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Neglected Right Femoral Neck Fracture

By Ayu Nurmuliawati Hanapi C 111 08 328


Advisors dr. Nasrah dr. Luthfi Supervisor dr. Notinas, Sp.OT Bagian Ortopedi dan Traumatologi Fakultas Kedokteran Universitas Hasanuddin Makassar 2013

PATIENTS IDENTITY
Name Age Sex RM Date of admission : Mrs. N : 78 years old : Female : 61 12 17 : 27/05/2013

History
Chief complaint: Pain of the right hip Since 1 month before admitted to hospital due to suddenly felt down. Mechanism of trauma: the patient was walking in front of her house and mechanism of felt is unclear. History of unconsciousness (-), nausea (-), vomit (-) History of bone setter (+)

General Status
Conscious/ Well-nourished BP : 130/80 mmHg HR : 82 x/min, regular RR : 24 x/min Temp. : 36.7C

Local Status
Right Hip Region
INSPECTION : deformity hematoma (+), wound (-)
PALPATION : tenderness (+) ROM : active and passive motion of the right hip is limited due to pain NVD : sensibility is good , dorsal pedis artery palpable, CRT < 2

(+),

swelling

(+),

Laboratory Findings (03/05/2013)


WBC RBC HGB HCT PLT RBG 5800 /uL 3.020.000 /uL 10,2 g/dl 32.1 % 207.000/uL 104 mg/dl SGOT SGPT HBsAg CT BT PT 25U/L 15 U/L Non Reactive 800 230 12.4

Ureum Creatinin Albumin

38 mg/dl 0,70mg/dl 3.0

INR APTT

1.0 26.6

PELVIC X-RAY AP 27/5/2013

FEMUR DEXTRA AP/LAT X-RAY

DIAGNOSIS
Neglected fracture of the right neck femur

TREATMENT
Hemiarthroplasty

Discussion

Anatomy of the Femur

Thompson,JD. Netter's concise atlas of orthopedic anatomy.2004.p169

Thompson JD, Netters concise orthopaedic anatomy p.254

Blood Supply
Lateral epiphysel artery
terminal branch Medial Femoral Circumflex artery predominant blood supply to weight bearing dome of head

Artery of ligamentum teres


from obturator artery supplies anteroinferior head

Lateral femoral circumflex a.


less contribution than MFC
Thompson JD, Netters concise orthopaedic anatomy p.254

Blood Supply
Greater fracture displacement = greater risk of vascular disruption to femoral head revascularization of the head
intact vessels vascular ingrowth across fracture site
importance of quality of reduction

metaphyseal vessels

Epidemiology
250,000 Hip fractures annually
Expected to double by 2050

At risk populations
Elderly: poor balance & vision, osteoporosis, inactivity, medications, malnutrition
incidence doubles with each decade beyond age 50

higher in white population Other factors: smokers, small body size, excessive caffeine & ETOH Young: high energy trauma
Apleys System of Orthopaedics and Fractures 9th edition p.847 Sellvadurai Nayagam

Mechanism of injury
low-energy trauma; most common in older patients:
Direct: A fall onto the greater trochanter (valgus impaction) or forced external rotation of the lower extremity impinges an osteoporotic neck onto the posterior lip of the acetabulum (resulting in posterior comminution). Indirect: Muscle forces overwhelm the strength of the femoral neck.

High-energy trauma: This accounts for femoral neck fractures in both younger and older patients, such as motor-vehicle accident or fall from a significant height. Cyclical loading-stress fractures: These are seen in athletes, military recruits, ballet dancers; patients with osteoporosis and osteopenia are at particular risk.
Handbook of fracture 3rd edition p.320 Koval, Kenneth J.; Zuckerman, Joseph D.

Classification
Anatomic Location
Subcapital Transcervical Basicervical

Handbook of fractures 3rd edition p. 232 Koval, Kenneth J.; Zuckerman, Joseph D.

Functional Classification
Stable
Impacted (Garden I) Non-displaced (Garden II)

Unstable
Displaced (Garden III and IV)

Gardens Classifications

A. Stage I B. Stage II C.Stage III

Incomplete (so- called abducted or impacted) the femoral head in this case is in slight valgus.

complete without displacement.

complete with partial displacement the fragments are still connected by the posterior retinacular attachment; the femoral head trabeculae are no longer in line with those of the innominate bone.

D. Stage IV

Displaced fracture. Complete fracture; total displacementcomplete with full displacement the proximal fragment is free and lies correctly in the acetabulum so that the trabeculae appear normally aligned with those of the innominate. .

Apleys System of Orthopaedics and Fractures 9th edition p.848 Sellvadurai Nayagam

Stage I

Stage II

Stage III

Stage IV

Apleys System of Orthopaedics and Fractures 9th edition p.848 Sellvadurai Nayagam

Fractures classification in clinical practice p.44 Sayed Behrooz Mostofi

Pauwels Classification

This is based on the angle of fracture from the horizontal Type I : 30 degrees Type II : 50 degrees Type III : 70 degrees
Increasing shear forces with increasing angle lead to more fracture instability.
Fractures classification in clinical practice p.44 Sayed Behrooz Mostofi

Clinical Manifestation
There is usually a history of a fall, followed by pain in the hip. If the fracture is displaced, the patient lies with the limb in lateral rotation and the leg looks short. With an impacted fracture the patient may still be able to walk, and debilitated or mentally handicapped patients may not complain at all even with bilateral fractures.
Apleys System of Orthopaedics and Fractures 9th edition Sellvadurai Nayagam

Treatment
Goals
o to minimize patient discomfort, o restore hip function, o allow rapid mobilization by obtaining early anatomic reduction o stable internal fixation or prosthetic replacement

Handbook of fractures 3rd edition p. 232 Koval, Kenneth J.; Zuckerman, Joseph D.

Management
Operative treatment Internal fixation screw Arthroplasty Arthroplasty excision Using prosthesis Half joint replacement arthroplasty Total replecement arthroplasty
Handbook of fractures 3rd edition p. 232 Koval, Kenneth J.; Zuckerman, Joseph D.

Complications
General complication

Deep vein thrombosis, pulmonary embolism,


pnemonia and bed sores.

Avascular necrosis
Non-union osteoarthritis
Apleys System of Orthopaedics and Fractures 9th edition p.848 Sellvadurai Nayagam

Thank You

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