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Fracture Neck Femur
Relevant anatomy:
1. Blood supply to the head of femur
Majority of blood supply (85%) via Medial and lateral circumflex femoral
vessels which are branches of profunda femoris artery. Together, they form
an extracapsular circular anastomosis around the trochanter.
Further, it gives rise to subsynovial intracapsular retinacular vessels which
travel along the neck of femur and then penetrate the head to vascularise
the head of femur.
10-15% of blood supply to the head comes from the foveal vessels
(branches of obturator artery). It penetrates the head via ligamentum teres
Intraosseous metaphyseal vessels from nutrient arteries
Fracture neck femur is an intracapsular #
Occurs in old age due to trivial trauma/fall and is often associated with osteoporosis
It is said that “it is the fracture which causes the fall and not the fall which causes the
fracture”. Due to osteoporosis, multiple micro fractures in the neck area render the
neck of femur weak and cause the fall!
# Neck femur in young adults is almost always due to high velocity trauma
In modern orthopaedics, almost all # Neck femur across the age groups need surgical
intervention except undisplaced # in paediatric population and or a moribund patient
who is medically unfit to undergo surgical intervention
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2. Trabeculae of proximal femur
Primary and secondary compression trabeculae
Primary and secondary tensile trabeculae
Greater trochanter group
- These trabeculae develop along the lines of maximum stress and
provide mechanical support to the proximal femur.
- Grading of trabecular prominence by Singh’s Index. Singh’s index is from
graded from VI to I. Grade VI is normal and grade I is severe
osteoporosis. Grade III and below is definite osteoporosis
- In the due course of ageing and osteoporosis, progressively these
trabeculae thin out and become less prominent rendering the neck area
weak susceptible to the fracture with minimal trauma.
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Classification of fracture neck femur
There are three common classification system. All are based upon radiological
evaluation.
1. Anatomical: Based upon location of fracture line
2. Pauwell’s: Based upon angle of fracture line wrt horizontal
3. Garden’s: Based upon displacement
Anatomical:
a) Subcapital
b) Transcervical
c) Basal
Pauwell’s
a) Type 1: Less the 300
b) Type 2: 30-500
c) Type 3: 700 or more
Garden’s Classification
Type 1: Incomplete fracture, trabeculae malaligned
Type 2: Complete fracture, Undisplaced, trabeculae aligned
Type 3: Complete Fracture, partially displaced, trabeculae malaligned
Type 4: Complete fracture, completely displaced, trabeculae aligned
Wrt acetabulum
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Clinical features:
Usually elderly
Associated osteoporosis
# NOF in young adult is associated
with high energy trauma
Pain, swelling around hip
Inability to bear weight
Lower limb externally rotated and shortened
Tender Scarpa’s triangle
Movements around hip painful
Investigations:
Plain xray of
1. Both hips: AP view
2. Affected hip: lateral view
Clinical difference between # NOF and # Intertrochanteric femur
“Every clinical feature is extra in intertrochanteric femur (ITF) #”
Extra age: ITF occurs in more elderly
Extra trauma needed for IT #
Extra pain and swelling over hip region
Extra shortening
Extra external rotation
Xray features of # NOF
1. Presence of #
2. Broken shenton line
3. Prominent lesser trochanter
4. Proximal migration of Greater
trochanter
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Treatment:
The principle of treatment of fracture neck femur is based upon few facts
1. All displaced Fractures need surgical treatment
2. Age less than 60 years: Save the head of femur
Plan internal fixation of fracture
3. Age more than 60 years: Sacrifice the head of femur
Plan replacement- hemireplacement/total hip replacement
“Undisplaced or minimally displaced” # NOF even if age is more than 60
years can be internally fixed
Complications of fracture neck femur
1. Non union
2. Avascular necrosis
Fracture NOF
Age of patient
< 60 years >60 years
CRIF /ORIF by
DHS or
Multiple Cannulated
Cancellous screws
Condition of Acetabulum
Normal Arthritic
Hemireplacement
Arthroplasty
Total Hip
Replacement
Why Nonunion is more common after fracture NOF?
- Lysis of fracture hematoma due to synovial fluid
- Absence of cambium layer from periosteum of neck femur
- Disruption of neck vasculature (retinacular vessels) during trauma leading to poor vascularity
