Updated: 2/12/2018

Femoral Neck Fx Nonunion

Topic
Review Topic
0
0
Questions
2
0
0
Evidence
1
0
0
Videos
2
https://upload.orthobullets.com/topic/12293/images/femo_neck_nonunion.jpg
Introduction
  • Failure to heal an intracapsular femoral neck fracture
  • Epidemiology
    • incidence
      • most common (L1)
      • 10-30% of femoral neck fractures after ORIF
    • demographics
      • No correlation with age or gender 
    • body location
      • where in the body/bone
    • risk factors
      • fracture Morphology
        • vertical fracture pattern (Pauwels type III)
      • displacement
        • greater displacement corresponds to higher nonunion and reoperation rates after ORIF (Garden IV)
      • comminution
        • posterior comminution contributes to loss of stable fixation which proceeds to nonunion
      • fracture fragment vascularity
  • Pathophysiology
    • quality and maintenance of the initial reduction is paramount
    • pathoanatomy
      • femoral neck fractures are intracapsular
      • bathed in synovial fluid - deters fracture healing
      • no callus formation during healing - intra-osseous healing only
        • achieving and maintaining an anatomic reduction is essential
  • Associated conditions
    • orthopaedic manifestations
      • list common conditions (L2)
      • detailed epidemiology (L4)
    • medical conditions & comorbidities
      • common conditions
      • impact on orthopaedic outcomes
      • side effects of medical drugs
  • Prognosis
    • natural history of disease
      • prognostic variable
        • favorable
        • negative
    • outcomes with treatment
      • prognostic variable
        • favorable
        • negative
Presentation
  • History
    • prior femoral neck fracture
    • original fracture mechanism
      • high energy = worse prognosis for healing
    • evaluation of medical history predisposing to nonunion
      • metabolic disease
      • nutritional deficiencies
  • Symptoms
    • hip pain
    • thigh pain
    • weakness
  • Physical exam
    • motion
      • painful hip ROM
    • inability to bear weight
    • antalgic gait
    • assessment of limb length and rotation
Imaging
  • Radiographs  
    • recommended views
      • AP Pelvis
      • AP Hip
      • cross table lateral hip
    • optional views
      • traction/internal rotation hip view
    • findings
      • radiolucent fracture line
      • vertical fracture line
      • osteopenia
      • segmental femoral head collapse
      • calcar comminution
      • varus malalignment
    • measuerment
      • measurement A (Cobb angle)
      • measurement A (pelvic incidence)
    • sensitivity and specificity
  • CT  
    • indications
      • useful if diagnosis uncertain or for surgical planning (identifying comminution)
    • views
      • best seen on sagital
    • findings
    • sensitivity and specificity
  • Bone scan
    • indications
      • Can be helpful to assess fracture union or femoral head osteonecrosis
    • sensitivity and specificity
Studies
  • Labs
    • indications
      • with femoral neck nonunions it is important to rule out infectious etiology
    • elevated WBC
    • elevated ESR
    • elevated CRP
  • Electrodiagnositcs
    • indications
    • findings
  • Diagnostic hip aspirations
    • indications
      • if suspicious for infection but laboratory analysis is inconclusive
    • findings
      • cell count
      • culture
Treatment
  • Nonoperative
    • observation
      • indications
        • only indicated if nonambulatory with comorbid conditions
  • Operative
    • revision fixation
      • indications
        • femoral head is salvageable
      • techniques
        • if small and does not warrant own section in techniques
        • bone graft 
      • outcomes
        • rarely a good outcome without bone graft due to pre-operative bone loss and deformity
    • proximal femoral osteotomy
      • indications
        • femoral neck nonunion with limb shortening
        • rotational deformity
        • varus collapse
        • physiologically young patient in which arthroplasty is not desirable
      • techniques
        • several available techniques
        • valgus intertrochanteric osteotomy
          • vertical fracture reoriented to a horizontal fracture to achieve compression   
          • 80% union rate
          • 67% femoral head salvage rate
        • high complication (12%) and revision rate (18%)
      • contraindicated if:
        • severe bone loss
        • joint incongruity
        • advanced age (relative)
    • total hip arthroplasty
      • indications
      • techniques
      • outcomes
        • excellent 10-year survivorship, reliable pain relief
        • complications include:
          • dislocation
          • early loosening
          • superficial infection
    • hip hemiarthroplasty
      • reserved for patients with
        • low physical demand and more comorbidities
        • cognitive decline
        • preserved acetabular cartilage
          • hardware cutout may damage it
      • may have higher dislocation rate compared with THA
Complications
 
 

Please rate topic.

Average 1.6 of 11 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
Questions (2)
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
ARTICLES (3)
VIDEOS (2)
Topic COMMENTS (2)
Private Note