracture (in relation to the joint capsule)

• Intracapsular Fractures: There is a risk of non-union and AVN. Treatment is often hemiarthroplasty, though some cases may benefit from total hip replacement (THR).
• Subcapital and Transcervical Fractures: Common types of intracapsular fractures.

Garden Classification System (Intracapsular Fractures)

• Type I: Incomplete fracture.
• Type II: Complete fracture (across the femoral neck), undisplaced.
• Type III: Complete fracture, partially displaced.
• Type IV: Complete fracture, fully displaced.

Extracapsular Fractures

• Trochanteric fractures.
• Transtrochanteric fractures.
• Subtrochanteric fractures.

Other Fractures

• Fractures of the pubic ramus (managed conservatively).
• Fractures of the acetabulum (managed conservatively).

Investigations

• Full Blood Count (FBC), clotting profile, Urea & Electrolytes (U&E), Chest X-Ray (CXR), Electrocardiogram (ECG), crossmatch 2 units, consent for surgery.
• AP Pelvis: Plain X-ray to compare both hips and assess for other fractures (e.g., pubic rami).
• Lateral X-ray of the Hip: Essential as not all fractures show on AP views.
• CT/MRI Scan: If X-rays are inconclusive or anatomy is unclear (10% may have X-ray negative fractures).

Prevention

• Multidisciplinary health/environment risk factor screening and interventions.
• Muscle strengthening and balance retraining programs (e.g., Tai Chi group exercises).
• Bisphosphonates can increase bone density and reduce the incidence of fractures.
• Calcium and vitamin D supplementation, and hormone replacement therapy reduce fracture risk.

The 30-day in-hospital mortality rate is about 10%, and the 12-month mortality rate is around 30%, largely reflecting co-morbidities.

Treatment Options

• Conservative Therapy: Reserved for patients who are not fit for surgery due to medical conditions or extreme frailty. Involves bed rest, pain management, and physiotherapy, though outcomes are generally poor.
• Surgical Therapy: Surgery is the gold standard for treating fractured neck of femur, aiming to restore function, reduce complications, and improve quality of life.
  • Internal Fixation:
    • Undisplaced intracapsular fractures can be treated with internal fixation using cannulated hip screws or sliding hip screws (dynamic hip screws).
    • Young patients with displaced fractures may also undergo fixation to preserve the femoral head.
  • Hemiarthroplasty:
    • For displaced intracapsular fractures in older patients, the femoral head is replaced with a prosthesis. This option allows for faster recovery and reduced pain compared to internal fixation in this population.
  • Total Hip Replacement (THR):
    • Indicated for active, independent elderly patients or younger patients with displaced intracapsular fractures. THR replaces both the femoral head and acetabulum, offering better long-term function but with higher surgical risks.
  • Intramedullary Nailing:
    • For extracapsular and subtrochanteric fractures, intramedullary nailing is commonly used. It involves inserting a metal rod into the medullary cavity of the femur to stabilize the bone and allow for early mobilization.
  • Dynamic Hip Screw (DHS):
    • Used for intertrochanteric fractures, the dynamic hip screw allows controlled collapse and healing of the fracture site.

Management

• ABC Approach: Ensure Airway, Breathing, and Circulation.
• Analgesia: Provide effective pain relief.
• IV Fluids: Maintain hydration and electrolyte balance.
• Early Involvement of Orthogeriatrics Team: For comprehensive patient management.
• Fascia Iliaca Compartment Block: For pain relief.
• If the patient cannot walk, they require admission for further evaluation, and if there is doubt, an MRI or CT scan may be needed to confirm or rule out an occult fracture.
• Address hydration, nutrition, pain management, and pressure sore risk.
• Assess mental state (depression, delirium, dementia) and coexisting medical issues.
• Surgery:
  • Intracapsular Fractures: Undisplaced fractures can be treated with cannulated hip screws. Displaced fractures usually require (hemi)arthroplasty or THR in medically fit, mobile patients.
  • Extracapsular Fractures: Cannulated hip screws or other fixation methods depending on the fracture type.
• VTE Prophylaxis: Start at admission (e.g., anti-embolism stockings, Low Molecular Weight Heparin (LMWH), Direct Oral Anticoagulants (DOACs)) and continue until the patient regains mobility.

Post-Surgical Care and Rehabilitation

• Early mobilization with physical therapy to restore function and prevent complications such as deep vein thrombosis (DVT).
• Pain management and infection control post-surgery are critical.
• Regular follow-up for monitoring complications, including surgical site infection, non-union, and prosthesis dislocation.
• Rehabilitation programs focus on strength, balance, and gait training to reduce the risk of future falls and fractures.

Complications

• Avascular Necrosis (AVN): Particularly in intracapsular fractures, where blood supply to the femoral head may be compromised.
• Nonunion: Failure of the bone to heal, especially in displaced fractures or poor fixation.
• Osteoarthritis: Degenerative changes can develop after fracture healing.
• Deep Vein Thrombosis (DVT): Due to immobilization, DVT prophylaxis is essential.
• Post-Surgical Infection: Particularly in prosthetic surgeries such as hemiarthroplasty or THR.

Prognosis

• Outcomes depend on age, overall health, and promptness of treatment.
• Approximately 30% of patients die within a year, largely due to pre-existing comorbidities rather than the fracture itself.
• Timely surgical intervention and effective rehabilitation can improve long-term outcomes and mobility.

Conclusion

Fractured neck of femur/femoral neck is a significant orthopedic emergency, particularly prevalent in the elderly population due to factors like osteoporosis and falls. Intracapsular fractures carry a high risk of avascular necrosis and non-union, necessitating prompt and appropriate management. Treatment options range from conservative therapy in unfit patients to various surgical interventions aimed at restoring function and reducing complications. Comprehensive post-surgical care and rehabilitation are essential for optimal recovery and prevention of future fractures. Early detection, timely intervention, and multidisciplinary care play crucial roles in improving patient outcomes and quality of life.

References

• Royal College of Physicians. Fractured Neck of Femur. Available at: https://www.rcplondon.ac.uk
• National Institute for Health and Care Excellence (NICE). Hip Fractures: The Management of Patients with Hip Fractures. Available at: https://www.nice.org.uk
• Mayo Clinic. Hip Fracture. Available at: https://www.mayoclinic.org
• UpToDate. Fractured Neck of Femur: Overview. Available at: https://www.uptodate.com
• British Orthopaedic Association. Management of Hip Fractures. Available at: https://www.boa.ac.uk
• Harrington, M., & Griffin, R. (2015). Fractured Neck of Femur. In Orthopaedic Surgery. Springer.