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Patient Age Sex Race : HBB : Female : 70yrs : Malay

General Hospital Kuala Lumpur

Most common ractures seen among t!e el"erly are !ip ractures# $!ese ractures !a%e a tremen"ous e ect on our !ealt! care system an" "espite t!e "e%elopment in implant "esigns& surgical tec!ni'ues an" patient care t!ey ten" to (e a ma)or consumption on our !ealt! care resources# *n s!ort our attempt in treating t!ese patients +oul" (e "irecte" to+ar"s optimi,ing patient-s !ealt!& early surgery& mo(ili,ation an" "isc!arge# $!e a(o%e is case o a p!ysiologically young patient +it! close "isplace racture nec. o emur +!ic! +as treate" +it! a unipolar !emiart!roplasty

A 70 year ol" Malay la"y +it! a !istory o all a(out a +ee. ago is ren"ering !er (e" ri""en# S!e +as (roug!t in (y !er "aug!ter +it! t!e complaint o (eing una(le to mo%e !er rig!t lo+er lim( an" constant pain# Her rig!t lo+er lim( +as note" to (e slig!tly s!orter an" externally rotate"# $!ere +as also (ruising o%er t!e lateral aspect o t!e rig!t t!ig!# S!e !a" no .no+n me"ically illness #$!e /0ray o t!e rig!t !ip )oint re%eale" a Gar"en type our racture nec. o emur# *t +as also note" t!at t!ere +as no art!ritic c!anges o%er t!e emoral !ea" an" aceta(ular cup# S!e +as opte" or a unipolar !emiart!roplasty 1uncemente"2# Patient +as put on traction an" sc!e"ule" or operation# *ntraoperati%ely an" postoperati%e perio"s +ere une%ent ul# A ter a"e'uate p!ysiot!erapy patient +as "isc!arge" +ell +it! rame support or mo(ili,ation# S!e +as ollo+e" up in clinic in 3 +ee.s time an" note" t!at !er


+oun" !a" !eale" +ell# /0ray re%eale" no apparent loosening o implants# Patient +as a(le to am(ulate +ell (ut still nee"e" t!e ai" o t!e rame# S!e +as gi%en !er next ollo+ up in 4 mont!s time

DISCUSSION Introduction
*n t!e treatment o racture nec. o emur t!ere !as (een speci ic milestones t!at !as (een passe" example rom re"uction (y "ynamic traction& t!e importance o anatomical re"uction an" maintenance in plaster& t!e "e%elopment o sta(le internal ixation "e%ices an" inally t!e "e%elopment o implant art!roplasty +!ic! t!en le" to t!e era o total )oint replacement# 5espite t!e a"%ances in t!e management o emoral nec. ractures& t!is con"ition is still re eree" to as 6t!e unsol%e" racture7# A compoun"ing pro(lem is t!e increase" inci"ence o emoral nec. ractures# $!is racture is commonly seen at t!e age o 77 in +omen an" 73 in men# Men su er 809 o t!ese ractures an" t!e racture rate "ou(les or eac! "eca"e o li e a ter t!e i t! "eca"e#

Fracture nec. o emur oun" to primarily to a ect t!e el"erly# :;< $!e inci"ence

steeply rises a ter t!e sixt! "eca"e o li e& especially in emales# $!e el"erly usually !a%e %isual pro(lems an" also associate" muscular +ea.ness +!ic! may (e attri(uting actors increasing t!e ris. o alling#

Etiology factor
Most o t!ese ractures are seen among t!e el"erly an" are attri(ute" to a all o some .in"# $!e ten"ency to all increases +it! age an" is "epen"ent on many actors +!ic! inclu"e poor %ision& "ecrease muscle po+er& la(ile (loo"0pressure an" co0existing


musculos.eletal pat!ology# :3<*n a normal young patient t!e impact o a all is usually (ro.en (y an outstretc!e" !an"# $!is reaction may re'uire e ecti%e neuromuscular response +!ic! may (e impaire" (y "egenerati%e c!anges in t!e el"erly# $!e loss o t!ese protecti%e mec!anism is normal component in aging# $!e (one is +ea.ene" (y t!ree pat!ological processes# Firstly t!e re"uction in (ot! t!e mineral an" organic matrix o (ones or example osteoporosis# Secon"ly t!e re"uction in mineral component o (one or example osteomalacia# $!ir"ly replacement o normal (one arc!itecture (y a(normal cells or example Paget-s "isease or metastatic "isease# =ortical (one is lost stea"ily t!roug!out li e in (ot! sexes (ut in +omen t!ere is an accelerate" post menopausal p!ase# Post menopausal osteoporosis is cause" (y t!e loss o estrogen secretion +!ic! results in increase (one resor(tion#

$!e %ascular supply to t!e emoral !ea" comes rom t!ree sources# $!ese are t!e retinacular %essels& t!e ligamentum teres an" t!e %essels +it!in t!e me"ullary ca%ity# $!e reticular %essels are t!e main (loo" supply +!ic! arises rom t!e extra capsular arterial ring orme" (y t!e me"ial an" lateral emoral circum lex arteries# $!e lateral epipyseal %essels are "eri%e" rom t!e posterior superior retinacular arteries# $!ey supply a large part o t!e emoral !ea" particularly "eri%e" rom t!e epip!ysis# $!e "amage o t!is %essel is implicate" +it! su(se'uent "e%elopment o a%ascular necrosis# :4< $!ey pass up t!e posterior superior part o t!e emoral nec. an" enter t!e (one close to t!e articular sur ace# $!e in erior metap!yseal arteries are "eri%e" rom t!e posterior in erior retinacular %essels# $!ey pass along t!e posterior in erior part o t!e nec. to supply t!e relati%e small part o t!e emoral !ea" "eri%e" rom t!e metap!ysic an" t!e posterior in erior part o t!e emoral !ea"# $!ese are not important in t!e etiology o a%ascular necrosis# Small retinacular %essels an" %essels t!at pass +it!in t!e me"ullary ca%ity o t!e emoral !ea" are completely transecte" in a "isplace"


racture o t!e emoral nec.# A""itional source o (loo" supply to t!e emoral !ea" is t!ro t!e ligamentum teres# $!ese usually enter t!ro t!e o%ea capitis an" are relati%ely unimportant in a"ults as t!e only supply a small area o (one aroun" t!e o%ea# :><

Clinical Pre entation

$!e most common presentation is el"erly emales +!o present a ter a all an" complain o a pain ul !ip +it! ina(ility to +eig!t (ear on t!e a ecte" lo+er lim(# $!e lim( +oul" (e s!ortene" an" externally rotate"# $!e classical sign an" symptom are not al+ays present an" ?ast+oo" :@< reporte" t!ere +as "elay in "iagnosis in a(out A9 o patients +it! !ip ractures# Bne 'uarter o t!ese patients "i" not present to t!e "octor imme"iately a ter t!e in)ury an" among t!e remaining t!ree 'uarter& 4C9 t!e general practioner aile" to "iagnose t!e racture an" in ;@9 t!ere +as "elay as urt!er in%estigation +as nee"e" to esta(lis! t!e "iagnosis# Failure to esta(lis! t!e "iagnosis can (e associate" +it! no !istory o all or trauma& patient con use" an" una(le to remem(er or racture occurs spontaneously# 5elay in "iagnosis can also (e attri(ute" to an un"isplace" racture# =onse'uences o "elay in "iagnosis +oul" result in continuing pain or t!e patient an" in most cases an un"isplace" racture (ecomes "isplace"#

Radiological E#a"ination
Ra"iograp!s o t!e a ecte" !ip )oint s!oul" (e ta.en in t+o %ie+s# Pel%ic x0ray is also recommen"e" in most cases to asses t!e 'uality o (one stoc. on t!e una ecte" si"e# Most x0rays o !ip ractures are ta.en +it! t!e lim( in external rotation as t!is is t!e most com orta(le position or t!e patient# *n t!is position t!e greater troc!anter lies posterior to t!e emoral nec. partially ( it# =on%entionally !ip x0ray is ta.en +it! t!e a ecte" lo+er lim( in internal rotation ;0 "egrees (ut in t!ese patients any mo%ement o t!at sort is pain ul# *t is note" t!at +it! internal rotation t!e emoral nec. is (roug!t parallel to t!e x0ray plate an" "etails o any racture aroun" t!at is


note" clearly# Lateral %ie+ can (e o(taine" (y Ds!oot t!roug! Dlateral +!ere t!e unin)ure" lo+er lim( is a("ucte" an" !ip an" .nee lexe" to A0 "egrees#

Cla ification
$!ere are many classi ications or t!e racture o emur (ut t!e most use ul or t!e

treatment +oul" (e t!e one "etermining +!et!er t!e racture is "isplace" or un"isplace"# Pau+el classi ie" racture nec. o emur into t!ree types on (asis o t!eir mec!anical sta(ility# $ype * is a racture resultant rom a orce at A0 "egree an" as a result t!e racture is su()ecte" to a compressi%e orce an" is relati%ely sta(le# *n $ype ** t!e orce is at A0 "egree to t!e nec. axis t!ere ore su()ecte" to s!ear an" consi"ere" unsta(le# *n $ype *** t!e racture plane is almost in line +it! t!e anatomical axis o t!e emoral s!a t& it su()ecte" to (ot! s!ear an" "istraction orces an" t!ere ore !ig!ly unsta(le# Gar"en classi ie" su(capital ractures into > types# $!is classi ication is (ase" on "egree o "isplacement& its- in luence on sta(ility an" inci"ence o a%ascular necrosis# $!e me"ial tra(eculae 1compression tra(eculae2 in t!e emoral !ea" an" t!e pel%is is use" as an in"ex o "isplacement# $!e racture +it! t!e !ea" impacte" in %algus 1Gar"en *2 an" un"isplace" 1Gar"en **2 compromise o t!e groups +it! lo+ inci"ence o a%ascular necrosis# $!e Partial "isplace" racture 1Gar"en ***2 an" completely "isplace" Fractures 1Gar"en *E2 compromise o t!e group +it! !ig!er inci"ence o a%ascular necrosis an" !ig!er inci"ence o implant ailure an" non union# AB classi ication o t!e proximal emur "i%i"es nec. o ractures +it! mar.e" "isplacement B4# su(capital +it! slig!t "isplacement B;F transcer%ical ractures o emur racture into type B# Fracture nec.& ractures B3F su(capital



Patient-s mo(ility assessment prior to t!e operation is important as a comparison o post operati%e mo(ility can (e ma"e# $!ose +!o !a%e impaire" mo(ility prior to t!e all is note" to !a%e an increase" mor(i"ity su(se'uently# Simple 'uestioning o +!et!er patient is a(le to get a(out t!e !ouse can get out o t!e !ouse an" +!et!er can lea%e t!e !ouse or s!opping coul" "o or t!e assessment

Acti'itie of Daily $i'ing

A simpli ie" orm o assessment can (e "one (y i t!e patient can ta.e care o !is "aily nee"s e#g# Bat!ing& +as!ing "ressing 1personal !ygiene2F preparing meals& teaG co ee 1"omestic acti%ities2F +!et!er patient is a(le to trans er rom (e" to c!air& sel toilet& an" stairs# $!e a(o%e acti%ity must (e gra"e" urt!er +!et!er patient "oes it alone or +it! t!e !elp o a secon" party an" also i a mec!anical ai" is nee"e" or not#

Mental A e "ent
$!ere are "i erent types o mental unction test an" t!e a((re%iate" mental test score !as (een oun" to (e s!orter an" easier to a"minister# :C< $!e mental state is measure" (y assessment o t!e mental unction an" is pro%en to (e a relia(le pre"ictor o mortality ollo+ing !ip ractures#

Social A e "ent
Social con"ition is an important actor in "etermining patient-s capa(ility in returning to pre0in)ury status# Li%ing con"ition s!oul" (e optimal to t!em so t!at +it!


appropriate assistance an" support a return to t!e pre0in)ury state +oul" (e a realistic goal#

P!y ical State

$!e ASA gra"e is recommen"e" as an assessment o t!e patient-s p!ysical status# *t is use" to asses t!e anaest!etic ris. an" !as (een s!o+n to pre"ict operati%e mortality# :7<

$a&oratory In'e tigation

$!e la(oratory in"ings are in erior +!en compare" to t!e !istory an" p!ysical assessment o t!e patient# Ho+e%er t!e la(oratory in"ings are re'uire" as a preoperati%e assessment# A lo+ !emoglo(in& lo+ lymp!ocyte count& lo+ serum al(umin an" !ig! (loo" calcium p!osp!ate pro"ucts !a%e a iliate" +it! !ig! mortality# A lo+ serum al(umin !as (een pro%en to (e associate" +it! an" increase" mortality an" inci"ence o ixation ailure# :8<

Degree of O teo(oro i
$!e "egree o osteoporosis present can (e assesse" using measurement o cortical (one t!ic.ness on metacarpal x0rays or using t!e Sing! in"ex# $!e Sing! in"ex is estimate" (y stu"ying t!e tra(eculae +it! t!e proximal emur# *t re'uires a reasona(le exposure o an intact !ip )oint& ta.en at ;00;@ "egrees internal rotation


*n t!ese ol"er patients more attention s!oul" (e "irecte" to+ar"s t!eir !ealt! con"ition t!at nee"s sta(ili,ation or optimi,ation# Hip ractures can (e treate" +it!

43 traction mo"e o immo(ili,ation till patient is more sta(le or "e initi%e surgical treatment# Pain relie in t!e orm o oral or parenteral analgesic s!oul" (e consi"ere"# $!ose patients +it! poor respiratory reser%es& opiates s!oul" (e a%oi"e" in ear o respiratory "epression# =orrection o "e!y"ration& electrolyte an" anemia an" nutrition status is essential as it is associate" +it! an increase" inci"ence o mortality Preoperati%e traction is recommen"e" (y most surgeons (y traction +it! a(out 30 4 .g& prior to surgery +it! aim o re"ucing pain# Finsen an" colleagues :A< carrie" out a ran"omi,e" trial comparing t!ree regimensF t!e use o 4 .g o traction& traction using ti(ial pin +it! ;09 o (o"y +eig!t or simply resting t!e (e" on pillo+# $!ere +as no "i erence in terms o preoperati%e analgesia& (ut t!e time ta.en to re"uce t!e racture intraoperati%ely +as signi icantly less in t!ose patients +it! t!eir leg reste" on pillo+s# $raction may also !a%e a "etrimental e ect on patients +it! intracapsular ractures as maintaining !ip in extension may increase t!e intracapsular pressure +it! resultant re"uction o (loo" lo+ to t!e emoral !ea"# Hypot!ermia may (e present prior to all as it !as (een implicate" in t!e aetiology o !ip ractures an" t!ose patients at ris. o "e%eloping !ip ractures are also t!ose +!o at ris. o "e%eloping !ypot!ermia# Bt!er ris. ractures inclu"e un"er nutrition& re"uce (o"y at& an" "iminis! a(ility to eel col" an" t!e use o !ypnotic "rugs# $!e importance o .eeping t!e patient +arm intra an" post operati%e s!oul" (e stresse"#


Patients +!o +ere completely immo(ile prior to surgery +ill clearly o(tain no (ene it orm surgery in terms o regaining mo(ility# Surgery +ill "e initely relie%e pain o t!e racture" lim(& ma.e t!e lim( more sta(le an" also acilitate easy nursing care# =onser%ati%e treatment can also ac!ie%e t!e a(o%e (ut t!e "uration o time re'uire" +ill (e longer# Lyon an" 5a%is :A< compare" ;> surgically treate" patients +it! ;3 conser%ati%ely treate" patients# All ;3 patients treate" conser%ati%ely sur%i%e" +it!out


complications (ut only one patient +as a(le +al.# Forty0t!ree percent o t!ose treate" surgically "e%elope" signi icant complication (ut still orty our percent o t!em +ere am(ulatory at t!e en" o treatment# $!us conser%ati%e treatment +as opte" as an optional treatment or t!ose patients +!o +ere poorly mo(ile or totally immo(ile prior to t!e racture# S!a tan :;0< compare" t!e results o ;0C patients treate" non0 operati%ely +it! >04 patients treate" operati%ely# $!e criteria or non0operati%ely +ere immo(ility or poor a(ility prior to t!e all# Hon Ioperati%e treatment inclu"e" traction& analgesia an" mo(ili,ation as early as patients tolerates# $!e !ospital mortality rate +as 379 in t!e cases t!ose treate" non0operati%ely compare" +it! 439 or t!ose treate" surgically& (ut only ;C9 o t!e ormer (ecame am(ulatory prior to "isc!arge compare" +it! @>9 o t!ose treate" operati%ely# Most o t!ese cases s!oul" (e sta(ili,e" ast an" surgery carrie" out as soon as possi(le to a%oi" complication suc! as pressure sores& urinary tract in ection an" pneumonia to +!ic! t!e (e" (oun" el"erly are prone an" +oul" increase t!e perio" o pain prior to surgery# Generally early surgery an" mo(ili,ation re"uces t!e ris. o t!rom(oem(olic pro(lems# Most o t!e stu"ies con"ucte" a(out !ip ractures pro%e t!at t!e use o eit!er +ar arin& !eparin an" "extran 70 are e ecti%e in re"ucing t!e inci"ence o t!rom(oem(olic complications# $!us to re"uce t!e mor(i"ity an" mortality cause" (y t!rom(oem(olic complications one o t!e a(o%e anti0t!rom(otic agents is a"%ise"# Bt!er p!ysical anti0t!rom(otic met!o"s are crepe stoc.ings& acti%e an.le exercises an" a%oi"ance o o%er trans usion# Prop!ylactic anti(iotics is a"%ise" prior to surgery an" proper aseptic measures ta.en t!roug!out surgery to a%oi" in ection o operati%e site# Most o t!ese patients are rail el"erly an" t!eir immunity against an in ection is o ten ina"e'uate an" can pro%e to


(e atal# Burnett :;;< in a ran"omi,e" trail o prop!ylactic anti(iotic usage reporte" a re"uction in ma)or +oun" in ection to 0#79 compare" to t!e place(o usage +!ic! is >#79 A re"uction in t!e operati%e time an" minimi,ation o intraoperati%e (loo" loss is recommen"e"# Sta(le ixation +oul" also ena(le early mo(ili,ation o t!ese patients t!us re"ucing post0operati%e mor(i"ity#


a* Pat!ology %ascular in gro+t! at t!e racture site is t!e main route (y +!ic! re%asculari,ation occurs# $!e arteries o ligamentum teres maintains t!e %ia(ility o a small area o (one aroun" o%ea capitis an" rom !ere %ascular in gro+t! may e%entually occur# $!e "egree o "eci"e" t!e possi(ility o remaining intact# &* Factor influencing fe"oral !ead 'ia&ility *n surgery +!ere preser%ation o t!e emoral !ea" is opte" or t!e actors t!at in luences t!e %ia(ility o t!e emoral !ea" an" promote racture !ealing s!oul" (e assesse"# Ma)ority o stu"ies s!o+ t!at inci"ence o non union increases +it! age# Barnes :;3< reporte" @09 non union among t!ose age" o%er 8> years compare" to 449 in t!ose un"er C@ years# Bro+n an" A(rami :;4< reporte" an increase inci"ence o non union among emales an" t!e Me"ical Researc! =ouncil in ;A7C a%ascular necrosis more among emales 13392 compare" to 1;C92 in males# racture "isplacement +oul" t!e lateral an" in erior metap!yseal arteries


5alen an" Jaco(sson :;>< reporte" an increase inci"ence o non union associate" +it! increase osteoporosis +!ic! +as assesse" using t!e Sing! gra"e in t!eir series o A> patients# Me"ical Researc! =ouncil :;3< !as s!o+n t!e proximal ractures to !a%e an increase" ris. o non union# $!e "egree o initial "isplacement o t!e racture strongly in luences t!e inci"ence o non union an" a%ascular necrosis# Me"ical Researc! =ouncil :;3< reporte" @9 non union an" ;09 a%ascular necrosis among t!e non "isplace" ractures an" 3;9 non union an" ;39 a%ascular necrosis among t!e "isplace" ractures# Sc!ec. :;@< reporte" t!at posterior comminution resulting in angulation o t!e racture site in 4@9 o cases# He recommen"e" re"ucing t!e racture to a position o %algus to pre%ent "isplacement o t!e racture# Barnes :;3< stu"ie" ;0CC patients an" oun" t!at a "elay in surgery up to C "ays "o not increase non union "ramatically# *n support to t!is Holm(erg :;@< stu"ie" ;3@; patients an" oun" t!ere +as no signi icant increase in t!e inci"ence o non union an" a%ascular necrosis among t!ose +!ose surgery is "elaye" or 7 "ays (ut a ter +!ic! t!e inci"ence increases rom 3>9 to @A9# Bn t!e AP %ie+ t!e angle (et+een t!e me"ial tra(eculae an" t!e line o t!e emoral s!a t is normally ;C0 "egrees an" on a lateral %ie+ t!e line passing t!e axis o t!e emoral nec. an" passing t!ro t!e center o t!e emoral !ea" is normally ;80 "egree# Barnes :;3< oun" t!at ractures internally ixe" +it! an AP tra(eculae angle (et+een ;70"egrees an" ;7A "egrees !a" t!e !ig!est union rate 17792# $!ose ixe" in %arus +it! a tra(eculae angle less t!an ;C0 "egreesF union rate +as only >>9# Among t!ose +it! a tra(ecular angle greater t!at ;80 "egrees t!e rate o a%ascular necrosis +as !ig!# Barnes also reporte" t!at more t!an 30 "egrees o in%ersions or retro%ersion increases t!e inci"ence o non union rom >A9 to 709 c* Prediction of fe"oral !ead 'ia&ility Arteriograp!y among racture nec. o emur s!o+e" t!at in t!ose +!om t!e posterior superior retinacular %essels +ere intact a%ascular necrosis "i" not


occur# $urner :;C< reporte" t!at out o ;@ patients +it! a normal preoperati%e AAm0tec!netium antimony colloi" scan only one "e%elope" a%ascular necrosis# But o ;3 patients +it! a(normal scan results ;; "e%elope" %ascular necrosis

Bot! t!e inci"ence o a%ascular necrosis an" non0union are important actors in t!e "ecision or t!e c!oice o treatment o racture nec. o emur# $!is "ecision is also (ase" on +!et!er t!e racture is "isplace" or not#


Fracture nec. o emur +!ic! are impacte"& a("ucte"& in %algus or gar"en $ype ; racture is (asically conser%ati%e +it! su icient

inclu"ing also Gar"en type ** ractures +!ic! are un"isplace" (ut not impacte"# $!e c!oice o treatment o t!is type o immo(ili,ation or internal ixation (y means o scre+s or pins# Art!roplasty is not really in"icate" as t!e initial treatment as t!e union ratein t!ese type o ractures are relati%ely !ig!# Kit! t!e pre0existing e%i"ence o art!ritis o !e !ip )oint t!en art!roplasty is consi"ere"# Jenson an" Hog! :;7< "emonstrate" an increase" ris. o non union among t!e Gar"en type ** ractures +!en compare" to t!e impacte" patterns 1non union o C;9 in t!e Gar"en $ype ** ractures an" ;;9 in t!e impacte" ractures2# $!e report suggests t!at t!e a(sence o impaction on t!e x0ray is an in"ication or operati%e treatment# Lo+ell :;8< stu"ie" t!at any racture +it! retro%ersion on t!e lateral x0ray +ill su(se'uently get "isplace" t!us early internal ixation is recommen"e"# =riteria or conser%ati%e treatment (ase" on ra"iological in"ings are t!e e%i"ence o impaction o t!e racture in t+o planes& no e%i"ence o racture "isplacement& Pau+els angle less t!an 70 "egree& clinical e%i"ence o sta(ility +it! a ull range o passi%e !ip


mo%ement& +it! minimal "iscom ort an" t!e a(ility to li t t!e leg rom t!e (e" in supine position# $!e a(o%e +as stu"ie" (y Martyn an" Glyn :;A< Bro"etti :30< suggeste" t!at (y .eeping t!e ixation "e%ice in t!e center o t!e emoral !ea" t!e occurrence o a%ascular necrosis is less# Prior to surgery t!e ris. o anaest!etic "rugs an" also t!e complication o t!e operation s!oul" (e consi"ere"# *n conser%ati%e treatment t!e long perio" o immo(ili,ation an" t!e complication arising rom t!at s!oul" (e consi"ere"#


5ue t!e pro(lems o %ascularity an" sta(ility at many times t!e racture nec. o emur is pre erre" to (e treate" (y replacement art!roplasty# Patients are (etter assesse" (ase" o t!eir "aily acti%ity rat!er t!an t!eir c!ronological age# *n a p!ysically young patient 1C@070 years2 a mo"e o open re"uction an" internal ixation s!oul" (e un"erta.en as an e ort to preser%e t!e emoral !ea"# *n case at a later "ate a re%ision surgery is re'uire" t!ese p!ysically acti%e patient +oul" (e a(le to +it!stan" t!e surgery# *n patients age" 7007@ years an on going "e(ate +!et!er t!e emoral !ea" s!oul" (e preser%e" or replace" still continues# Hicole :3;< an" Gar"en :33< "o not support t!e policy routine o !emiart!roplasty consi"ering it D"ecapitation (y age- +!ere a %alua(le %ia(le portion o t!e emoral !ea" is sacri ice"# *n clinical practice t!e use o p!ysiological age is more appropriateF patients +!o are in"epen"ently mo(ile an" acti%e are consi"ere" to (e less t!an 70 years an" t!ose +!o are !ouse (oun" an" !as limite" a(ilities is consi"ere" to (e more t!an 70 years# $!ese groups o patients +oul" (ene it +it! a !emiart!roplasty# Ho+e%er i !is patient is completely immo(ile prior to operation t!an conser%ati%e management s!oul" (e consi"ere"# $!e a(o%e patient +as t!at +it! a p!ysiological age o o%er 70 years an" Gar"en $ype *E racture t!us a !emiart!roplasty +as carrie" out# $!e aceta(ular o t!is patient on x0


ray s!oul" e%i"ence o art!ritis or +ear# Bipolar !emiart!roplasty is use" in patients +!o are expecte" to outli%e t!e prost!esis an" +ear aceta(ulum is note"# Kit! t!e use o (ipolar t!e re%ision surgery at a later "ate is ma"e easy as only t!e aceta(ular component is c!ange" an" t!e emoral component nee" not (e replace"# *n (ipolar !emiart!roplasty t!e use o cement apparently re"uces post operati%e pain ena(ling patient or early mo(ili,ation& pro%i"es sta(ility or t!e prost!esis (y pre%enting sin.age o loosening o prost!esis# Ho+e%er t!e "isa"%antages o t!e use o cemente" are t!e increase in t!e cost& increase in t!e ris. o "islocation re'uiring an open re"uction an" t!e "isa"%antage o t!e cement it sel causing an increase" ris. in car"io%ascular collapse# REFERANCES :;< Martin A"& Sil%ert!orn KG& Ber!ar"son S& Ka")a A& Brs LL# $!e inci"ence o racture o t!e proximal emur in t+o million =ana"ians rom ;A730;A8># =lin Brt!op ;AA;F 3CC: ;;;0;;8 :3< :4< :>< Katerston JA# Falls in t!e el"erly0 uture strategies# Journal o social me"icine ;AA;F 8>:;8A0;A; =la ey $J# A%ascular necrosis o t!e emoral !ea"F an anatomical stu"y# J Bone a Joint Surg# ;AC0F >3B: 803080A# Se%itt S& $!ompson RG# $!e "istri(ution an" anastomosis o @74 :@< :C< :7< ?ast+oo" H5H# 5elaye" "iagnosis in t!e emoral nec. ractures in t!e el"erly# Age ageing ;A87F ;C 4780483# Lures!i KH& Ho".inson HM# ?%aluation o instutionalise" el"erly# Ageing ;A7>F 4: ;@30;@7 5a%is Fm& Koolner 5F& Frampton =& Kil.inson A& Grant A& Harrison P$& Ro(ert M$S& $!a"a.a R# Prospecti%e multicenter trail o mortality ollo+ing general or spinal anaest!esia or !ip racture surgery in t!e el"erly# Britis! Journal o Anaest!esia ;A87F @A: ;0800;088 a ten mental test in t!e arteries supplying t!e emoral !ea" an" nec. #J Bone an" Joint Surg ;AC@F >7B:@C00


:8< :A< :;0< :;;<

Hunn 5# Sl"ing !ip scre+ an" me"ial "isplacement osteotomy# Journal o social me"icine# ;A88F 8: ;>00;>3 Lyon LJ& He%ins MA# Management o !ip ractures in nursing !ome patients& to treat or not to treatM Journal Am Geriartr Soc ;A8>F 43F 4A;04A@ S!a tan GK& Her(sman H& Pa%li"es =# Selecti%e conser%ati%e treatment in !ip ractures# Surgery ;AC7F C;: @3>0@37 Burnatt JK& Gustilo RB& Kiliams 5H& Kin" A=# Prop!ylactic anti(iotic * !ip ractures : a "ou(le (lin" prospecti%e stu"y # J Bone an" Joint Surg ;A80F C3A: >@70>C3

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Barnes R& Bro+n J$& Gar"en RS& Hicoll ?A# Su(capital racture o t!e emur: a prospecti%e re%ie+# J Bone an" Joint Surg ;A7CF @8B:303> Bro+ns J$& A(rami G# $ranscer%ical emoral racture: a re%ie+ o ;A@ patients treate" (y sli"ing nail plate ixation# J Bone an" Joint Surg ;AC>F >CB: C>80CC4

:;>< :;@<

5alen H& Joco(sson B# Factors in luencing t!e inci"ence o reoperation a ter emoral nec. ractures# *nt Brt!op ;A8@F A: 34@0347 Sc!ec. M# *ntracapsular racture o ;A@AF >;A: ;;870;300 emoral nec.: comminution o t!e posterior nec. cortex as a cause o un sta(le ixation# J Bone an" Joint Surg


$urner JH# Post Itraumatic a%ascular necrosis o t!e emoral !ea" pre"icte" (y preoperati%e tec!netium 0AAm antimony colloi" scan# J Bone an" Joint Surg ;A84F C@AF 78C07A7


Jensen J& Haug! J# Fractures o t!e emoral nec.: a ollo+0up stu"y a ter non operati%e treatment o Gar"en Stage * an" ** ractures# in)ury ;A84F ;>F 44A0 4>3

:;8< :;A< :30<

Lo+ell J5# Results an" complications o emoral nec. ractures# =lin Brt!op ;A80F ;@3: ;C30;73 Martyn JP& Glyp AP# Hip racture management# $reatment o intracapsular racture emur& Bx or"& Blac.+ell pu(lication Bro"etti A# $!e (loo" supply o t!e emoral nec. an" !ea" in relation to t!e "amaging e ects o scre+s an" nails& J Bone an" Joint Surg ;AC0 F >3B F 7A>0 80;


:3;< :33<

Hicoll ?A# $!e unsol%e" racture# ) Bone an" Joint Surg ;AC4F >B: 34A03>; Gar"en RS # Selecti%e surgery in me"ial racture o t!e emoral nec.# *n)ury ;A77F A: @07