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http://upload.orthobullets.com/topic/1037/images/femoral neck blood supply 2.jpg
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Introduction
  • Epidemiology
    • increasingly common due to aging population
    • women > men
    • whites > blacks
    • United states has highest incidence of hip fx rates worldwide
    • most expensive fracture to treat on per-person basis
  • Mechanism
    • high energy in young patients
    • low energy falls in older patients
  • Pathophysiology
    • healing potential
      • femoral neck is intracapsular, bathed in synovial fluid
      • lacks periosteal layer
      • callus formation limited, which affects healing
  • Associated injuries
    • femoral shaft fractures
      • 6-9% associated with femoral neck fractures  
      • treat femoral neck first followed by shaft
  • Prognosis
    • mortality
      • ~25-30% at one year (higher than vertebral compression fractures)  
    • predictors of mortality
      • pre-injury mobility is the most significant determinant for post-operative survival 
      • in patients with chronic renal failure, rates of mortality at 2 years postoperatively, are close to 45%   

 

Anatomy
  • Osteology
    • normal neck shaft-angle 130 +/- 7 degrees
    • normal anteversion 10 +/- 7 degrees
  • Blood supply to femoral head  
    • major contributor is medial femoral circumflex (lateral epiphyseal artery)
    • some contribution to anterior and inferior head from lateral femoral circumflex
    • some contribution from inferior gluteal artery
    • small and insignificant supply from artery of ligamentum teres
    • displacement of femoral neck fracture will disrupt the blood supply and cause an intracapsular hematoma (effect is controversial) q q
Classification
 
Garden Classification
(based on AP radiographs and does not consider lateral or sagittal plane alignment)

Type I Incomplete, ie. valgus impacted  
Type II Complete fx. nondisplaced  
Type III Complete, partially displaced  
Type IV Complete, fully displaced  
Posterior roll-off and/or angulation of femoral head leads to increased reoperation rates
 
Simplified Garden Classification
Nondisplaced Includes Garden I and II
Displaced Includes Garden IIII and IV
 
Pauwels Classification
 
(based on vertical orientation of fracture line)

Type I < 30 deg from horizontal

Type II 30 to 50 deg from horizontal

Type III > 50 deg from horizontal (most unstable with highest risk of nonunion and AVN)

 
Presentation
  • Symptoms
    • impacted and stress fractures
      • slight pain in the groin or pain referred along the medial side of the thigh and knee
    • displaced fractures
      • pain in the entire hip region
  • Physical exam
    • impacted and stress fractures
      • no obvious clinical deformity
      • minor discomfort with active or passive hip range of motion, muscle spasms at extremes of motion
      • pain with percussion over greater trochanter
    • displaced fractures
      • leg in external rotation and abduction, with shortening
Imaging
  • Radiographs
    • recommended views
      • obtain AP pelvis and cross-table lateral, and full length femur film of ipsilateral side
      • consider obtaining dedicated imaging of uninjured hip to use as template intraop
      • traction-internal rotation AP hip is best for defining fracture type q
      • Garden classification is based on AP pelvis
  • CT
    • helpful in determining displacement and degree of comminution in some patients
  • MRI 
    • helpful to rule out occult fracture q
    • not helpful in reliably assessing viability of femoral head after fracture
  • Bone scan
    • helpful to rule out occult fracture
    • not helpful in reliably assessing viability of femoral head after fracture
  • Duplex Scanning
    • indication
      • rule out DVT if delayed presentation to hospital after hip fracture 
Treatment
  • Nonoperative
    • observation alone
      • indications
        • may be considered in some patients who are non-ambulators, have minimal pain, and who are at high risk for surgical intervention
  • Operative
    • ORIF
      • indications
        • displaced fractures in young or physiologically young patients
          • ORIF indicated for most pts <65 years of age
    • cannulated screw fixation 
      • indications
        • nondisplaced transcervical fx
        • Garden I and II fracture patterns in the physiologically elderly
        • displaced transcervical fx in young patient
          • considered a surgical emergency
          • achieve reduction to limit vascular insult
          • reduction must be anatomic, so open if necessary
    • sliding hip screw or cephalomedullary nail
      • indications
        • basicervical fracture
        • vertical fracture pattern in a young patient
          • biomechanically superior to cannulated screws
      • consider placement of additional cannulated screw above sliding hip screw to prevent rotation
    • hemiarthroplasty 
      • indications
        • controversial
        • debilitated elderly patients
        • metabolic bone disease
    • total hip arthoplasty q q    
      • indications
        • controversial
        • older active patients
        • patients with preexisting hip osteoarthritis
          • more predictable pain relief and better functional outcome than hemiarthroplasty
        • arthroplasty for Garden III and IV in patient < 85 years
Techniques
  • General Surgical Consideration
    • time to surgery
      • controversial
        • reduction method and quality has more pronounced effect on healing than surgical timing
      • elderly patients with hip fractures should be brought to surgery as soon as medically optimal 
        • the benefits of early mobilization cannot be overemphasized
          • improved outcomes in medically fit patients if surgically treated less than 4 days from injury 
    • treatment approach based on
      • degree of displacement
      • physiologic age of the patient (young is < than 50
      • ipsilateral femoral neck and shaft fractures 
        • priority goes to fixing femoral neck because anatomic reduction is necessary to avoid complications of AVN and nonunion
    • fixation with implants that allow sliding
      • permit dynamic compression at fx site during axial loading
      • can cause shortening of femoral neck
        • prominent implants
        • affects biomechanics of hip joint
        • lower physical function on SF-36
        • decreased quality of life
      • anatomic reduction with intraop compression and placement of length stable devices decrease shortening
    • open versus closed reduction 
      • worse outcomes with displacement > 5 mm (higher rate of osteonecrosis and nonunions)
      • no consensus on which reduction approach is superior
      • multiple closed reduction attempts are associated with higher risk of osteonecrosis of the femoral head
  • ORIF
    • approach
      • limited anterior Smith-Peterson 
        • 10cm skin incision made beginning just distal to AIIS
        • incise deep fascia
        • develop interval between sartorious and TFL
        • external rotation of thigh accentuates dissection plane
        • LFCN is identified and retracted medially with sartorius
        • identify tendinous portion of rectus femoris, elevate off hip capsule
        • open capsule to identify femoral neck
      • Watson-Jones
        • used to gain improved exposure of lower femoral neck fractures
        • skin incision approx 2cm posterior and distal to ASIS, down toward tip of greater trochanter
        • incision curved distally and extended 10cm along anterior portion of femur
        • incise deep fascia
        • develop interval between TFL and gluteus medius
        • anterior aspect of gluteus medius and minimus is retracted posteriorly to visualize anterior hip capsule
        • capsule sharply incised with Z-shape incision
        • capsulotomy must remain anterior to lesser trochanter at all times to avoid injury to medial femoral circumflex artery
      • reduction (method may vary)
        • evacuate hematoma
        • place A to P k-wires into femoral neck/head proximal to fracture to use as joysticks for reduction
        • insert starting k-wire (for either cannulated screw or sliding hip screw) into appropriate position laterally, up to but not across the fracture
        • once reduction obtained, drive starting k-wire across fracture
        • insert second threaded tipped k-wire if adding additional fixation
  • Cannulated Screw Fixation
    • technique
      • three screws if noncomminuted (3 screw inverted triangle shown to be superior to two screws)
      • order of screw placement (this varies)
        • 1-inferior screw along calcar
        • 2-posterior/superior screw
        • 3-anterior/superior screw
      • obtain as much screw spread as possible in femoral neck
      • inverted triangle along the calcar (not central in the neck) has stronger fixation and higher load to failure 
      • four screws considered for posterior comminution
        • clear advantage of additional screws not proven in literature
      • starting point at or above level of lesser trochanter to avoid fracture
      • avoid multiple cortical perforations during guide pin or screw placement to avoid development of lateral stress riser
  • Hemiarthroplasty
    • approach
      • posterior approach has increased risk of dislocations
      • anterolateral approach has increased abductor weakness
    • technique
      • cemented superior to uncemented
      • unipolar vs. bipolar
  • Total Hip Replacement
    • technique
      • should consider using the anterolateral approach and selective use of larger heads in the setting of a femoral neck fracture
    • advantages
      • improved functional hip scores and lower re-operation rates compared to hemiarthroplasty 
    • complications
      • higher rate of dislocation with THA (~ 10%)
        • about five times higher than hemiarthroplasty 
 
Complications
  • Osteonecrosis 
    • incidence of 10-45% q q
    • recent studies fail to demonstrate association between time to fracture reduction and subsequent AVN
    • increased risk with
      • increase initial displacement
        • AVN can still develop in nondisplaced injuries
      • nonanatomical reduction
    • treatment
      • major symptoms not always present when AVN develops
      • young patient
        • > 50% involvement then treat with FVFG vs THA
      • older patient
        • prosthetic replacement (hemiarthroplasty vs THA)
  • Nonunion
    • incidence of 5 to 30%
      • increased incidence in displaced fractures
      • no correlation between age, gender, and rate of nonunion
    • varus malreduction most closely correlates with failure of fixation after reduction and cannulated screw fixation. 
    • treatment
      • valgus intertrochanteric osteotomy   
        • indicated in patients after femoral neck nonunion
          • can be done even in presence of AVN, as long as not severely collapsed
          • turns vertical fx line into horizontal fx line and decreases shear forces across fx line q
      • free vascularized fibula graft (FVFG)
        • indicated in young patients with a nonviable femoral head 
      • arthroplasty  
        • indicated in older patients or when the femoral head is not viable
        • also an option in younger patient with a nonviable femoral head as opposed to FVFG
      • revision ORIF
  • Dislocation
    • higher rate of dislocation with THA (~ 10%)
      • about seven times higher than hemiarthroplasty
 

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Questions (17)

(OBQ13.123) A 65-year-old female sustained the injury seen in Figure A after a slip and fall getting out of the shower. She is an avid golfer and walks the course on most days. Her past medical history includes borderline hypertension and migraine headaches. Which treatment option has shown to have the lowest re-operation rate and best clinical outcomes scores in this patient population? Review Topic

QID:4758
FIGURES:
1

Closed reduction with cannulated screw fixation

1%

(25/1699)

2

Open reduction with cannulated screw fixation

1%

(12/1699)

3

Closed reduction and short intramedullary nail fixation

1%

(14/1699)

4

Hemiarthroplasty

7%

(118/1699)

5

Total hip arthroplasty

90%

(1523/1699)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

Figure A shows a displaced right femoral neck fracture in an active, healthy elderly patient. Treatment of her hip fracture with total hip arthroplasty (THA) has shown to have the lowest re-operation rates and best functional outcome scores when compared to internal fixation devices and hemiarthroplasty.

Large studies have shown the incidence of femoral head AVN to be approximately 30-45% with displaced femoral neck fractures (Garden III-IV). For this reason, treatment of these injuries in elderly patients have supported arthroplasty over ORIF. Treatment of patients with THA vs. hemiarthroplasty have also been investigated. Studies have shown that THA has lower re-operation rates and improved functional outcome scores in younger, active elderly patients compared to hemiarthroplasty.

Avery et al. prospectively followed a cohort of 81 patients treated with THA vs. hemiarthroplasty in high functioning elderly patients with displaced femoral neck fractures. They showed a lower mortality rate (p = 0.013) and trend towards superior function in patients treated with THA. Advantages with THA vs hemiarthroplasty must be traded off against a slightly higher risk of dislocations.

Hedbeck et al. performed a randomized controlled trial involving 120 elderly patients with acutely displaced femoral neck fractures that were treated with either bipolar hemiarthroplasty or THA. They showed Harris hip scores and EQ-5D scores in favour of THA. They suggested treatment with THA in elderly, lucid patients with displaced femoral neck fractures.

Figure A is a AP pelvic radiograph. The most obvious finding is a displaced femoral neck fracture.

Incorrect Answers:
Answers 1,2,3: Arthroplasty of any type has been shown to have the least amount of complications and greatest functional outcome scores compared to internal fixation devices. Indications for treatment of femoral neck fractures with internal fixation include: (1) stable or unstable fractures in young or physiologically young patients (2) stable fragility fractures (Garden I and II) in low demand elderly patients.
Answer 4: Hemiarthroplasty is most appropriate for displaced femoral neck fractures (Garden III or IV) in low-functional demand elderly patients.


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(SBQ12.1) A 65-year-old patient sustains the injury shown in Figure A. His medical history is significant for hypertension, Type 2 diabetes and dialysis dependent chronic kidney failure. A postoperative radiograph is shown in Figure B. Based on his risk factors, what is his most likely post operative mortality at two years after surgery? Review Topic

QID:3916
FIGURES:
1

13%

5%

(183/3358)

2

25%

26%

(883/3358)

3

45%

45%

(1508/3358)

4

60%

22%

(740/3358)

5

100%

1%

(32/3358)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

Based on the injury sustained and the risk factors (namely chronic renal failure) shown, the patient will likely have a postoperative mortality of 45% at 2-years post operatively.

Hip fractures often occur older patients from low energy type mechanisms of injury. In femoral neck fractures, the relative pre-injury mobility is the most significant determining factor for the postoperative survival.

Bhattacharya et al. reviewed factors affecting acute mortality in patients undergoing orthopaedic procedures. They found that patients with history of chronic renal failure had an univariate mortality rate of 9%. The most predictive factors of death were: chronic renal failure, CHF, COPD, hip fracture and an age greater than 70 years of age.

Karaeminogullari et al. reviewed clinical outcomes of operative treatment of hip fractures in patients on chronic hemodialysis. A total of 29 patients sustained 32 hip fractures. The mortality rate, with an average follow up of 23 months, was found to be 45%. They found a significant association between age and risk of mortality.

Figure A shows an AP radiograph demonstrative of a displaced femoral neck fracture. Figure B shows a postoperative radiograph with an appropriately placed hip hemi-arthroplasty. Illustration V is a video that provides a brief overview of the evaluation and management of femoral neck fractures.

Incorrect Answers
1, 2, 4, 5: Based on the current literature, the post operative mortality rates at close to 2 years of follow up are 45%

ILLUSTRATIONS:

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(OBQ12.104) Which of the following injuries is anticipated to have a 20% chance of mortality and 50% chance of loss of independence at one year when sustained by an 85-year-old female? Review Topic

QID:4464
1

Intra-articular distal humerus fracture

0%

(9/2189)

2

Distal radius fracture

1%

(25/2189)

3

Femoral neck fracture

95%

(2072/2189)

4

Trimalleolar ankle fracture-dislocation

2%

(33/2189)

5

Periprosthetic distal femur fracture

2%

(33/2189)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

A femoral neck fracture has been shown to have an estimated mortality rate of 20% or more at one year after injury, and estimates regarding loss of independence are at 50%.

Most literature on the topic points out the highest mortality rate is in the first 3-6 months, with mortality rates of 14-36% at one year; mortality rates have been found to return to normal, age-matched controls after that.

Egol et al. provide a review of the factors involved in functional recovery of patients with femoral neck fractures. They report the successes of integrated care pathways and review the risk factors (institutionalization, comorbidities, etc.) that go into the outcomes of these patients. They recommend comanagement of these patients with a medical or geriatric service in order to improve patient outcomes.

Incorrect Answers:
Answer 1,2,4,5: These can be debilitating injuries, but no evidence exists to show these injuries are associated with these levels of morbidity and mortality at one year.


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(OBQ11.233) A 48-year-old active female underwent percutaneous screw fixation of a minimally displaced femoral neck fracture six months ago. There were no immediate post-operative complications, and she was progressed to full weight bearing three months after surgical fixation. Initial post-operative radiographs, and radiographs taken 3 months post-op revealed anatomic reduction of the fracture with no shortening. At her latest clinic visit she reports severe right groin pain, and difficulty ambulating. A current radiograph is shown in Figure A. What is the most appropriate surgical treatment? Review Topic

QID:3656
FIGURES:
1

Hemiarthroplasty

11%

(178/1683)

2

In situ dynamic hip screw revision fixation

3%

(57/1683)

3

Core decompression and bone grafting

2%

(34/1683)

4

Valgus intertrochanteric osteotomy with blade fixation

70%

(1180/1683)

5

Open reduction, bone grafting, and revision percutaneous screw fixation

13%

(227/1683)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

The clinical presentation is consistent with a femoral neck nonunion, which is supported by the presence of new varus collapse and shortening which was not noted on prior radiographs. The most appropriate method to treat this complication is valgus intertrochanteric osteotomy of the femur with blade plate fixation.

Valgus intertrochanteric osteotomies function by making a vertical fracture more horizontal, converting shear into compressive forces. It also helps correct the varus position of the fracture nonunion.

Watson et al performed a retrospective review of the complications associated with combination femoral neck/shaft fractures and found 13 patients who had healing complications develop after their index surgical procedure. Eight femoral neck nonunions occurred, and these healed after either valgus intertrochanteric osteotomy (seven patients) or compression hip screw fixation (one patient).

Jackson et al state that nonunion may occur in up to 43% of displaced intracapsular femoral neck fractures. The authors present an evidence-based algorithm regarding procedures for treatment of femoral neck nonunion and the roles of refixation, osteotomy, grafting, and prosthetic replacement when indicated.

Angelini et al provide a review on salvage procedures after failed fixation of hip fractures. The authors state that in the setting of a nonunion in the younger patients with a well-preserved hip joint, treatment should typically involve revision internal fixation with or without osteotomy or bone grafting. They conclude that overall, salvage of nonunions of femoral neck and intertrochanteric hip fractures in properly selected patients can provide patients with good to excellent results.

Figure A shows a femoral neck nonunion with varus collapse. Illustration A shows an example of a valgus intertrochanteric osteotomy with blade fixation.

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(OBQ11.269) Which of the following cannulated screw configurations used in the treatment of subcapital femoral neck fractures is optimal? Review Topic

QID:3692
1

Inverted triangle pattern with the inferior screw posterior to midline and adjacent to the calcar

76%

(1228/1608)

2

Inverted triangle pattern with the inferior screw anterior to midline and adjacent to the calcar

12%

(197/1608)

3

Triangle pattern with the superior screw posterior to midline and adjacent to the calcar

1%

(22/1608)

4

Inverted triangle pattern with the inferior screw posterior to midline and central in the femoral neck

8%

(130/1608)

5

Inverted triangle pattern with the inferior screw anterior to midline and central in the femoral neck

2%

(27/1608)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

The strongest portion of the femoral neck is the posterior inferior neck in the region of the femoral calcar. The optimal biomechanical configuration includes an inverted triangle pattern with the single screw in the inferior aspect of the femoral neck adjacent to the calcar.

Booth et al performed a cadaveric study comparing central versus calcar (cortical-adjacent) fixation. The results demonstrated significant improved stability, load, stiffness, and displacement in all tested parameters for the group with calcar-adjacent screw fixation.

Lindequist and Törnkvist performed a Level 4 study of 72 femoral neck fractures. They found that all 5 of their nonunions had screws placed greater than 3mm from the femoral calcar. Additionally, 16 of 18 fractures healed in the group of displaced fractures where both the fixating screws were placed within 3 mm from the femoral neck cortex.

Gurusamy et al performed a Level 4 study of 395 patients undergoing femoral neck fixation. They found a reduced spread of the screws on the lateral view was associated with an increased risk of nonunion of the fracture.

Illustration A depicts the optimal configuration of an inverted triangle with the single screw being inferior and all of the screws being cortical adjacent.

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(OBQ10.79) A 25-year-old man sustains the fracture seen in Figure A and is seen in pre-op holding prior to surgery. What position of his lower extremity would result in the lowest intracapsular hip pressure? Review Topic

QID:3167
FIGURES:
1

Neutral rotation and flexion

1%

(6/474)

2

External rotation and flexion

81%

(384/474)

3

Internal rotation and extension

4%

(17/474)

4

External rotation and extension

4%

(21/474)

5

Internal rotation and flexion

9%

(45/474)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

The femoral neck fracture seen in Figure A is considered by most to be a surgical emergency in a 25-year old due to the at risk blood supply of the femoral head. Due to the intra-capsular hematoma and hemarthrosis that occurs, the involved extremity is often found to be in external rotation and flexion as the intra-capsular volume is the highest in this position. Debate exists of the significance of the pressure caused by the fracture hemarthrosis as it is believed by some to cause a local compartment syndrome adding further insult to the already tenuous blood supply. Advocates of early fixation have proposed that reduction maneuvers without capsulotomy can compromise the circulation of the femoral head by increasing the hip joint pressure. Maruenda et al showed in their study of 34 consecutive patients with femoral neck fractures that the mean intracapsular pressure was the highest with the hip in extension and internal rotation.

Bonnaire et al in their prospective study of 55 patients with intracapsular femoral neck fractures found the lowest pressure to be at 70 degrees of flexion. Both Maruenda and Bonnaire's studies showed no significant intracapsular pressure difference based on fracture displacement.

Corollary to adult fracture patients, it is also noted that pediatric patients with a septic hip hold their hip in a flexed and externally rotated position to maximize intracapsular volume as shown in Illustration A.

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(OBQ10.82) A 15-year-old male falls from his bicycle and lands directly on his left hip. He is unable to bear weight and presents to the emergency department with the AP pelvis radiograph seen in Figure A. Which of the following radiographic views could aid in classifying this patient's fracture pattern? Review Topic

QID:3170
FIGURES:
1

Iliac oblique (Judet) view

4%

(40/900)

2

Traction AP of the hip with the leg in neutral rotation

6%

(55/900)

3

Outlet view of the pelvis

1%

(9/900)

4

Traction AP of the hip with the leg internally rotated 15°

76%

(682/900)

5

Traction AP of the hip with the leg externally rotated 15°

12%

(111/900)

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PREFERRED RESPONSE 4

The ability to define the location of a femoral neck fracture aids in determining the optimal treatment. The addition of a "traction-internal rotation" view (as described in Answer 4) to standard hip radiographs may assist with classification of femoral neck fractures by accounting for the anteversion of the femoral neck.

Koval et al performed a study in which proximal femur fractures were classified with standard radiographs (AP pelvis, AP hip, cross-table lateral), followed by the addition of a physician-assisted view with traction and 15 degrees of internal rotation. The inclusion of the traction-internal rotation view led to increased agreement in classification between the authors, and was especially helpful for differentiating displaced femoral neck fractures versus stable intertrochanteric fractures.


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(OBQ09.79) A 79-year-old cyclist is involved in an accident and sustains a displaced femoral neck fracture as seen in Figure A. What is the optimal treatment? Review Topic

QID:2892
FIGURES:
1

Open reduction internal fixation

8%

(120/1557)

2

Bipolar hemiarthroplasty

8%

(128/1557)

3

Unipolar hemiarthroplasty

5%

(72/1557)

4

Total hip arthoplasty

79%

(1235/1557)

5

Nonoperative treatment

0%

(0/1557)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

An AP pelvis radiographs with a displaced femoral neck fracture is seen in Figure A. It important to note that degenerative changes are seen on this image. Both references suggest that elderly active individuals should be treated with a primary total hip after displaced femoral neck fractures.

In the first study by Blomfeldt et al, the group reviewed a series of patients who underwent either an acute primary total hip arthroplasty for a femoral neck fracture or a delayed primary hip after an attempt at ORIF. They found that the group treated with an acute primary total hip arthroplasty had better Harris hip and quality of life scores.

The second reference from Blomfeldt et al, studies a population of active elderly patients randomized to either a total hip arthroplasty or bipolar for femoral neck fractures. The group found no mortality or dislocation difference between the groups, but higher Harris hip scores at 1 year in patients treated with a total hip
arthroplasty.


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(OBQ09.220) A 27-year-old man sustains a displaced femoral neck fracture and undergoes urgent open reduction internal fixation. What is the most prevalent complication after this injury? Review Topic

QID:3033
1

Flexion contracture

1%

(6/428)

2

Hip instability

2%

(7/428)

3

Nonunion

6%

(25/428)

4

Abductor lurch

6%

(25/428)

5

Osteonecrosis

85%

(364/428)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

Femoral neck fractures in young patients are difficult to treat, and AVN is a significant concern. Despite advances in both imaging and implants, this injury often leads to functional impairment.

Haidukewych et al followed treatment of femoral neck fractures in young patients. They found almost 10% of displaced fractures were associated with the development of nonunion, where as 27% were associated with the development of osteonecrosis. Their results were influenced by fracture displacement and the quality of reduction. Varus malreduction most closely correlates with failure of fixation after reduction and cannulated screw fixation.

Swiontkowski reviews both the treatment and post operative complications in intracapsular hip fractures. In this Current Concept Review, the rate of AVN was discussed as being related to the pre-operative degree of displacement seen on radiographs.

Incorrect Responses:
Answers 1 & 4: While each of these complications do occur, they are less common and are related to the approach and degree of surgical dissection.
Answer 2: Hip instability is relatively uncommon.
Answer 3: Nonunion rate is significant but lower than the AVN rate. It is has been associated with the degree of initial displacement and varus malreduction.


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(OBQ07.174) A 70-year-old woman trips on the grass while playing golf and sustains a displaced comminuted femoral neck fracture. What is the optimal treatment for this patient? Review Topic

QID:835
1

Open reduction internal fixation

1%

(4/470)

2

Bipolar hemiarthroplasty

11%

(53/470)

3

Total hip arthroplasty

84%

(393/470)

4

Unipolar hemiarthroplasty

4%

(18/470)

5

Traction and non operative treatment

0%

(1/470)

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PREFERRED RESPONSE 3

The answer is total hip arthroplasty (#3).Both references suggest that elderly active individuals should be treated with a primary total hip after displaced femoral neck fractures.

Keating et al randomized 207 patients to be either treated with ORIF, bipolar hemiarthroplasty, or total hip arthroplasty. There was no mortality difference among the three groups, however the rate of secondary surgery was highest in the ORIF group (39% compared with 5% in the group treated with bipolar hemiarthroplasty and 9% in the group treated with total hip replacement). Furthermore, the fixation group had the worst hip-rating-questionnaire and EuroQol scores at four and twelve months.

Tidermark et al in a randomized controlled trial, studied the difference between ORIF and total hip replacement in 102 patients. The total hip replacement group showed a lower overall complication rate (36% versus 4%) and higher hip function scores in regard to pain, movement and walking.

Illustration A shows the division of proximal femur fractures according to location.

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(OBQ07.227) A 65-year-old male falls from a standing height and sustains the injury seen in Figure A and undergoes the treatment seen in Figure B. Compared to a total hip arthroplasty, this treatment is associated with which of the following: Review Topic

QID:888
FIGURES:
1

Increased blood loss

1%

(8/1076)

2

Lower incidence of revision surgery

3%

(32/1076)

3

Increased risk of peri-prosthetic fracture

2%

(23/1076)

4

Lower dislocation risk

93%

(1005/1076)

5

Increased risk deep venous thrombosis

0%

(5/1076)

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PREFERRED RESPONSE 4

Figure B shows a bipolar hemiarthroplasty that was performed for a displaced femoral neck fracture. The advantages of hemiarthroplasty, compared with total hip arthroplasty, for the treatment of displaced femoral neck fractures include the more limited nature of the procedure (decreased blood loss and operative time) and the lower risk of instability. The disadvantages include the possible development of pain in the groin and acetabular erosion which increases the risk for revision surgery. Sim et al reviewed 126 consecutive hybrid total hip arthroplasties done for acute femoral neck fractures. Minimum follow up was 10.1 years. They noted a high dislocation rate (10%), yet overall good clinical outcome with 87/102 patients who were alive at latest follow up reporting either no or only minimal pain.


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(OBQ06.170) A 75-year-old ambulatory male who lives independently presents with the fracture shown in Figure A. Which of the following is true regarding timing of surgical fixation and post-operative mortality? Review Topic

QID:356
FIGURES:
1

30 day mortality is decreased if surgery is delayed 4-7 days

3%

(56/1905)

2

1 year mortality is increased if surgery is delayed greater than 4 days

81%

(1550/1905)

3

Delay of surgery due to treatment of acute medical comorbidities has no effect on post-operative mortality rates

11%

(216/1905)

4

90 day mortality rate is decreased if surgery is delayed greater than 7 days

1%

(21/1905)

5

Timing of surgical fixation has no statistically significant affect on post-operative mortality

3%

(53/1905)

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PREFERRED RESPONSE 2

Figure A shows a displaced femoral neck fracture.

Moran et al studied 2660 elderly patients who underwent surgical treatment of a hip fracture to determine whether a delay in surgery affects postoperative mortality. The 30-day mortality for patients for whom the surgery had been delayed for more than 4 days was 10.7%, compared to 7.3% in those delayed 1-4 days. The group delayed >4 days also had significantly increased mortality at 90 days and 1 year. Patients who had been admitted with an acute medical comorbidity that required treatment prior to the surgery had a 30-day mortality of 17%, which was nearly 2.5 times greater than that for patients without and acute comorbidity. The study concluded that patients with medical comorbidities that delayed surgery had 2.5 times the risk of death within 30 days after the surgery compared with patients without comorbidities. Mortality was not increased when the surgery was delayed up to four days for patients who were otherwise fit for hip fracture surgery, however, a delay of more than four days significantly increased mortality.

Healy et al examined 120 patients who underwent surgical treatment of 186 displaced femoral neck fractures with either internal fixation, hemiarthroplasty, or total hip arthroplasty. Arthroplasty was associated with more independent living, and was more cost-effective than internal fixation. There was no difference in rates of reoperation or mortality, but arthroplasty produced a longer interval to reoperation or death. They concluded that total hip arthroplasty was the best treatment for displaced fractures of the femoral neck in their series.

Illustration A shows a scoring system developed by Rogmark et al to aid in decision making.

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(OBQ05.264) A 25-year-old male is involved in an high-speed motor vehicle collision and sustains a closed femoral shaft fracture. During further evaluation, a CT scan of the chest/abdomen/pelvis reveals a non-displaced ipsilateral femoral neck fracture. Which of the following treatment options will most likely achieve anatomic healing of the femoral neck and minimize the risk of complications? Review Topic

QID:1150
1

Retrograde femoral nail followed by compression hip screw

15%

(61/414)

2

Lag screw fixation followed by plating of the femoral shaft

3%

(11/414)

3

Antegrade femoral nail followed by lag screw fixation

12%

(49/414)

4

Lag screw fixation followed by retrograde femoral nail

70%

(290/414)

5

Proximal femoral locking plate

0%

(1/414)

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PREFERRED RESPONSE 4

An ipsilateral femoral neck fracture occurs in approximately 6% to 9% of all femoral shaft fractures. A comminuted midshaft femoral fracture secondary to axial loading should alert the treating physician to the possibility of an associated femoral neck fracture. As a result, trauma CT scans should be reviewed for non to minimally displaced femoral neck fractures during the initial work up.

Watson et al did a retrospective review of 13 patients who had healing complications develop after their index surgical procedure for ipsilateral femoral shaft and neck fractures. Six of the eight (75%) femoral neck nonunions occurred after the use of a second generation, reconstruction-type intramedullary nail. Factors contributing to nonunion of the femoral shaft were the presence of an open fracture, use of an unreamed, small diameter intramedullary nail, and prolonged delay to weightbearing. Lag screw fixation of the femoral neck fracture and reamed intramedullary nailing for shaft fracture stabilization were associated with the fewest complications.

Peljovich et al discuss that several treatment options are described in the literature, but no clear consensus exists regarding the optimal treatment of neck/shaft fractures. Due to the the potentially devastating complications of the femoral neck fracture in young patients (avascular necrosis, nonunion, and malunion), the neck fracture should be treated first followed by the shaft. Current recommendations involve treating the neck with a sliding hip screw versus cannulated screws followed by intramedullary nailing of the femoral shaft.


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(OBQ04.14) Increased hip intracapsular pressures can lead to diminished femoral head perfusion. Which of the following limb positions has been shown to create the lowest intracapsular hip pressures after a femoral neck fracture? Review Topic

QID:125
1

flexion and internal rotation

6%

(25/438)

2

extension and external rotation

6%

(27/438)

3

flexion, abduction, and external rotation

80%

(350/438)

4

extension, adduction, and internal rotation

4%

(16/438)

5

there are no differences in hip pressures with any position

4%

(19/438)

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PREFERRED RESPONSE 3

After a femoral neck fracture, patients often present with their injured hip in a flexed, abducted, and externally rotated position due to decreased pain from minimization of the capsular distension from fracture hematoma (if the capsule isn't disrupted).

In the referenced study by Bonnaire et al, extension and internal rotation had the highest intracapsular pressure. They found that the greatest decrease in pressure was found with flexion, abduction and external rotation. This is a possible etiology to the common position in which these patients will present to the emergency room. Traction was shown to increase pressure in the joint capsule.

Incorrect Answers: 1,2,4,5: All of these positions have increased pressure as compared to the position of flexion, abduction, and external rotation.


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(OBQ04.57) A 30-year-old male sustains the injury seen in Figure A after a motor vehicle collision. Which of the following is the most likely complication at 2-year follow-up? Review Topic

QID:1162
FIGURES:
1

Avascular necrosis

85%

(743/870)

2

Hip instability

0%

(3/870)

3

Malunion

12%

(104/870)

4

Chondrolysis

1%

(8/870)

5

Ipsilateral medial knee degenerative changes

1%

(10/870)

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PREFERRED RESPONSE 1

Figure A shows a displaced femoral neck fracture. Avascular necrosis (AVN) and nonunion are the two most common complications after femoral neck fractures in the young adult.

Dedrick et al found nonunion of the fracture site was observed in 20% and avascular necrosis in 36% of young patients with femoral neck fractures. In addition, they reported that of patients with subcapital fractures, 83% developed nonunion or avascular necrosis, compared to 21% with a more distal femoral neck fracture.


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(OBQ04.183) Valgus intertrochanteric osteotomy with blade plate fixation is the most appropriate treatment for which of the following figures? Review Topic

QID:1288
FIGURES:
1

Figure A

7%

(81/1124)

2

Figure B

4%

(47/1124)

3

Figure C

83%

(937/1124)

4

Figure D

2%

(20/1124)

5

Figure E

3%

(37/1124)

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PREFERRED RESPONSE 3

Figure C shows a femoral neck fracture that underwent closed reduction and percutaneous pinning with three screws, that has gone on to femoral neck nonunion. Figure A shows slipped capital femoral epiphysis (SCFE). Figure B shows a subtrochanteric fracture status post intramedullary nailing. Figure D shows a hip labral tear. Figure E shows hip avascular necrosis.
In the case of femoral neck nonunion, a valgus intertrochanteric osteotomy helps to convert any shear force of a vertical fracture line (especially with a high Pauwel's angle) into a horizontal compressive force (Illustration A.)

In their series of 50 patients with femoral neck nonunions, Marti et al treated all patients with Pauwels valgus intertrochanteric osteotomies. At an average followup of seven years, they reported that only 7 patients needed prosthetic replacement. However, nearly half of the patients showed radiographic signs of avascular necrosis (only 3/22 were symptomatic). They conclude that valgus intertrochanteric osteotomy yields good results for young patients with femoral neck nonunions.

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(OBQ04.223) An 82-year-old female sustains a valgus-impacted subcapital femoral neck fracture and undergoes cannulated screw fixation as shown in Figure A. She returns for her first follow-up visit one week later following another fall and now complains of severe hip pain. She is unable to bear weight on the limb, and a new radiograph reveals varus displacement of her fracture. She subsequently undergoes revision fixation but during this procedure, the femoral neck fracture displaces and becomes comminuted. Which is the most appropriate next step in management? Review Topic

QID:1328
FIGURES:
1

Skeletal traction

0%

(6/1544)

2

Revision fixation of the femoral neck fracture

3%

(54/1544)

3

Hardware removal and placement of a sliding hip screw device

9%

(146/1544)

4

Hardware removal and hip arthroplasty

84%

(1303/1544)

5

Resection hip arthroplasty

2%

(32/1544)

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PREFERRED RESPONSE 4

In the scenario of an elderly patient with questionable fixation into the femoral head and a non-healed femoral neck fracture, proper treatment is arthroplasty. In a physiologically younger patient, reduction and fixation of the fractures (femoral neck and subtrochanteric, if present) with methods such as a valgus producing osteotomy at the level of the subtrochanteric fracture are recommended.

Figure A shows cannulated screw fixation of a right femoral neck fracture.

The referenced study by Oakey et al evaluated strength of proximal femurs after cannulated hip screw placement and found that placement of an inverted triangle had a higher ultimate load to failure than placement in a standard triangle format (two screws distal).


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