AO Foundation

Education

Femoral neck fractures

Piet de Boer, York, UK.

Ian Harris, Adelaide, Australia
Mariusz Bonczar, Crocow , Poland

Objectives

outline the biological and mechanical problems in

treating femoral neck fractures

identify the indication for fixation and arthroplasty

Anatomy, classification

31B
3

lateral circumflex artery

Blood supply
4

medial circumflex artery

Anterior

posterior

medial circumflex artery

6

Blood supply
Cranial anastomosis

biological effect

The posterior retinuacular vessels from the medial circumflex artery

provides the main nutrition of the femoral head
7

Proximal femoral fractures

neck fracture
intracapsular,
extraarticular

31-B

trochanteric
areaextracapsular

31-A
8

head fractureintracapsular,
intraarticular

31-C
Classification

AO Classification

B1

subcapital with slight displacement

valgus position
mostly impacted
breakdown of trabecular line

elderly patients
low energy
osteoporosis
female

AO Classification

B2
transcervical
different fracture line angle
and position
displacement

10

younger patients
high energy
male

AO Classification

B3
subcapital displaced
no impaction
different degree of displacement

11

Garden Classification (1961)

II

III

IV

appearance of the trabeculae of the femoral head on AP X-ray

high degree of interobserver variation

difficult to predict complication ( esp. grade III and IV )
only division on undisplaced ( I, II) and displaced (III, IV)

12

Pauwels classification (1935)

< 30

30 - 70

> 70

shearing forces at the site of fracture

high degree of inter and intraobserver variation
preoperative angle has no correlation with the subsequent
incidence of complications (except undisplaced fractures)

13

Classification?
what does determine outcome?
displacementundisplaced vs displaced
stabilitystable vs unstable
valgus impacted are stable

14

Incidence
Elderly

Majority

Low energy

Osteoporosis

Female

Young

15

High energy

Male

Diagnosis

AP and lateral x-ray

Hip pain in elderly patient post-fall with normal x-ray

16

Bone scan

Limited MRI (magnetic resonance imaging)

CT (computed tomography) scan

Classification

17

Displaced (stable) vs undisplaced (unstable)

Valgus impacted are stable

impacted
valgus
stable

do not reduce
18

Prognosis
Depends on displacement

Avascular necrosis

Nonunion

Osteoarthritis

Deformity (shortening, varus)

19

Undisplaced fractures

Internal fixation will result in only 10% failure rate

Safe and simple to fix

-

20

Percutaneous or mini-open

Indication for fixation

Impacted and undisplaced fracture: cannulated screwsimplant of choice

minimal exposure
parallel to allow
compression

21

Displaced fractures

22

Elderly patients (the majority)

-

High rate of failure for internal fixation

Joint arthroplasty gives most reliable results

Early weight bearing

Lower failure rate

Young patients
-

Internal fixation is more reliable than in elderly

Arthroplasty is less reliable

Treatment algorithm

no significant co-morbidity

displaced

under 55
23

55-85

over 85

Internal fixation
Reduction

24

Traction table

Open reduction if required

Internal fixation

Multiple cannulated screws

Dynamic hip screw

25

Internal fixation

26

Multiple cannulated screws

-

Minimal exposure

Parallel to allow compression

Dynamic hip screw

-

Increased stability

Increased exposure and bone loss

Allow compression

Internal fixation

27

Internal fixationcomplications

28

30% fixation failure/loss of reduction

Avascular necrosis
Nonunion

Arthroplasty
Indications

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Primary: Elderly, low demand, osteoporotic

Secondary: Failed fixation, nonunion

Arthroplastyoptions

Hemi- vs total joint arthroplasty

Bipolar vs unipolar

Cemented vs uncemented

Approach

30

Arthroplastyoptions

31

Arthroplastyoptions

32

In the elderly, cement is preferred

No significant difference between bipolar and unipolar
Hemi-arthroplasty vs total hip
- Smaller operation
- Lower dislocation rate
- May not last as long as total joint replacement
Anterolateral vs posterior approach

Arthroplastycomplications

33

Dislocation
Infection
Acetabular erosion
Leg length inequality

Further reading
Internal fixation vs
arthroplasty:
- Cochrane
- Orthopaedic trauma
directions

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Summary

Prognosis is dependent on displacement

Internal fixation is indicated for all undisplaced (stable)

fractures, and for all fractures in young patients

Arthroplasty is indicated for displaced fractures in the

elderly

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Summary
Treatment is mechanically based

but results

Results are biologically dependent!

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