Femoral Neck Fractures

Brian Boyer, MD

Anatomy
Physeal closure age 16 Neck-shaft angle 130 7 Anteversion 10 7 Calcar Femorale
Posteromedial dense plate of bone

Blood Supply
Lateral epiphysel artery
terminal branch MFC artery predominant blood supply to weight bearing dome of head

Artery of ligamentum teres

from obturator artery supplies anteroinferior head

Lateral femoral circumflex a.

less contribution than MFC

Blood Supply
fracture displacement=vascular disruption revascularization of the head
intact vessels vascular ingrowth across fracture site
importance of quality of reduction

metaphyseal vessels

Epidemiology
250,000 Hip fractures annually
Expected to double by 2050

At risk populations
Elderly: poor balance&vision, osteoporosis, inactivity, medications, malnutrition
incidence doubles with each decade beyond age 50

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

Classification
Pauwels [1935]
Angle describes vertical shear vector

Classification
Garden [1961]
I Valgus impacted or incomplete II Complete Non-displaced III Complete Partial displacement IV Complete Full displacement ** Portends risk of AVN and Nonunion I II

III

IV

Classification
Functional Classification
Stable
Impacted Non-displaced (Garden I) (Garden II) (Garden III and IV)

Unstable
Displaced

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

Treatment
Options
Non-operative
very limited role Activity modification Skeletal traction

Operative
ORIF Hemiarthroplasty Total Hip Replacement

Treatment Decision Making Variables

Patient Characteristics
Young (arbitrary physiologic age < 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

Treatment Young Patients

(Arbitrary physiologic age < 65)

Non-displaced fractures
At risk for secondary displacement Urgent ORIF recommended

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

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
Unpredictable risk of secondary displacement
AVN rate 2X

Standard of care is operative for all femoral neck fractures

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

Treatment Pre-operative Considerations

Skin Traction not beneficial
No effect on fracture reduction No difference in analgesic use Pressure sore/ skin problems Increased cost Traction position decreases capsular volume
Potential detrimental effect on blood flow

Treatment Pre-operative Considerations

Regional vs. General Anesthesia
Mortality / long term outcome
No Difference

Regional
Lower DVT, PE, pneumonia, resp depression, and transfusion rates

Further investigation required for definitive answer

Treatment 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

Hemi

ORIF
THR

Non-displaced Fractures
ORIF standard of care
Predictable healing
Nonunion < 5%

Minimal complications
AVN < 8% Infection < 5%

Relatively quick procedure

Minimal blood loss

Early mobilization
Unrestricted weight bearing with assistive device PRN

ORIF
Ideal reduction is Anatomic
Acceptable: < 15 valgus < 10 AP angulation
* may need to open in order achieve reduction

Fixation: Multiple screws in parallel

No advantage to > 3 screws Uniform compression across fracture In-situ pin impacted fractures
* AVN with disimpaction [Crawford 1960]

Fixation most dependent on bone density

ORIF
Screw location
Avoid posterior/ superior quadrant
Blood supply Cut-out

Biomechanical advantage to inferior/ calcar screw

[Booth 1998]

ORIF
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

ORIF Intracapsular Hematoma

incidence- 75% have some
no difference displaced/nondisplaced

? Amount of > 100 mm in 25% sensitive to leg position

extension + internal rotation= bad

animal models: pressure= perfusion Theoretical benefit with NO clinical proof

but it doesnt hurt

Displaced Fractures Hemiarthroplasty vs. ORIF

ORIF is an option in elderly
** Surgical emergency in young patients **

Complications
Nonunion 10 -33% AVN 15 33%
AVN related to displacement Early ORIF no benefit

Loss of reduction / fixation failure 16%

Displaced Fractures Hemiarthroplasty vs. ORIF

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]

[Iorio CORR 2001]

Hemiarthroplasty Unipolar vs. Bipolar

Bipolar theoretical advantages
Lower dislocation rate Less acetabular wear/ protrusio Less Pain More motion

Hemiarthroplasty Unipolar vs. Bipolar

Bipolar
Disadvantages
Cost Dislocation often requires open reduction Loss of motion interface (effectively unipolar) Polyethylene wear/ osteolysis not yet studied for Bipolars

Hemiarthroplasty Unipolar vs. Bipolar

Complications / Mortality / Length of stay
No Difference

Hip Scores / Functional Outcomes

No significant difference Bipolar slightly better walking speeds, motion, pain

Revision rates
Unipolar 20% vs. Bipolar 10% (7 years)

Unipolar more cost-effective

Literature supports use of either implant

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:
1% cemented hemi for fx vs. 0.015% for elective arthroplasty

Non-cemented (Press-fit)
Pain / Loosening higher Intra-op fracture (theoretical)

Hemiarthroplasty 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

Treatment Pre-operative Considerations

Surgical Approach
Posterior approach to hip
60% higher short-term mortality vs. anterior

Dislocation rate
No significant difference
[Lu-Yao JBJS 1994]

Total Hip Replacement

Dislocation rates:
Hemi 2-3% vs. THR 11% (short term)
2.5% THR recurrent dislocation [Cabanela Orthop 1999]

Reoperation:
THR 4% vs. Hemi 6-18%

DVT / PE / Mortality
no difference

Pain / Function / Survivorship / Cost-effectiveness

THR better than Hemi [Lu Yao JBJS 1994] [Iorio CORR 2001]

Keating et al OTA 2002

ORIF or Replacement?
Prospective, randomized study ORIF vs. cemented bipolar hemi vs. THA ambulatory patients > 60 years of age
37% fixation failure (AVN/nonunion) similar dislocation rate hemi vs. THA (3%) ORIF 8X more likely to require revision surgery than hemi and 5X more likely than THA THA group best functional outcome

Stress Fractures
Patient population:
Females 410 times more common
Amenorrhea / eating disorders common Femoral BMD average 10% less than control subjects

Hormone deficiency Recent increase in athletic activity

Frequency, intensity, or duration Distance runners most common

Stress Fractures
Clinical Presentation
Activity / weight bearing related Anterior groin pain Limited ROM at extremes Antalgic gait Must evaluate back, knee, contralateral hip

Stress Fractures
Imaging
Plain Radiographs
Negative in up to 66%

Bone Scan
Sensitivity 93-100% Specificity 76-95%

MRI
100% sensitivity / specificity Also Differentiates: synovitis, tendon/ muscle injuries, neoplasm, AVN, transient osteoporosis of hip

Stress Fractures
Classification
Compression sided
Callus / fracture at inferior aspect femoral neck

Tension sided
Callus / fracture at superior aspect femoral neck

Displaced

Stress Fractures Treatment

Compression sided
Fracture line extends < 50% across neck
stable Tx: Activity / weight bearing modification

Fracture line extends >50% across neck

Potentially unstable with risk for displacement Tx: Emergent ORIF

Tension sided
Unstable
Tx: Emergent ORIF

Displaced
Tx: Emergent ORIF

Stress Fractures Complications

Tension sided and Compression sided fxs (>50%) treated non-operatively
Varus malunion

Displacement
30-60% complication rate
AVN 42% Delayed union 9% Nonunion 9%

Femoral Neck Nonunion

Definition: not healed by one year 0-5% in Non-displaced fractures 9-35% in Displaced fractures Increased incidence with
Posterior comminution Initial displacement Inadequate reduction Non-compressive fixation

Femoral Neck Nonunion

Clinical presentation
Groin or buttock pain Activity / weight bearing related Symptoms
more severe / occur earlier than AVN

Imaging
Radiographs: lucent zones CT: lack of healing Bone Scan: high uptake MRI: assess femoral head viability

Femoral Neck Nonunion

Treatment
Elderly patients
Arthroplasty
Results typically not as good as primary elective arthroplasty

Girdlestone Resection Arthroplasty

Limited indications deep infection?

Femoral Neck Nonunion

Young patients
(must have viable femoral head)

Varus alignment or limb shortened

Valgus-producing osteotomy

Normal alignment
Bone graft / muscle-pedicle graft Repeat ORIF

Osteonecrosis (AVN) Femoral Neck Fractures

5-8% Non-displaced fractures 20-45% Displaced fractures Increased incidence with
INADEQUATE REDUCTION Delayed reduction Initial displacement associated hip dislocation ?Sliding hip screw / plate devices

Osteonecrosis (AVN) Femoral Neck Fractures

Clinical presentation
Groin / buttock / proximal thigh pain May not limit function Onset usually later than nonunion

Imaging
Plain radiographs: segmental collapse / arthritis Bone Scan: cold spots MRI: diagnostic

Osteonecrosis (AVN) Femoral Neck Fractures

Treatment
Elderly patients
Only 30-37% patients require reoperation

Arthroplasty
Results not as good as primary elective arthroplasty

Girdlestone Resection Arthroplasty

Limited indications

Osteonecrosis (AVN) Femoral Neck Fractures

Treatment
Young Patients
NO good option exists

Proximal Osteotomy
Less than 50% head collapse

Arthroplasty
Significant early failure

Arthrodesis
Sugnificant functional limitations

** Prevention is the Key **

Femoral Neck Fractures Complications

Failure of Fixation
Inadequate / unstable reduction Poor bone quality Poor choice of implant

Treatment
Elderly: Arthroplasty Young: Repeat ORIF Valgus-producing osteotmy Arthroplasty

Femoral Neck Fractures Complications

Post-traumatic arthrosis
Joint penetration with hardware AVN related

Blood Transfusions
THR > Hemi > ORIF Increased rate of post-op infection

DVT / PE
Multiple prophylactic regimens exist
Low dose subcutaneous heparin not effective

Femoral Neck Fractures Complications

One-year mortality 14-50% Increased risk:
Medical comorbidities Surgical delay > 3 days Institutionalized / demented patient Arthroplasty (short term / 3 months) Posterior approach to hip
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