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HIP FRACTURES Dr Sami Nugod 06/14/22 1 Hip fractures- Dr sami nugod - Sept 2013

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Page 1: HIP FRACTURES Dr Sami Nugod 10/1/2015 1 Hip fractures- Dr sami nugod - Sept 2013

HIP FRACTURES

Dr Sami Nugod

04/19/231 Hip fractures- Dr sami nugod - Sept 2013

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Overview

Incidence is highest in >65 years of age but also in young adults due to RTA

320,000 admission in the US each year15-20% die within 1 year of fractureF>MTwo types: intracapsular and extracapsular

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Anatomy

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Blood Supplyintracapsular are at

risk of non union and avascular necrosis due to interruption of the blood supply to the femoral headVia cruicate (med and

lat circumflex) and intramedullary

Garden classification

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Risk FactorsAge: >65 yearsCo-morbid factors: osteoporosis, endocrine disorders

(hyperthyroidism, hypogondaism), GIT disorders interfering with calcium/ Vit D absorption, neurological disorders (Parkinsons, MS)

Gender: FRTA

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Risk FactorsNutrition: lack of calcium and Vit D in diet, eating

disorders (anorexia), high caffeine intake

SmokingAlcoholMedication: steroids, anticonvulsants, diuretics

Environmental factors: loose rugs, dim lighting, cluttered floors

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Osteoporosis:

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PresentationP/C: severe pain, bruising, swelling unable to weight bear on that leg.O/E: may have shortened leg with external

rotation

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InvestigationsFull history and physical examAssess patient as per ATLS protocolX-rays AP and lateral, CT, MRI, bone scanRoutine bloods, group and holdECG, CXR

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ClassificationClassified on

geographical position: intracapsular:

SubcaptialTranscervicalbasicervical

Extracapsular:Intertrochantericsubtrochanteric

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Garden ClassificationGarden I: incomplete

fracture of the femoral neckGarden II: complete

fracture without displacement

Garden III: complete fracture with partial displacement

Garden IV: complete fracture with full displacement

 

 

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Pauwels ClassificationThe more vertical the line the greater the

risk of non union because increased shear stresses across the fracture

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Subcapital Fracture:Most common

intracapsular fracture of the hip

X-ray: white line of increased density of impacted bone may be seen at base of femoral head

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Transcervical FractureOccurs across neck

of femurEasy to view when

hip x-ray obtained in internal rotation

a/w varus deformity

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Basicervical FractureBase of femoral

neckAre Intracapsular

two part fractures with fracture plane running along line of capsular insertion

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Management of Femoral Neck FractureConservative: analgesia, bed rest, traction

if pt not willing to consent for surgery or if not expected to survive surgery

Surgical: Manninger et al showed significant reduction in osteonecrosis and segmental collapse if performed within 6 hrHead sparing: screws, DHSHead sacrificing: hemi, THR

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Young PatientsNon-displaced fractures

At risk for secondary displacement Urgent ORIF recommended

Displaced fracturesPatients native femoral head bestAVN related to duration and degree of displacementIrreversible cell death after 6-12 hoursEmergent ORIF recommended

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Elderly PatientsOperative 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 fracturesNon-operative tx may have developing role in select

patients with impacted/ non-displaced fractures [Raaymakers 2001]

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Cannulated Screws.

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Cannulated Screws (Richard)Used for undisplaced femoral neck fracturesGood for fracture which are more horizontalKrastman (2004):

112 pt study had 95% consolidation rate with 2 cannulated screws in intracapsular stable fracture

Position of screw did not interfere w consolidationRates negatively affected by inadequate

anatomical reduction and unstable fractures

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Dynamic Hip Screw Good for fracture with more vertical fracture line Problem w this is that cannulated screw will prevent fracture

impaction non union Sacrifices large amount of bone Anti-rotation screw often needed

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Hemiarthroplasty Hip: Indications:

Poor general healthPathological hip

fractureSevere osteoprosisPhysiological age

>70 Inadequate closed

reductionPre-existing hip

disease

Contraindication:Pre existing sepsisYoung patientFailure of internal

fixation devicePre-existing

disease of the acetabulum

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Hemiarthroplasty Hip:Hemi associated with (Luyao 1994, lorio 2001)

Lower reoperation rate (6-18% vs. 20-36%)Improved functional scoresLess painMore cost-effectiveSlightly increased short term mortality

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Bipolar Bipolar theoretical advantages

Lower dislocation rateLess acetabular wear/ protrusionLess PainMore motion

Bipolar DisadvantagesCostDislocation often requires open reductionLoss of motion interface (effectively unipolar)

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Femoral Neck Fracture ComplicationsFailure of Fixation

Inadequate / unstable reductionPoor bone qualityPoor choice of implant

TreatmentElderly: ArthroplastyYoung: Repeat ORIF

Valgus-producing osteotomy Arthroplasty

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Femoral Neck AVN5-8% Non-displaced fractures20-45% Displaced fracturesIncreased incidence with

INADEQUATE REDUCTIONDelayed reductionInitial displacementassociated hip dislocation

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Femoral AVNTreatment

Elderly patientsoOnly 30-37% patients require

reoperationArthroplasty

Results not as good as primary elective arthroplasty

Girdlestone Resection Arthroplasty

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Femoral AVNTreatment

Young PatientsNO good option exists

Proximal OsteotomyLess than 50% head collapse

ArthroplastySignificant early failure

ArthrodesisSignificant functional limitations

** Prevention is the Key **

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Extracapsular Fractures

Inter-trochanteric fracture NOF.Sub-trochanteric fracture NOF.

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Intertrochanteric FractureMost common

extracapsular hip fracture

a/w varus deformityClassified by Evans as

stable or unstableMost commonly used

classification is Jensen where type 1&2 are stable and 3-5 are unstable

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Jensen Classification

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Subtrochanteric Fracture

Classified by Seinsheimer: divided into undisplaced, two part, and comminuted

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Seinsheimer classification

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Isolated fracture of Greater Trochanter:

Occurs mainly in osteoporotic females

Result of a fall on the greater trochanter or avulsion type fracture from pull of gluteus medius insertion

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Management of Extra-capsular Fractures:

DCSDHSIM nailing

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Compression Hip Screw W Plate

Compression hip screws with a plate have gained increased popularity for the treatment of intertrochanteric fractures

These implants provide secure fixation and controlled impaction of the fracture

The rate of complications is relatively low with most frequent mode of failure being cut out of the screw from the femoral head (Davis 1990)

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Percutaneous Compression PateInserted at parallel to femoral diaphysis

through a small incision therefore less blood loss

Shorter operating time compared to DHS (30 min)

Neck screws are telescopic and provide double axis fixation in femoral neck increases rotational stability by fracture compression and preventing collapse of neck (Giancola 2004)

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Percutaneous compression plate Vs. DHSA decreased trend in overall mortality was

seen in the PCCP group [95% CI, 0.48-1.47, Chi-square = 1.36, P = 51]

Similar trends favouring the PCCP technique were seen with the other outcomes

PCCP has the potential to become the gold standard in the repair of intertrochanteric hip fractures (Panesar 2008)

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IM Nailingintramedullary nails combine the advantages

of intramedullary fixation with those of a sliding screw

Mechanically, the shorter lever arm of the intramedullary nail decreases the tensile strain on the implant and reduces the risk of failure of the implant (Kaufer medline)

• Rates of clinical failure range from 0-4.5% (Dean 2004)

• Has a better mobility score at 1 year when compared to sliding hip screw (Hardy 1998)

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IM Nail

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Hip dislocation

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Became more common (RTA).Classified according the direction of the

femoral head.

Posterior Anterior Central

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Posterior dislocationMechanism :Dashboard injury.

Clinical features:PainDeformity Signs of nerve injury ?

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X-rays:

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Treatment

ABCs.Urgent reduction.Surgery Rehabilitation

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Complications Early Nerve injury (sciatic)Vascular injuryAssociated #sLateAVNMyositis ossificansUnreduced dislocationOsteoarthritis

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Anterior dislocation

Rare injury.Caused mainly by RTAs or air crash.

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Central dislocation

Associated with acetabular #Caused by lateral force.Treatment is always surgical.

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Thank- you

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