Neck of Femur Fractures -

Principles

Treatment choices are based on the patient’s age, mobility, independence, bone stock & the fracture configuration & classification

Intracapsular fractures classified on Garden’s system
- AP hip XR.
- Normal angle between primary compressive trabeculae of the neck & the longitudinal axis of the shaft is normally 160°

Type	Description
1	greater than 160°
2	equals 160°
3	less than 160°
4	equals 160° but trabeculae of head & neck fragments are parallel, not continuous i.e. overlapped

Garden’s Classification of Intracapsular Fractures of the Femoral Neck

Extracapsular fractures are described as stable of unstable depending on posteromedial buttress

Best result is with healed fracture in anatomical position without AVN
Quality of reduction is the best predictor of reduction
No randomised study has shown benefit of capsulotomy or aspiration
AVN risks (slight ↑ if DHS & derotation used instead of lag screws only)
- undisplaced fracture 5%
- displaced 10 – 15%
Non union risks
- undisplaced fracture – 5 – 10%
- displaced fracture 15 – 30%
Young patient closed or open reduction if required
- Fixation with three lag screws
Old patient, Independent walker
- Undisplaced
  - fix as above
- Displaced
  - fix vs hemi vs THR
Associated joint disease
- ( RA, Osteoarthritis, Pagets)
- Total joint
Old patient, nursing home, walker
- Undisplaced
  - fix
- Displaced
  - cemented hemi or THR
Old patient, non walker
- Pain, fix undisplaced or Moores for displaced
- Little pain, non operative management

If stable, or able to create stability by reconstruction of calcar, DHS (IM screw has higher risk of thigh pain & higher risk of fracture at cross bolts)
Unstable, & normal joint IM hip screw
Unstable / Unreconstructable + arthritic joint Calcar replacing THR / Unipolar

Supine on table
Whitmann
- supine, extension, traction, abduction, IR
Leadbetter
- supine, flexion, traction, IR 45°, circumduction to position of abduction & extension, stable if remains IR with heel on hand
Flynn
- supine, flexion, traction, lateral traction, IR, extension
On traction table
- traction, ER, IR, release traction

Individually mechanically as good as Knowels pins. Probably X 3 (same bending strength as 4, 2X8 mm screws shown to give adequate bending strength but ↓ torsional strength)
- Parallel within 10°
- Spread > 15mm
- Frontal alignment 130°
Shank should touch strong cortical neck bone
( 3 point fixation )
no support in centre of neck allows shank to shear through cancellous bone displacing fracture
Inverted triangle: 1. inferior 2. posterior (mid) 3. anterior (mid)
Tip should sit at 5mm from surface

Screw in centre of intersection of primary compressive & tension trabeculae
2 & 3 hole plates have been shown to be just as mechanically stable as 4 hole plates in stable fracture configurations, but this does not take into account the risk of poor screw fixation of plate in osteoporotic diaphyseal bone

Moores 30% revision at 2 years
Cemented hemi much lower revision rates than Moores, but no account for other morbidity
- (operative time, blood loss, cement pressurization complications, difficulty of revision)
Bipolar generally no better than unipolar in terms of pain relief or ROM
( ??? less acetabular wear demonstrated in some studies but others show no difference )
Bipolar also difficult or impossible to reduce in case of dislocation

Has higher dislocation & early loosening rates than in arthritic hips
Better ROM & pain relief though
Indicated if arthritic or Pagets
Logically should have better results with anterior approach, large head M on M. but no studies to date

Post Operative Management

PWB only for young patients, all oldies should be allowed WBAT to prevent complications of recumbency
Watch for AVN in subcap Fracture’s (usually about 8-12 weeks, but up to 2 years)