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Average 4.2 of 71 Ratings
Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
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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?
Closed reduction with cannulated screw fixation
Open reduction with cannulated screw fixation
Closed reduction and short intramedullary nail fixation
Total hip arthroplasty
Select Answer to see Preferred Response
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.
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.
Avery PP, Baker RP, Walton MJ, Rooker JC, Squires B, Gargan MF, Bannister GC.
J Bone Joint Surg Br. 2011 Aug;93(8):1045-8. PMID: 21768626 (Link to Abstract)
Avery, BJJ 2011
Hedbeck CJ, Enocson A, Lapidus G, Blomfeldt R, Törnkvist H, Ponzer S, Tidermark J.
J Bone Joint Surg Am. 2011 Mar 2;93(5):445-50. PMID: 21368076 (Link to Abstract)
Hedbeck, JBJS 2011
Please rate question.
Average 3.0 of 16 Ratings
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?
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.
1, 2, 4, 5: Based on the current literature, the post operative mortality rates at close to 2 years of follow up are 45%
Bhattacharyya T, Iorio R, Healy WL.
J Bone Joint Surg Am. 2002 Apr;84-A(4):562-72. PMID: 11940616 (Link to Abstract)
Bhattacharyya, JBJS 2002
Karaeminogullari O, Demirors H, Sahin O, Ozalay M, Ozdemir N, Tandogan RN.
J Bone Joint Surg Am. 2007 Feb;89(2):324-31. PMID: 17272447 (Link to Abstract)
Karaeminogullari, JBJS 2007
Average 1.0 of 50 Ratings
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?
Intra-articular distal humerus fracture
Distal radius fracture
Femoral neck fracture
Trimalleolar ankle fracture-dislocation
Periprosthetic distal femur fracture
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.
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.
Egol KA, Koval KJ, Zuckerman JD.
J Orthop Trauma. 1997 Nov;11(8):594-9. PMID: 9415867 (Link to Abstract)
Egol, JOT 1997
Average 4.0 of 12 Ratings
A 48-year-old active female runner 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?
In situ dynamic hip screw revision fixation
Core decompression and bone grafting
Valgus intertrochanteric osteotomy with blade fixation
Open reduction, bone grafting, and revision percutaneous screw fixation
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.
Watson JT, Moed BR
Clin. Orthop. Relat. Res.. 2002 Jun;(399):78-86. PMID: 12011697 (Link to Abstract)
Watson, CORR 2002
Jackson M, Learmonth ID.
Clin Orthop Relat Res. 2002 Jun;(399):119-28. PMID: 12011700 (Link to Abstract)
Jackson, CORR 2002
Angelini M, McKee MD, Waddell JP, Haidukewych G, Schemitsch EH.
J Orthop Trauma. 2009 Jul;23(6):471-8. PMID: 19550237 (Link to Abstract)
Angelini, JOT 2009
Average 3.0 of 26 Ratings
Which of the following cannulated screw configurations used in the treatment of subcapital femoral neck fractures is optimal?
Inverted triangle pattern with the inferior screw posterior to midline and adjacent to the calcar
Inverted triangle pattern with the inferior screw anterior to midline and adjacent to the calcar
Triangle pattern with the superior screw posterior to midline and adjacent to the calcar
Inverted triangle pattern with the inferior screw posterior to midline and central in the femoral neck
Inverted triangle pattern with the inferior screw anterior to midline and central in the femoral neck
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.
Booth KC, Donaldson TK, Dai QG.
Orthopedics. 1998 Nov;21(11):1173-6. PMID: 9845448 (Link to Abstract)
Booth, ORTHO 1998
Lindequist S, Törnkvist H.
J Orthop Trauma. 1995 Jun;9(3):215-21. PMID: 7623173 (Link to Abstract)
Lindequist, JOT 1995
Gurusamy K, Parker MJ, Rowlands TK.
J Bone Joint Surg Br. 2005 May;87(5):632-4. PMID: 15855363 (Link to Abstract)
Gurusamy, BJJ 2005
Average 4.0 of 19 Ratings
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?
Neutral rotation and flexion
External rotation and flexion
Internal rotation and extension
External rotation and extension
Internal rotation and flexion
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.
Bonnaire F, Schaefer DJ, Kuner EH.
Clin Orthop Relat Res. 1998 Aug;(353):148-55. PMID: 9728169 (Link to Abstract)
Bonnaire, CORR 1998
Maruenda JI, Barrios C, Gomar-Sancho F.
Clin Orthop Relat Res. 1997 Jul;(340):172-80. PMID: 9224253 (Link to Abstract)
Maruenda, CORR 1997
HPI - History OF RTA, sustained crush injury of the leg,and proximal femur fracture
What are the treatment options?
Average 4.0 of 24 Ratings
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?
Iliac oblique (Judet) view
Traction AP of the hip with the leg in neutral rotation
Outlet view of the pelvis
Traction AP of the hip with the leg internally rotated 15°
Traction AP of the hip with the leg externally rotated 15°
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.
Koval KJ, Oh CK, Egol KA.
Bull NYU Hosp Jt Dis. 2008;66(2):102-6. PMID: 18537778 (Link to Abstract)
Average 2.0 of 56 Ratings
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?
Open reduction internal fixation
Total hip arthoplasty
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
Blomfeldt R, Törnkvist H, Ponzer S, Söderqvist A, Tidermark J.
Acta Orthop. 2006 Aug;77(4):638-43. PMID: 16929442 (Link to Abstract)
Blomfeldt R, Törnkvist H, Eriksson K, Söderqvist A, Ponzer S, Tidermark J.
J Bone Joint Surg Br. 2007 Feb;89(2):160-5. PMID: 17322427 (Link to Abstract)
Blomfeldt, BJJ 2007
Average 3.0 of 36 Ratings
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?
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.
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.
J Bone Joint Surg Am. 1994 Jan;76(1):129-38. PMID: 8288657 (Link to Abstract)
Swiontkowski, JBJS 1994
Haidukewych GJ, Rothwell WS, Jacofsky DJ, Torchia ME, Berry DJ.
J Bone Joint Surg Am. 2004 Aug;86-A(8):1711-6. PMID: 15292419 (Link to Abstract)
Haidukewych, JBJS 2004
Average 4.0 of 20 Ratings
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?
Total hip arthroplasty
Traction and non operative treatment
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.
Keating JF, Grant A, Masson M, Scott NW, Forbes JF
J Bone Joint Surg Am. 2006 Feb;88(2):249-60. PMID: 16452734 (Link to Abstract)
Keating, JBJS 2006
Tidermark J, Ponzer S, Svensson O, Soderqvist A, Tornkvist H
J Bone Joint Surg Br. 2003 Apr;85(3):380-8. PMID: 12729114 (Link to Abstract)
Tidermark, BJJ 2003
Average 3.0 of 32 Ratings
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:
Increased blood loss
Lower incidence of revision surgery
Increased risk of peri-prosthetic fracture
Lower dislocation risk
Increased risk deep venous thrombosis
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.
Lee BP, Berry DJ, Harmsen WS, Sim FH.
J Bone Joint Surg Am. 1998 Jan;80(1):70-5. PMID: 9469311 (Link to Abstract)
Lee, JBJS 1998
Average 4.0 of 22 Ratings
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?
30 day mortality is decreased if surgery is delayed 4-7 days
1 year mortality is increased if surgery is delayed greater than 4 days
Delay of surgery due to treatment of acute medical comorbidities has no effect on post-operative mortality rates
90 day mortality rate is decreased if surgery is delayed greater than 7 days
Timing of surgical fixation has no statistically significant affect on post-operative mortality
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.
Moran CG, Wenn RT, Sikand M, Taylor AM.
J Bone Joint Surg Am. 2005 Mar;87(3):483-9. PMID: 15741611 (Link to Abstract)
Moran, JBJS 2005
Healy WL, Iorio R.
Clin Orthop Relat Res. 2004 Dec;(429):43-8. PMID: 15577464 (Link to Abstract)
Healy, CORR 2004
HPI - Fall from a standing height 3 weeks ago , the patient denies to be operated
When is the best time to operate?
Average 2.0 of 22 Ratings
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?
Retrograde femoral nail followed by compression hip screw
Lag screw fixation followed by plating of the femoral shaft
Antegrade femoral nail followed by lag screw fixation
Lag screw fixation followed by retrograde femoral nail
Proximal femoral locking plate
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.
Peljovich AE, Patterson BM.
J Am Acad Orthop Surg. 1998 Mar-Apr;6(2):106-13. PMID: 9682073 (Link to Abstract)
Peljovich, JAAOS 1998
Average 3.0 of 27 Ratings
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?
flexion and internal rotation
extension and external rotation
flexion, abduction, and external rotation
extension, adduction, and internal rotation
there are no differences in hip pressures with any position
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.
Average 3.0 of 30 Ratings
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?
Ipsilateral medial knee degenerative changes
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.
Dedrick DK, Mackenzie JR, Burney RE.
J Trauma. 1986 Oct;26(10):932-7. PMID: 3773004 (Link to Abstract)
Dedrick, JTACS 1986
Valgus intertrochanteric osteotomy with blade plate fixation is the most appropriate treatment for which of the following figures?
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.
Marti RK, Schüller HM, Raaymakers EL.
J Bone Joint Surg Br. 1989 Nov;71(5):782-7. PMID: 2584247 (Link to Abstract)
Marti, BJJ 1989
Average 3.0 of 23 Ratings
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?
Revision fixation of the femoral neck fracture
Hardware removal and placement of a sliding hip screw device
Hardware removal and hip arthroplasty
Resection hip arthroplasty
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).
Oakey JW, Stover MD, Summers HD, Sartori M, Havey RM, Patwardhan AG.
Clin Orthop Relat Res. 2006 Feb;443:302-6. PMID: 16462455 (Link to Abstract)
Oakey, CORR 2006
Average 3.0 of 38 Ratings
HPI - Fell at home onto his left side. Inability to ambulate following the fall.
Is this closed reduction and fixation acceptable?
HPI - 90F, fall from standing height after slipping walking in her own house. Pain in right groin and unable to straight leg raise.
What should have been the initial management for the basicervical femur fracture?
HPI - motor vehicle accident
HPI - 48M, chronic alcoholic.
4 days post-op following ORIF for a right transcervical proximal femur fracture with 3 cannulated screws.
The patient developed delirium tremens in the post-op period and had another fall.
AP X-Ray of the right proximal femur is shown.
How would you have managed the initial fracture on presentation (see Pre-Procedure Images ABOVE) in this chronic alcoholic?
HPI - 70M, fell at home.
Unable to ambulate following the fall secondary to right hip pain.
No previous falls.
No other injuries. Isolated right hip fracture.
What further imaging would you order for this patient?
HPI - 50M patient presents to the trauma bay following a road traffic accident.
XRays confirm isolated, ipsilateral, displaced left femoral neck and shaft fractures (see XRays).
What additional imaging (if any) would you order on this patient?
HPI - left hip pain 8 months duration - no trauma - no systemic symptoms -
what will be your treatment option
HPI - • Fell at home with no prodromal symptoms or head trauma
• Admitted under hospitalist team
• Partner consulted initially
• Patient and family refusing surgery
• 72 hours later I was consulted
• Baseline: ambulates with a walker
Given the delay in surgery, would you have done any further preoperative testing?
HPI - isolated injury to right femur. closed - neurovascularly intact - initial hypotension resuscitated.
What would be your choice of implant?
HPI - MVC, polytrauma treated at other hospital
Right side: Femoral neck fracture with infraisthmal femur fracture, tibial shaft fracture
Left side: tibial shaft fracture
Right side treated with femoral neck screws, femoral plating, tibial casting
Left side treated with a tibial nail
Subsequently, the femoral neck fracture was infected and the screw was removed; the infection was diagnosed as treated at outside hospital
Now unable to walk.
How would you have treated the right femur fractures?
HPI - 30 year old male status post trauma with right femur fracture
How would you treat this fracture?
HPI - Simple trip and fall whilst mobilising
HPI - Condition started 1 month ago after fall on to the RT hip , with pain, tenderness and limited mobility of the affected hip ,
How would you treat this patient? (HWR = hardware removal)
HPI - Restrained driver in an MVC, transferred from outside hospital approximately 5 hours after injury.
What is your recommended treatment for this femoral neck NONUNION (see Postoperative P1 images below)?
HPI - Motorcycle accident 3 months ago, fx of the femoral neck and middle of the femur. Treated with DCP for both.
Now can not walk because of painful hip
What is your plan to treat this patient ?
HPI - The patient had a closed fracture of the left femur following road traffic accident 3 month ago. The patient was treated by open intramedullary nailing which was complicated by iatrogenic fracture of the neck of the femur. Pinning of the fractured neck femur was done on the second day.
3 days later the patient had yellowish discharge from the wound used for reduction of the fracture. C & S: Klebsiella treated by imipenem and cilastatin for 15 days.
Labs on April 15th:
CRP: 2 ( N LESS THAN 0.5)
Labs on May 17th:
CRP: 1.7 (N LESS THAN 0.5)
In your opinion, what is the best treatment option?
HPI - Pt. Came one year back to ER complaining from a acute right hip pain following a minor trauma. He was diagnosed to have fracture neck of right femur with a suspicion of a metabolic bone disease, fixed with cannulated screws, been referred to endocrine, been followed for 2/12, then he disappeared for 10/12, then he came again to ER with an acute left hip pain again following a minor trauma. He was lost his follow up with endocrine. Pt. Was diagnosed to have a fresh Pathological fracture neck of left femur together with nonunion fracture neck of right femur. Pt. Was referred again to endocrine and he was started on medications with the impression of a metabolic bone disease.
How to treat fracture in left femoral neck.
HPI - Road trafic accident 6 months ago. Intially treated by "bone settler."
Would you initially treat both injuries (femur fracture and malunion) simultaneously?
HPI - NOF fx 2 years back fixed with screws.patient had traumatic dislocation 6 months back,which was reduced closely but dislocation after 1 week.again reduced.
he didt came back to follw up untill now.it has been tried to reduce it which it does easily but dislocates on table.very unstable
MRI cant be done as the screws are of steel(locally made,not 316L for sure )
How would you treat this chronic dislocation?
HPI - She had a Fx NOF 2 years back,quack treated.
Now has difficulty in activities of daily living.
No fever,no other joint involvement
What to do?
HPI - Standing fall. Tripped on the foot of a wheelchair.
Cannot bear weight on the right lower limb
Severe pain right Hip
What method of treatment would you choose?
HPI - -
What additional studies would you perform prior to going to the operating room?
HPI - Patient had a subtrochanteric femur fracture treated 5 years prior to presentation. The patient did well initially but then slowly developed progressive deformity & limping following that.
What will be the treatment option?
HPI - The patient has a history of untreated hypothyroidism and had an unknown trauma to his hip three months prior to presentation.
What would be your next step in treatment of this patient?
HPI - MCA , closed fracture ...presented to our hosbital after 1,5 m
How would u manage this case?
HPI - Pt has a road traffic accident 4 months back when he fractured his shaft femur and was operated for the fracture In another hospital .6 weeks post op when pt was stated weight bearing he had pain in hip .pain was more on weight baring.
How would you currently treat this patient (4 months after his initial presentation)
HPI - Patient with previous left femur fracture secondary to a gunshot. Patient involved in an MVA with isolated left hip pain
What would be your preferred treatment for this patient?
HPI - History of basal neck fracture fixed with canulated screws
How would you treat this patient?
HPI - pt having h/o of neck femur 28 days back
operated with cemented modular bipolar
post op uneventfull
wt bear from 5 day and on 8th day c/o of pain hen ihe try to cross leg
visited on 12 day with dilocated bipolar
reduced under sedation and adductor tenotomy done wtih ankle skeletal traction given
on pt id non compliance
not maintain traction
pt came on 28th day with re dislocation this time painless
not reductible under sedation
no evidence of infection
What is the most likely cause of dislocation?
HPI - fracture of left hip a year ago,she didnot operate because of a cardiac ischamic episode
operation or not
HPI - 0: Motorcycle accident - presented extracapsular femur fracture.
1: 48h - CRIF with a 135º SHS. Postoperative care with no complication.
3: At 8 weeks has some complaints with ambulation, still wears crutches, limb discrepancy 1 cm.
4: At 6 months maintains important pain on ambulation, limb discrepancy 3cm. CT showed no evidence of infection or tumour. ESR 14mm, CRP <0,5 mg/dl, normal white count.
How would you manage this?
HPI - pt was treated by bone setter for fracture shaft femur resulting into malunion with shortening and external rotation deformity . now he develops pain in left hip , unable to walk . xray shows #/nonunion neck femur.
how to manage this case
HPI - fall from stairs one year back.
what is the further treatment option for a 30 years old male with non union neck of femur fracture after poor osteosynthesis?
HPI - History of Rt femoral shaft fracture 10/2012, IM femoral Nail, uneventful recovery, sebsequent follow ups showed good signs of healing both clinically and radiologically.
Pt fell 2/52 ago, delayed presentation(social issues).
Xrays show displaced intracapsular NOF.
What is the best option of management of this patient?
HPI - Fall from standing height, active person
What is the best treatment?
HPI - 21 M involved in high speed MCA.
What implant would you use?
HPI - 25 y/o male with left hip pain after being involved in a gun fight
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