Femoral neck fracture is a violation of the integrity of the upper part of the femur in the area just below the hip joint, between the femoral head and the large trochanter. It is a fairly common injury, occurs more often in everyday life and is detected in elderly people suffering from osteoporosis. It is manifested by moderate pain, restriction of support and movement, as well as a pronounced shortening of the limb. The diagnosis is made based on the symptoms and the results of radiography. With such injuries, the risk of non-fusion is very high, surgery is usually required to restore the function of the limb.
ICD 10
S72.0 Femoral neck fracture
Meaning
Femoral neck fracture is damage to the upper part of the femur. It accounts for about 6% of the total number of fractures, while in 90% of cases elderly people suffer. Femoral neck fractures are detected twice as often in women as in men. In 20% of cases, such injuries cause death. In elderly patients with osteoporosis, this damage can occur even with minor traumatic effects.
Since there is no obvious trauma in the anamnesis, and clinical manifestations are mild or moderate, some patients do not even assume serious injuries and do not immediately turn to doctors. Sometimes patients with fractures of the femoral neck (especially impaled) are treated independently for osteochondrosis, sciatica or hip arthrosis for a long time. Meanwhile, the lack of qualified care can negatively affect both the condition of the proximal fragment and the general condition of the patient, therefore, if characteristic symptoms occur, you should immediately contact an orthopedic traumatologist.
Femoral neck fracture causes
Hip fracture is a fairly common injury, occurs more often in everyday life and is found in elderly people suffering from osteoporosis. The immediate cause of the damage is usually a fall on the side of the house or on the street. In elderly patients with a marked decrease in bone strength, trauma can develop even with a sharp tilt or an awkward turn in bed. In young patients, a hip fracture is usually preceded by a more severe high–energy impact – a car accident or a fall from a height.
Pathanatomy
The hip joint is one of the largest joints. It performs a supporting function and carries a significant load when running and walking. The joint consists of a spherical femoral head and a deep rounded acetabulum, surrounded by a capsule and powerful ligaments. Another large ligament is located right in the center of the joint and connects the bottom of the acetabulum with the femoral head. In its peripheral part, the head passes into the neck, and the neck into the body of the femur. The neck is located at an angle to the main part of the bone, in the area of the angle there are large and small trochanters.
The blood supply to the head is carried out in three ways. The first is through the vessels located in the capsule of the joint, the second is through the arteries passing inside the bone, and the third is through the vessel located inside the ligament between the femoral head and the acetabulum. With age, the blood supply to the femoral head worsens, the vessels narrow, and the artery inside the ligament completely closes and stops “working”. With fractures of the neck, the proximal fragment is deprived of nutrition from the intraosseous vessels. The arteries in the capsule are not enough to adequately supply the bone with blood, so the proximal bone fragment does not grow to the distal one, and in some cases it completely resolves. This condition is called avascular necrosis or osteonecrosis of the neck and femoral head.
Classification
All classifications of these fractures accepted in traumatology and orthopedics are of a clinical nature, reflect the peculiarities of the course of the disease and help to choose the optimal treatment method taking into account specific circumstances. One of the essential criteria is the location of the fracture in relation to the femoral head. The higher this line, the worse the blood supply to the proximal fragment and the greater the likelihood of developing avascular necrosis or non-fusion of the fracture. Taking into account this criterion , hip neck fractures are divided into:
- Basicervical – the fracture line runs at the base of the neck, just above the trochanter.
- Transcervical – the fracture line is located in the center or close to the center of the femoral neck.
- Subcapital – the fracture line runs close to the femoral head.
Another important indicator is the angle at which the fracture line is located. The more vertically it passes, the higher the probability of displacement and the lower the chances of normal fusion. To describe this feature, the Powell classification is used:
- 1 degree – an angle of less than 30 degrees.
- 2 degree – an angle of 30-50 degrees.
- 3 degree – an angle of more than 50 degrees.
And, finally, a number of traumatologists use the Garden classification for an approximate assessment of the viability of the femoral neck and the choice of treatment tactics (within the framework of this classification, only subcapital injuries are considered):
- Stage 1 – incomplete or incomplete fracture. The lower part of the bone breaks like a “green branch”, the upper part turns slightly, which on X-rays creates the illusion of the formation of a punctured fracture. Without treatment, it can go into a complete fracture.
- Stage 2 – complete or complete fracture without displacement. The integrity of the bone is completely violated, but the ligaments hold the proximal fragment in a normal or almost normal position.
- Stage 3 is a complete fracture with partial displacement. The fragments are partially held by the posterior ligamentous attachment, the head “goes” to the abduction position and turns inward.
- Stage 4 is a complete fracture with a complete displacement. The fragments are completely disconnected.
Femoral neck fracture symptoms
Victims with a hip fracture complain of mild pain, which increases with movements. Bruising in the area of injury is usually absent, edema is insignificant. With the displacement of fragments, shortening of the limb is possible (does not exceed 4 cm, more noticeable in the supine position with straightened legs). In most cases, a symptom of a “stuck heel” is detected – the patient cannot lift the heel above the surface on his own. The foot is unfolded and rests on the bed with its outer edge. When pounding on the heel, there is pain in the hip joint and sometimes in the groin. Palpation of the injury area is painful.
Complications
Most of the complications of this injury are caused by prolonged forced immobility of patients in combination with their advanced age. Elderly patients who have been on bed rest for a long time often suffer from congestive pneumonia, which can cause the development of respiratory failure and subsequent death. With prolonged stay in bed, patients often develop bedsores in the buttocks and sacrum.
Another serious complication of this injury is deep vein thrombosis, also caused by prolonged immobility of patients. A complication of such thrombosis may be the separation of a thrombus with subsequent pulmonary embolism. In addition, elderly patients with hip fractures often develop psychoemotional disorders – depression or psychosis. All this, as well as the high probability of non-fusion of the fracture, is the most serious argument in favor of surgical treatment.
Thus, at present, surgical intervention for violations of the integrity of the femoral neck in elderly patients is considered as the main method of treatment used for vital indications. Young patients also have a hard time enduring prolonged immobility. The probability of developing the above complications in young people is lower than in the elderly, however, prolonged bed rest in them contributes to the development of muscle atrophy and the formation of post-traumatic contractures of the knee and hip joint. Therefore, modern traumatologists consider surgery as the main method of treating hip fractures in both elderly and young patients.
Diagnostics
Diagnostic search is carried out by a traumatologist. To confirm the diagnosis, an X-ray of the hip joint is performed. In doubtful cases, CT of the hip joint, MRI of the hip joint or scintigraphy are performed. Since surgical treatment is usually indicated for this injury, the patient is prescribed a full examination to identify somatic pathology, assess anesthetic and operational risks.
Femoral neck fracture treatment
Conservative treatment
Treatment of this pathology is carried out in the conditions of the traumatology department. Conservative therapy is carried out only in special circumstances – in the presence of serious contraindications to surgery (for example, with a recent myocardial infarction). In doubtful cases, an individual approach is used, the risks of prolonged bed rest (with conservative treatment) and anesthesia in combination with large-scale surgery (with surgical treatment) are compared. Possible treatment options:
- Skeletal traction. They are applied to sufficiently active patients of young, middle and elderly age with contraindications to surgical treatment.
- Derotation boot. It is the best option in the treatment of elderly patients (80-85 years and older), especially in the presence of senile dementia and other mental disorders. This technique, as a rule, does not provide fusion of the femoral neck, but makes it possible to simplify patient care and makes it possible to maintain at least a minimum level of physical activity for the period until a connective tissue callus forms in the fracture area.
Surgical treatment
Surgical intervention is indicated for preserved patients. The choice of the surgical treatment method is carried out taking into account the patient’s age and the level of his physical activity before the fracture. Active patients under 65 years of age are repositioned and osteosynthesis of the fracture is performed using various metal structures. People over 65 years of age, provided that they moved freely before the injury and went outside, install bipolar endoprostheses. Patients over 75 years old who had limited movement within the house or apartment before the fracture are undergoing unipolar endoprosthesis with a cement endoprosthesis.
For osteosynthesis of the femoral neck, three large cannulated (hollow) screws are more often used. First, an open reposition is performed, then several spokes are inserted into the fragments, a control radiography is done, the most successfully performed spokes are selected and screws are “put on” them, using the spoke as a guide. Less often, more massive compression screws, special plates or three-bladed nails are used to fix fragments.
In old age, when the risk of osteonecrosis and non-fusion of the fracture increases, as well as with a significant displacement of fragments, hip replacement becomes the best option. Bipolar endoprosthetics involves replacing not only the neck and head of the femur, but also the acetabulum. Cementless prostheses are used – special porous structures into which bone subsequently germinates. Sometimes the bowl replacing the acetabulum is additionally fixed with screws. This method is better suited for fairly young patients – it provides reliable fixation and is more convenient for subsequent replacement of the endoprosthesis.
The best option for a hip fracture in the elderly, as a rule, is the installation of a cement endoprosthesis – a structure that does not involve ingrowth of bone tissue, but is fixed to the bone with the help of a special polymer cement. The use of this technique allows for reliable rapid fixation of the endoprosthesis even with severe osteoporosis. At the same time, the type of endoprosthesis is determined not only by age – prostheses are selected individually for all elderly patients, and in case of good bone condition in old age, in some cases, cement-free structures are installed.
In the postoperative period, analgesics are prescribed, antibiotic therapy is performed. If necessary, anticoagulants (fondaparinux, warfarin, dalteparin sodium, enoxaparin sodium, etc.) are used to prevent the development of thromboembolic complications. After normalization of the patient’s condition, physical therapy and physiotherapy are prescribed. In the recovery period, rehabilitation measures are carried out.
Prognosis and prevention
The prognosis for hip fractures depends on the general health of the patient, the correct choice of treatment method, adequate preparation for surgery, the quality of rehabilitation measures and a number of other parameters.
With conservative treatment, true fusion is usually absent, bone fragments are retained due to fibrous scar tissue, which negatively affects the function of the limb. When installing the metal structure, the fragments also do not coalesce, but are held by a stronger retainer, which provides higher functionality. The best results are observed after endoprosthetics. Prevention consists in the prevention of injuries, early detection and treatment of osteoporosis.
Literature