Fractures of the Femoral Neck

and Intertrochanteric Fractures

Knut Strömsöe, MD PhD, Orthopaedic

Department, Aker University Hospital,
Oslo, Norway
Classification of fractures in
the proximal femur
The Comprehensive AO/ASIF Classification (Müller et al.
1990) of fractures in the proximal femur
The comprehensive classification of
neck fractures of the proximal femur
Pauwel’s classification of neck fractures
(1965) (based on the angle the fracture line with the
resultant of forces (R))
 Garden’s classification
(based on the relationship of the medial trabeculae in the
head and pelvis)
Reported annual incidence of hip fractures
per 100 000 of population (Parker and Pryor
1993)
• Sweden 165
• Canada 103
• Finland 91
• UK 86
• USA 80
• Malayasia 70
• Israel 59
• Korea 34
 Number of hip fractures in
Norway 1979-1999:

population 4 000 000

• 1979: 6 800
• 1989: 9 900 12000

• 1999: 11800 (290 per 100 000)10000

8000

6000

4000

2000

0
1979 1989 1999
We have to define our problem
500000
Norwegians aged 80 year and more in 2050
Life expectancy in year 2050
is estim ated to be 80 years for men and
84.years for women 8.3%
400000

A
300000
g
i 4.3% 4.5%
200000
n 3.8%
4.1%

g
100000
2.0% prognosis
1.3% 1.4%

1900 19301930
1900 1960 1960
1990 1990 1997 22020
1997 2000 20002050 2020
 Cooper C, Campion G, Melton
LJ (1992) Osteoporosis
Int;2:285-289
• 6.25 million is an estimated number of hip
fractures world wide by 2050
• Increasing world population and increasing
life expectancy seems to be the most
important reason for this increase
Why do we experience an
increase the number of
fractures?
• Falling frequency increases with age
• Porosity of bone increases with age

Cooper C, Campion G, Melton LJ

(1992)
Osteoporosis Int;2:285-289
Determinants of fracture risk
-Neuromuscular function
-Environmental hazards
-Time spent at risk Risk of fall

Type of fall
Protective responses Force of impact
Energy absorption
Risk of fracture
Geometry of bone Strength of bone
Bone mineral mass
Quality of bone
Choice of Treatment policy
Fracture related pattern of femoral
neck fractures representing risk for
osteofixation failure, non-union and
avascular necrosis

• Grade of dislocation (Garden 1972, Thorngren 1991)

• Size of head fragment (Benterud et al. Acta Orth Scand
1994)

• Posterior comminution (Benterud et al.1997)

• Osteoporosis (Bentley 1972, Riska 1969, Anderson 1969,
Thorngren 1995)
 Fracture related pattern of femoral
neck fractures leading to a
“treatment policy”..
• Impacted fractures are reported to have less
incidence of non-unions (Bentley G, JBJS;50
B:551,1968, Raymakers, 1993)
• Impacted fractures develop less segmental
collapse in avascular necrosis of the head ?
Crawford reported 12 % of avascular necrosis in 50 impacted
fractures out of 339 femoral neck fractures with an overall
incidence of avascular necrosis in 37% (Crawford H, JBJS; 47
A:830,1965)
Preservation of the femoral head
or hemi (total) arthroplasty?
Julius Nicolaysen (1831-
1909), from Bergen, worked
as a Professor in Oslo. He
nailed a medial femoral neck
fracture in 1893, 2 years
before Wilhelm Konrad
Røntgen discovered the X-
ray
Femoral neck fractures in the young
or “young geriatric” patient have
different aspects as to the older
patient..
• Osteoporosis is frequent not the main
problem
• Fracture pattern is often different as to the
older patient
• Prosthetic replacement as a primary
treatment alternative has to be chosen with
greater care than in the older patient
Transcervical and subcapital femoral neck
fracture (31 B and 31-C3) in the “young
geriatric” patient

• Hip replacement (hemi or total arthroplasty)

represents an internal amputation with all its
implications
• Preservation of the joint (as in all joint
fractures) should be what we aim at in the
treatment
Secondary failures like secondary osteofixation
failure as well as segmental collapse may be handled
by secondary arthroplasty

• “Primary and secondary Charmley-Hastings

hemiarthroplasty in displaced femoral neck
fractures and their sequelae”
Benterud JG, Kok WL, Alho A. In: Ann Chir Gynaecol
1996; 85(1):72-6
What do we do with the impacted
femoral neck fracture (31-B2) ?

Functionally treated:
No.of Patients Age Instable
59 15-69 2 = 3%

73 70-94 16 = 22 %

Raaymakers 1993
What do we do with the impacted
femoral neck fracture (31-B2) ?
In the literature we find:

Instability:

After early mobilisation

without weightbearing: 8-19%

After immediate
full weight bearing: 32-65 %
What do we do with the impacted
femoral neck fracture (31-B2) ?

Mortality in impacted femoral neck

fractures:

Operative treatment > 10 %

Conservative treatment 1.8 - 3.3.%

(Raaymakers 1993)
 What do we do with the impacted
femoral neck fracture (31-B2) ?

“It is impossible at the Retroversion is not

time the patient presents an important
himself to predict which reason for higher
fractures will undergo instability
desimpaction”

(Bentley,Crawford, Judet,
(Raaymakers 1993)
Asser, Hansen, Famos,Jeannaret)
 What do we do with the impacted
femoral neck fracture (31-B2) ?
Conclusion may be as follows:
Age less than 70: Internal fixation in
situ

Age more than 70: Conservative treatment. If

secondary dislocation or
AVN: Arhroplasty
In dislocated femoral neck fractures..
Timing of Surgery
• As preservation of the femoral head is the
main goal of our treatment surgery should
be performed as soon as possible and latest
within 6 hours
• The value of decompression of the
intracapsular haematoma still is unknown
In dislocated femoral neck fractures..
Timing of Surgery. If not immediate ?

• The value of immobilisation in traction is

questionable in concern of development of
avascular head necrosis
• Positioning of the hip in the most
comfortable position to the patient probably
also is the position where the intracapsular
pressure is at lowest
 Is the viability of the femoral head
predictable?

Preoperative Intraoperative
• Intraoperative by
bleeding?
• By fracture
classification? • Intraoperative by
measuring of electric
• By scintigraphy?
potential with
• MRI temporary implanted
platine electrodes and
gas insuflation
(H2O2)?
 In femoral neck fractures..

Is the viability of the

femoral head
predictable?

MRI
Reduction technique in
intracapsular fractures of the
femoral neck
• Loosen the fracture
by “unpack” it
• After having
obtained the
reduction “pack the
fracture” and then
fix it

Mark Flynn injury 1973

Impacted fracture Non displaced fracture
Impacted
fracture

Displaced fracture Reduction manoeuvre (Leadbetter)

Intracapsular fractures of the
femoral neck
ventral
• Internal rotation of the
foot should result in
the femoral head, neck
and shaft all appearing
dorsal
in a straight line with
no residual anglulation
at the fracture site
Choice of Implant
Choice of Implant
• Cannulated bone screws
• Non cannulated bone screws
• Nails with hooks (Hansen nails)
• 130 Angle blade plate
0

• Sliding Screw Plate Systems

(DHS, HCS)
 Implant demands..
• The implant shall provide stability
- prevent dislocation in varus
- prevent dislocation in retroversion
- prevent rotational micromovements
• Allow axial sintering along the implant
without penetrating into the joint
• In case of delayed union and non union
migration into the joint/pelvis should not be
possible
Choice of Implant:
Sliding Screw Plate System
 Choice of Implant
Benterud JG, Husby T, Nordsletten L, Alho A:
“Fixation of displaced femoral neck fractures
with a sliding screw plate and a cancellous screw
or two Olmed screws. A prospective study of 225
elderly patients with a 3-year follow up”.

Ann Chir Gynaecol 1997; 86 (4) 338-42

 Choice of Implant
Ann Chir Gynaecol 1997; 86 (4) 338-42

Conclusions. Both treatment methods

resulted in high rate of osteofixation
failures (18.5 % in the SSP group
and 19.5 % in the Olmed group)
and non-unions (6.2 % and 8.5%
respectively)
 Choice of Implant
• In 31- B2 fractures of
the “young geriatric”
patient a 4 hole DHS
with an antirotational
screw, however, is the
implant of choice. The
fixation on the tensile
side of the femur and
gliding cylinder for
the screw provides
stability over time
Choice of Implant

Angle blade plate

and cancellous screw
Femoral neck fractures:
If screws: Two or three screws? Position of
the screws? Dimensions of the screws?

Three screw fixation

technique in fixation of
cervical fractures of the
proximal femur
 Choice of Implant

Screws with head and washer

preventing axial migration in
instability Screws without head
and equal diameter
of thread and shank
 Fate of the medial neck fracture
after ORIF
• Early osteofixation failure in 8-16 %
• Non-union in 8 -10%
• AVN in 6-10 %

• This makes an overall failure rate of 20-

30%
• but- in the first year after a medial neck
fracture 25 % of the patient are dead to
unrelated fracture desease
Classification of trochanteric fractures (31-A 1-3)
Bone mass related to age in
cancellous bone and cortical bone
Bone mass

Trochcanteric area

Neck of the
femur

50 years 100 years

Age
 Fractures in the proximal Femur at
Aker Hospital, Oslo,Norway1999

Diagnose No Median age male female

Cervical Frx 282 84 (29-104) 53 229

Pertrochanteric Frx 186 88 (54-102) 75 111

Subtrochanteric Frx 37 86 ( 39-95) 20 17

505 148 357
Biomechanichs of the proximal femur
Biomechanichs of the proximal femur
Biomechanichs of the proximal femur
Fracture pattern reflects biomechanichs
of the proximal femur in different stages by falling

• Falling activates
tensile forces of the
muscles
• Falling induces
rotation of the femur
on the fixed leg
• Forces act on the
trochanter by direct
contact at the end of
the fall
 In unstable trochanteric fractures in the
elderly the implant chosen have to:

• respect the instability of the fracture

• allow fracture impaction during motion
without fixation failure
• secure retention of the fracture in acceptable
position during healing
• build a biomechanical construct with the
bone allowing early weight bearing
 31-A3.3 Fracture. DHS and TSP
• sliding screw -plate
system allowing the
fracture sintering
• plate on the tensile site
neutralising tension
forces
• Trochanteric
Supporting Plate
preventing femoral
shaft medialisation
• Additional
antirotational screw Week 0 Week 8
 31-A3.3 Fracture., The -nail

• sliding screw-nail
• nail in the centre of the
femoral axis
• reduction of the lever
arm
• no neutralisation on
the tensile side
• sintering in varus with
“cutting through”
 31-A3.3 Fracture. The -nail

Day 1 Day 160

Day 126
 In unstable trochanteric fractures in the
elderly the implant chosen have to:

• respect the instability of the fracture

• allow fracture impaction during motion
without fixation failure
• secure retention of the fracture in acceptable
position during healing
• build a biomechanical construct with the
bone allowing early weight bearing
Fractures at the tip of the short
- nail

51 days
 Fractures at the tip of the nail
• Aune et al. Acta Orthop Scand 1994; 65
(2):127-30: HCS vs.Gamma nail
378 patients: 5.6 %
• Madsen et al: J Orthop Trauma 1998
Vol.12. No 4 50 patients 2.9%
• Osnes et al. Norw.proceedings 1998:
379 patients 5.3%
Stress measurements at the end of the nail. A
comparative study between the -nail and the
PFN. E.Euler. LMU München 1999
A photoelastic loading study

Stress by cyclic loading with

700 N up to 7 times as high
in the Gamma nail as in the PFN

DHS + TSP
 The Medoff sliding plate

• A sliding screw plate

system allowing
sintering along the
neck axis as well as
along the femoral axis
The Medoff sliding plate used in a 31-A3.2 fracture with
reversed fracture line
 "A great responsibility rests on the surgeon who
introduces a new method of treatment.
The desire to have a new idea published
is so great that the originator is often led astray,
and the method is broadcast before it has been
proved worthwhile and before
the technique has been perfected."

Smith-Peterson, Cave &

Vangorder
Archives of Surgery 1931
Thank you for your attention